DOI: 10.1111/ajag.12075
Research Factors associated with refraining from buying prescribed medications among older people in Europe Mindaugas Stankunas School of Public Health, Griffith University, Gold Coast, Queensland, Australia; Department of Health Management, Lithuanian University of Health Sciences, Kaunas, Lithuania
Joaquim FJ Soares and Eija Viitasara Department of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden
Maria Gabriella Melchiorre Scientific Technological Area, Socio Economic Research Centre, Italian National Institute of Health and Science on Aging (INRCA), Ancona, Italy
Örjan Sundin Department of Psychology, Division of Social Sciences, Mid Sweden University, Östersund, Sweden
Francisco Torres-Gonzales Centro de Investigación Biomedica en Red de Salud Mental (CIBERSAM), University of Granada, Granada, Spain
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ever refrained from buying prescribed medication and care?’ Results: About 11.9% of older people refrained from buying prescribed medications. The multiple regression analysis showed that ages 60–64 (odds ratio (OR) = 2.08; 95% confidence interval (95%CI): 1.38–3.13) and 65–69 (OR = 1.73; 95%CI: 1.16–2.57) years, experience of financial strain (OR = 1.59; 95%CI: 1.27–2.01), as well as exposure to abuse (OR = 1.64; 95%CI: 1.31–2.06) when taking into account country of participant were independently associated with refraining from buying medications, while an opposite association was observed for being male (OR = 0.72; 95%CI: 0.58–0.91). Conclusions: The study found that refraining from buying prescription medications is a problem among older people and identified a number of factors associated with this. Key words: aged 60 and over, aged, elder abuse, medication adherence.
Aurima Stankuniene Department of Pharmaceutical Technology and Social Pharmacy, Lithuanian University of Health Sciences, Kaunas, Lithuania
Mark Avery School of Public Health, Griffith University, Gold Coast, Queensland, Australia
Elisabeth Ioannidi-Kapolou Department of Sociology, National School of Public Health, Athens, Greece
Henrique Barros Department of Hygiene and Epidemiology, Faculty of Medicine, University of Porto, Porto, Portugal
Jutta Lindert Department of Public Health, Protestant University of Applied Sciences, Ludwigsburg; Department of Medical Sociology and Psychology, Faculty of Medicine, University of Leipzig, Leipzig, Germany
Aim: To evaluate the associations between refraining from buying prescribed medications and selected factors among older people. Methods: A total of 4467 people aged 60–84 years from seven European countries answered a questionnaire (response rate 45.2%). Refraining from buying prescribed medications was measured with the question: ‘Have you Correspondence to: Dr Mindaugas Stankunas, School of Public Health, Gold Coast Campus, Griffith University. Email: [email protected] Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
Introduction It is known that older people experience a greater prevalence of chronic diseases than younger people, are the main users of health-care services, and consume a disproportionately large proportion of all prescribed drugs [1]. An outcome of this is that the use of medications among older persons involves significant expenditures for households [2]. For instance, Rogowski et al. suggest that people in the United States aged ≥65 years with diabetes spent an average of 4.1% of their household income on prescription drugs, and those with conditions such as heart failure, angina and ulcers spent between 3.7 and 3.9% [3]. Increasing prices and proportion of out-of-pocket payments in purchasing necessary pharmaceuticals lead to the situation that some older people might refrain from buying prescribed medications [4,5]. Reports on underuse of medication due to costs in older age vary from 3% in Australia, Canada, New Zealand and the Netherlands; 8% in Germany; 9% in the United States [6] and 15.2% in Lithuania [7]. This nonadherence to medication use causes serious problems to the health status of patients and increased cost to health-care systems [8]. Data from Australia suggest that at least 4500 older Australians are hospitalised each year as a result of medication-related problems representing 20–30% of unplanned hospital admissions for this age group [9]. This argues that the appropriate use of medicines by older people is a growing concern in public health care. It is crucial E25
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to understand the reasons as to why older people refrain from buying prescribed medications. The current literature offers little evidence of how other factors, such as marital status, living status, profession and abuse, are associated with the decision to refrain from buying prescribed drugs. Therefore, the aim of this study is to evaluate the associations between refraining from buying prescribed medications and selected factors among older persons.
Methods Data for this study were collected during the European project ‘Elder abuse: A multinational prevalence survey’ (ABUEL) [10]. The target population for ABUEL was people aged 60–84 years not suffering from dementia or other cognitive impairments and living in communities in Stuttgart (Germany), Athens (Greece), Ancona (Italy), Kaunas (Lithuania), Porto (Portugal), Granada (Spain) and Stockholm (Sweden). Recruitment of eligible participants and data collection were performed from January to July 2009. Before and in conjunction with the data gathering, the survey respondents were carefully informed about all the details of the research project and about what was expected of them in both writing and verbally, and appropriate informed consent was requested. Great emphasis was put on confidentiality, anonymity and the rights of older persons. The ethical permissions for the project were given by: Germany, Ethikkommission des Landes Baden-Wuerttenberg; Italy, Bioethics Advisory Committee of National Institute of Health and Science on Aging, Italian National Institute of Health and Science on Aging; Lithuania, The Lithuanian State Data Protection Inspectorate and the Kaunas Regional Bioethics Committee; Portugal, Comité de Ética do Hospital de João; Spain, Comité de Etica en Investigación de la Universidad de Granada; and Sweden, Regional Ethical Committee at Karolinska Institutet. In Greece, the QED (market research company) conducted the fieldwork under the codes and guidelines of International Chamber of Commerce/European Society for Opinion and Market Research which are similar to ethical provisions in the other participating countries. The total sample comprised 4467 respondents with a mean response rate across countries of 45.2%. More detailed description of sampling, data collection, differences between responders and non-responders and study limitations are described in a separate ABUEL methodology paper [11]. The participants completed a standardised questionnaire with various scales and questions. For this paper, we used questions related to refraining from buying prescribed medications, demographic/socioeconomic characteristics, life style and abuse. Self-reported refraining from buying prescribed medications was measured with the question: ‘Have you ever refrained from buying prescribed medication and care?’ (yes/no choice). Demographic/socioeconomic variables were assessed (i.e. country, age, sex, marital status, migrant background, educaE26
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tion, profession, financial support, financial strain, habitation, living situation, and if still in work). Financial strain (worries about how to make ends meet) was measured with one question in a no/sometimes/often/always format. A participant was defined as having ‘financial strain’ if he/she selected any response other than no. Four questions (e.g. place of birth) addressed the issue of whether older persons were indigenous inhabitants or migrants. The demographic and socioeconomic variables were customised for each country but were similar in content. Life style variables were assessed in the form of alcohol and cigarette use and body mass index (BMI). Alcohol use was assessed with a modified version of ‘Alcohol Use Disorders Identification Test’ consisting of five items (e.g. do you drink alcohol) [12]. A similar strategy was applied for the assessment of cigarette use. For this study, the focus was on use of alcohol and cigarettes in a ‘yes/no’ format. BMI, based on self-reported height and weight, was computed for each older person with the formula kg/m2. Abuse was assessed with 52 questions based on the ‘Conflict Tactic Scales 2’ [13] and on the UK study of abuse/neglect of older people [14]. Psychological abuse comprised 11 questions (e.g. threatened to hit or throw something at you); physical abuse 17 questions (e.g. beat you up); sexual abuse 8 questions (e.g. had sexual intercourse with you against your will); physical abuse with injury 7 questions (e.g. you passed out from being hit on the head); and financial abuse 9 questions (e.g. took or kept power of attorney over you against your will). The participants were asked if they had sustained these acts and how often they had occurred (chronicity). The abuse acts may have occurred once, twice, 3–5, 6–10, 11–20 or >20 times during the past year, did not occur in the past year, but before or never occurred. Additionally, we assessed neglect with 13 questions (e.g. routine housework), where the respondents were asked whether they needed help and received it, needed help but did not receive it, or did not need help. Data were also collected on the perpetrator’s main characteristics (e.g. age) and where the abuse occurred and what were participants’ reactions to the abuse and whether they were affected by it. The focus in the current study was on any kind of violence during the past 12 months. Bivariate analyses of the relationship between refraining from buying prescribed medications, demographics/ socioeconomics, religion, life style and violence were performed by means of χ2 tests. For evaluation of the impact of explanatory variables on the analysed event (binary dependent variable), the Enter model of multiple logistic regression analysis was used. The dependent variable was refraining from buying prescribed medications, and the independent variables were country, age, sex, profession, education, financial support, financial strain, religion and violence. The associations between refraining from buying prescribed medications and the various independent Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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variables were measured by computing odds ratios with the respective 95% confidence intervals (95%CI). Significance level for bivariate and multivariate analyses was set at P < 0.05. Data were analysed using the Statistical Package for the Social Sciences for Windows Version 13.0 (SPSS for Windows 13).
Results Of the 4467 respondents, 1908 (42.5%) were male and 2559 (57.5%) were female. The distribution of respondents by age was: 60–64 years (25.2%), 65–69 years (24.4%), 70–74 years (21.1%), 75–79 years (16.1%) and 80–84 years (12.2%); and by education: cannot read/write (3.1%), without any degree (4.2%), less than primary school (7.5%), primary school/similar (24.4%), secondary school/similar (40.0%), university/similar (19.2%) and other (1.6%). The results showed that 11.9% (n = 531) of respondents had refrained from buying prescribed medications. As shown in Table 1, older interviewees in Germany, Italy and Lithuania more often refrained from buying medications than respondents in other countries (χ2(6) = 448.63, P < 0.0001). Among the age groups, only the youngest people in the study cohort (60–64 years) refrained more often from buying medications (χ2(4) = 13.35, P = 0.0097). Additionally, more women than men (χ2(1) = 14.55, P < 0.0001), and compared to counterparts highly educated (χ2(3) = 21.89, P < 0.0001), middle/ high white-collar workers (χ2(4) = 15.64, P = 0.0035) and work retirees (χ2(4) = 18.34, P = 0.0011) more often refrained from buying medications. Finally, older people who experienced financial strain (χ2(1) = 15.12, P < 0.0001), and were religious (χ2(1) = 5.25, P = 0.0219) and exposed to violence (χ2(1) = 25.93, P < 0.0001) more often refrained from buying medications. There were no other significant differences. As shown in Table 2, refraining from buying medications was strongly associated with people from Germany, Italy, Lithuania and Portugal, and also with people from Greece but with a lower statistical significance (P < 0.05). Moreover, those being in the age interval of 60–64 and 65–69 years, who experienced or were experiencing financial strain, and were or had been exposed to violence were also significantly related to refraining from buying medications with statistically significant values. Conversely, refraining from buying prescribed medications was negatively associated with being male. The model explained 20.7% of the variance in refraining from buying medications.
Discussion Our study revealed that refraining from buying medication was independently linked to being from Germany, Greece, Italy, Lithuania and Portugal; aged 60–64/65–69 years and female; and experiencing financial strain and abuse.
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Table 1: People refraining from buying prescribed medications by demographic/socioeconomic characteristics, religion, life style and abuse Variables
Country (n) Germany Greece Italy Lithuania Portugal Spain Sweden Age groups (n) (year) 60–64 65–69 70–74 75–79 80–84 Sex (n) Female Male Marital status (n) Single Married/cohabitant Divorced/separated Widow/er Living status (n) Alone Spouse/partner Spouse/partner/other† Other† Foreign background (n) Yes No Housing (n) Own Rent Other‡ Education (n) Cannot read/write Primary school/similar Secondary school/similar University/similar Profession (n) At home Blue-collar worker Low white-collar worker Middle/high white-collar worker Armed forces/police Financial support (n) Work pension Social/sickness benefits/ pension Partners income Work Other§ Still working (n) Yes No Financial strain (n) Yes No Religious (n) Yes No Use of cigarettes (n) Yes No Use of alcohol (n) Yes No Abuse (n)¶ Yes No
Number of older people refraining (%) n = 531 (11.9)
Number of older people not refraining (%) n = 3936 (88.1)
120 (22.6) 30 (5.6) 96 (18.1) 205 (38.6) 55 (10.4) 13 (2.4) 12 (2.3)
528 (13.4) 613 (15.6) 532 (13.5) 425 (10.8) 601 (15.3) 623 (15.8) 614 (15.6)
154 (29.0) 136 (25.6) 115 (21.7) 84 (15.8) 42 (7.9)
970 (24.6) 952 (24.2) 846 (21.5) 665 (16.9) 503 (12.8)
345 (65.0) 186 (35.0)
386 (72.7) 29 (5.4)
2214 (56.3) 1722 (43.7) (3935.0) 235 (6.0) 2578 (65.5) 294 (7.5) 828 (21.0) (3921.0) 942 (24.0) 1955 (49.9) 629 (16.0) 395 (10.1) (3923.0) 212 (5.4) 3711 (94.6) (3934.0) 2984 (75.9) 820 (20.8) 130 (3.3) (3932.0) 128 (3.3) 1464 (37.2) 1541 (39.2) 799 (20.3) (3881.0) 601 (15.5) 1114 (28.7) 1078 (27.8) 1046 (26.9) 42 (1.1) (3930.0) 2553 (65.0) 214 (5.4)
45 (8.5) 60 (11.3) 11 (2.1)
582 (14.8) 482 (12.3) 99 (2.5)
96 (18.1) 435 (81.9)
656 (16.7) 3280 (83.3)
380 (71.6) 151 (28.4) (526.0) 469 (89.1) 57 (10.9) (530.0) 70 (13.2) 460 (86.8) 332 (62.5) 199 (37.5)
2477 (62.9) 1459 (37.1) (3913.0) 3344 (85.4) 569 (14.5) (3933.0) 466 (11.8) 3467 (88.2) (3933.0) 2534 (64.4) 1399 (35.6)
166 (31.3) 365 (68.7)
843 (21.4) 3093 (78.6)
35 (6.6) 325 (61.2) 49 (9.2) 122 (23.0) (528.0) 136 (25.8) 253 (47.9) 77 (14.6) 62 (11.7) (526.0) 26 (4.9) 500 (95.1) 408 (76.8) 110 (20.7) 13 (2.5) 8 (1.5) 153 (28.8) 241 (45.4) 129 (24.3) (528.0) 55 (10.4) 163 (30.9) 136 (25.7) 171 (32.4) 3 (0.6)
†For example, daughter; ‡For example, home for older people; §For example, own capital; ¶Any kind of abuse during the past 12 months.
As mentioned earlier, findings from our study suggest the existence of significant differences in refraining from buying Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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Table 2: Factors associated with older people refraining from buying prescribed medications (n = 4095) Independent variables
Country Germany Greece Italy Lithuania Portugal Spain Sweden Age groups (year) 60–64 65–69 70–74 75–79 80–84 Sex Male Female Education Primary school/similar Secondary school/similar University/similar Cannot read/write Profession Blue-collar worker Low white-collar worker Middle/high white-collar worker Armed forces/police At home Financial support Work Work pension Social/sickness benefits/pension Partners income Other† Financial strain Yes No Religious Yes No Abuse‡ Yes No
Older people refraining Odds ratio
95%CI
12.46*** 2.27* 10.20*** 22.91*** 3.69*** 1.00 1.00
6.59–23.53 1.09–4.73 5.33–19.54 12.12–43.31 1.87–7.28 0.43–2.35
2.08*** 1.73** 1.45 1.48 1.00
1.38–3.13 1.16–2.57 0.97–2.17 0.96–2.24
0.72** 1.00
0.58–0.91
0.54 0.51 0.54 1.00
0.24–1.21 0.22–1.17 0.23–1.31
1.01 0.79 1.02 1.26 1.00
0.66–1.55 0.51–1.24 0.63–1.65 0.35–4.57
1.36 1.21 1.25 1.13 1.00
0.56–3.29 0.53–2.76 0.49–3.19 0.47–2.73
1.59*** 1.00
1.27–2.01
0.76 1.00
0.54–1.06
1.64*** 1.00
1.31–2.06
*P < 0.05; **P < 0.01; ***P < 0.0001. †For example, own capital; ‡Any kind of abuse during the past 12 months. 95%CI, 95% confidence interval.
medication by country. The organisation and financing of health-care systems could be one of the reasons in explaining this variation. The lowest rate of refrain was found in Sweden, which should not be surprising as this Nordic country has universal health insurance, where 94% of the health-care system is publicly financed and prescribed medication is subsidised. All residents in Sweden are entitled to free prescribed medicines after spending 1800 SEK (equivalent to $US257) within the preceding 12 months [15]. Nevertheless, Lithuania, which has reported the highest percentage of refrain, has a very similar system for reimbursement of expenditures for medications. The Lithuanian Sickness Fund provides 100% compensation of costs for buying most of the drugs used by older people [16]. In Italy, the states set different rules in reimbursing the cost of medication for older persons. However, a compensation system applies E28
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only to specific groups of medication [17]. It is noteworthy that all ABUEL study’s countries had pharmaceutical benefit schemes. This suggests that financing of health-care system can only partly explain differences in refraining from buying prescribed medications among older persons. A possible explanation of this pattern could be that most of pharmaceutical benefit schemes are more beneficial to older patients than younger ones. This suggests that health-care system’s financing models are more important to young patients than older ones. Results from other studies seem to confirm this. A recent study in Canada revealed that cost-related nonadherence was reported by 26.5% of respondents who had no drug coverage. For people who did have insurance coverage for prescription drugs, only 6.8% reported cost-related non-adherence [18]. In spite of the presence of cost reimbursement mechanisms, patients need to make co-payments (or in some cases to pay full price) for prescribed medications. In addition, studies indicate that chronic diseases require significant proportions of household incomes for buying medications [3]. This suggests that the purchasing power of inhabitants in the particular country can play a major role and be related with the economic situation in the country. Lithuania, which has reported the highest refrain rates, had the lowest gross domestic product (at the time of conducting this study) of all participating countries in the study [19]. It could be that economic factors influenced Lithuanians who decided not to use prescriptions from their doctors. Our hypothesis can be supported by findings from another study which has identified that almost half (48%) of all refraining in Kaunas (Lithuania) was associated with financial issues [7]. This percentage is considerably higher in comparison with more economically developed countries [6]. The above-mentioned findings underline the associations between the economic situation and refraining from buying prescription medications, and are in line with results from our study revealing that the decision not to purchase medications was independently linked to experiencing financial strain. Similar patterns have been noticed in studies from Australia, Canada, New Zealand, United Kingdom and United States [6,18]. Our findings showed that the younger elders (aged 60–64/ 65–69) were at higher ‘risk’ of refrain. Other studies have observed that the oldest elders are less likely to refrain from buying medication (even if they have financial reasons for doing this) [5,6], and this is because they can spend more money for this than those in the younger elder groups [20]. Some studies have emphasised that the chronic nature of health problems among the oldest people in these groups reduces the risk of refraining from buying the prescribed medications [21]. This indicates that the presence of chronic health problems motivates the oldest to follow more precisely physician recommendations and buy the prescription drugs [22]. However, some studies suggest opposite associations [23]. This suggests that more research is needed to explain the link between refraining from buying prescription medications and health status. Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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According to our findings, women were more likely to refrain from buying prescribed medications. Many studies indicate that women use medications more often than men [24,25]. For instance, a study in United States has identified that women (aged 65 and over) spent about $1178 on drugs, about 17% more than the $1009 average expenditure by men [26]. One of explanation of this pattern could be that women in general report more bodily distress, and more numerous, intense and frequent somatic symptoms than men [27]. This may cause women to purchase more pharmaceutical products [28] and spend a considerable amount of the household income on them. Other authors explain this sex pattern by arguing that women are central to the process of communication about health and therapies and they appear to draw on a richer repertoire of knowledge, perceptions and attitudes regarding medications [29]. Subsequently, that position leads to reporting higher overall use of medication than men do. Thus, our findings are at odds with these data. An explanation may be that the women decided not to buy some of these prescribed medications in order to save financial resources. However, we need further studies on causes of refrain in order to understand this sex pattern.
Some possible study limitations are noteworthy. First, the samples (women/men) were recruited from urban centres in seven European countries. This could cause results to be different for population samples from non-urban areas and other countries in Europe or elsewhere (e.g. United States). Second, the attrition rate was high, which may have led to the ‘selection’ of women/men with particular characteristics diverging from those of women/men in general. For example, we may have an underrepresentation of women/men with somatic complaints. However, there were no major differAustralasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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ences (age/sex) between refusals and non-refusals nor did they differ substantially from the general population in each participating country [11]. Third, the accuracy of the data was dependent on the participants’ subjective assessments of their situations. No objective evaluations (e.g. hospital records) have been performed to corroborate their responses.
Conclusions
The current study suggests that about 12% (n = 531) of older people refrained from buying prescribed medications, with marked variations between countries. Country, age, financial strain and violence were associated with refraining from buying medications. However, more research is needed to explain the association with the country of residence.
Acknowledgements We would like to express our appreciation for the financial support for this initiative by the European Union through the Executive Agency for Health and Consumers (EAHC) which made possible the realisation of the project. We extend also our appreciation to the staff of EAHC, and in particular Dr Guy Dargent, for their help. Furthermore, we would like to express their appreciation to all participating institutions and to the staff involved in ABUEL. Finally, and most of all, all authors appreciate the kindness, efforts and answers of older persons who participated in ABUEL. This study was supported by the EAHC and participating institutions. The study was designed and performed by the ABUEL groups in each participating country.
Our findings showed an association between refraining from buying medication and experiencing abuse. Although many studies have discussed associations between violence and use of health-care services [30], we were not able to find any information regarding the link between abuse and refrain to buy prescribed medications in this study. Thus, our findings may be the first to suggest this association. However, it could be that the abuse is not directly related to refraining from buying prescribed medications. Because of the relative isolation (emotional neglect) of many older people who are mistreated, many victims could face some difficulties in obtaining doctor visits in respect to having money (financial abuse, financial neglect) in order to buy medications. Victims of abuse may also be disabled and thus in need of help for buying medications. In other words, the abuse itself may be the cause of not using medication, for example, physical abuse/neglect including withholding of medication, not providing health care and under-medicating (medical abuse). However, there is a need for more research in order to develop adequate and scientific reliable explanations of association between refraining from buying prescribed medications and abuse.
Limitations
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Key Points • The current study revealed that about 12% of older people in selected European countries refrained from buying prescribed medications. • Country, younger age financial strain and violence were factors associated with refraining. • More research is needed in order to develop adequate and scientific reliable explanations of association between refraining from buying prescribed medications and abuse.
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Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
Research Factors associated with refraining from buying prescribed medications among older people in Europe Mindaugas Stankunas School of Public Health, Griffith University, Gold Coast, Queensland, Australia; Department of Health Management, Lithuanian University of Health Sciences, Kaunas, Lithuania
Joaquim FJ Soares and Eija Viitasara Department of Public Health Sciences, Mid Sweden University, Sundsvall, Sweden
Maria Gabriella Melchiorre Scientific Technological Area, Socio Economic Research Centre, Italian National Institute of Health and Science on Aging (INRCA), Ancona, Italy
Örjan Sundin Department of Psychology, Division of Social Sciences, Mid Sweden University, Östersund, Sweden
Francisco Torres-Gonzales Centro de Investigación Biomedica en Red de Salud Mental (CIBERSAM), University of Granada, Granada, Spain
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ever refrained from buying prescribed medication and care?’ Results: About 11.9% of older people refrained from buying prescribed medications. The multiple regression analysis showed that ages 60–64 (odds ratio (OR) = 2.08; 95% confidence interval (95%CI): 1.38–3.13) and 65–69 (OR = 1.73; 95%CI: 1.16–2.57) years, experience of financial strain (OR = 1.59; 95%CI: 1.27–2.01), as well as exposure to abuse (OR = 1.64; 95%CI: 1.31–2.06) when taking into account country of participant were independently associated with refraining from buying medications, while an opposite association was observed for being male (OR = 0.72; 95%CI: 0.58–0.91). Conclusions: The study found that refraining from buying prescription medications is a problem among older people and identified a number of factors associated with this. Key words: aged 60 and over, aged, elder abuse, medication adherence.
Aurima Stankuniene Department of Pharmaceutical Technology and Social Pharmacy, Lithuanian University of Health Sciences, Kaunas, Lithuania
Mark Avery School of Public Health, Griffith University, Gold Coast, Queensland, Australia
Elisabeth Ioannidi-Kapolou Department of Sociology, National School of Public Health, Athens, Greece
Henrique Barros Department of Hygiene and Epidemiology, Faculty of Medicine, University of Porto, Porto, Portugal
Jutta Lindert Department of Public Health, Protestant University of Applied Sciences, Ludwigsburg; Department of Medical Sociology and Psychology, Faculty of Medicine, University of Leipzig, Leipzig, Germany
Aim: To evaluate the associations between refraining from buying prescribed medications and selected factors among older people. Methods: A total of 4467 people aged 60–84 years from seven European countries answered a questionnaire (response rate 45.2%). Refraining from buying prescribed medications was measured with the question: ‘Have you Correspondence to: Dr Mindaugas Stankunas, School of Public Health, Gold Coast Campus, Griffith University. Email: [email protected] Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
Introduction It is known that older people experience a greater prevalence of chronic diseases than younger people, are the main users of health-care services, and consume a disproportionately large proportion of all prescribed drugs [1]. An outcome of this is that the use of medications among older persons involves significant expenditures for households [2]. For instance, Rogowski et al. suggest that people in the United States aged ≥65 years with diabetes spent an average of 4.1% of their household income on prescription drugs, and those with conditions such as heart failure, angina and ulcers spent between 3.7 and 3.9% [3]. Increasing prices and proportion of out-of-pocket payments in purchasing necessary pharmaceuticals lead to the situation that some older people might refrain from buying prescribed medications [4,5]. Reports on underuse of medication due to costs in older age vary from 3% in Australia, Canada, New Zealand and the Netherlands; 8% in Germany; 9% in the United States [6] and 15.2% in Lithuania [7]. This nonadherence to medication use causes serious problems to the health status of patients and increased cost to health-care systems [8]. Data from Australia suggest that at least 4500 older Australians are hospitalised each year as a result of medication-related problems representing 20–30% of unplanned hospital admissions for this age group [9]. This argues that the appropriate use of medicines by older people is a growing concern in public health care. It is crucial E25
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to understand the reasons as to why older people refrain from buying prescribed medications. The current literature offers little evidence of how other factors, such as marital status, living status, profession and abuse, are associated with the decision to refrain from buying prescribed drugs. Therefore, the aim of this study is to evaluate the associations between refraining from buying prescribed medications and selected factors among older persons.
Methods Data for this study were collected during the European project ‘Elder abuse: A multinational prevalence survey’ (ABUEL) [10]. The target population for ABUEL was people aged 60–84 years not suffering from dementia or other cognitive impairments and living in communities in Stuttgart (Germany), Athens (Greece), Ancona (Italy), Kaunas (Lithuania), Porto (Portugal), Granada (Spain) and Stockholm (Sweden). Recruitment of eligible participants and data collection were performed from January to July 2009. Before and in conjunction with the data gathering, the survey respondents were carefully informed about all the details of the research project and about what was expected of them in both writing and verbally, and appropriate informed consent was requested. Great emphasis was put on confidentiality, anonymity and the rights of older persons. The ethical permissions for the project were given by: Germany, Ethikkommission des Landes Baden-Wuerttenberg; Italy, Bioethics Advisory Committee of National Institute of Health and Science on Aging, Italian National Institute of Health and Science on Aging; Lithuania, The Lithuanian State Data Protection Inspectorate and the Kaunas Regional Bioethics Committee; Portugal, Comité de Ética do Hospital de João; Spain, Comité de Etica en Investigación de la Universidad de Granada; and Sweden, Regional Ethical Committee at Karolinska Institutet. In Greece, the QED (market research company) conducted the fieldwork under the codes and guidelines of International Chamber of Commerce/European Society for Opinion and Market Research which are similar to ethical provisions in the other participating countries. The total sample comprised 4467 respondents with a mean response rate across countries of 45.2%. More detailed description of sampling, data collection, differences between responders and non-responders and study limitations are described in a separate ABUEL methodology paper [11]. The participants completed a standardised questionnaire with various scales and questions. For this paper, we used questions related to refraining from buying prescribed medications, demographic/socioeconomic characteristics, life style and abuse. Self-reported refraining from buying prescribed medications was measured with the question: ‘Have you ever refrained from buying prescribed medication and care?’ (yes/no choice). Demographic/socioeconomic variables were assessed (i.e. country, age, sex, marital status, migrant background, educaE26
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tion, profession, financial support, financial strain, habitation, living situation, and if still in work). Financial strain (worries about how to make ends meet) was measured with one question in a no/sometimes/often/always format. A participant was defined as having ‘financial strain’ if he/she selected any response other than no. Four questions (e.g. place of birth) addressed the issue of whether older persons were indigenous inhabitants or migrants. The demographic and socioeconomic variables were customised for each country but were similar in content. Life style variables were assessed in the form of alcohol and cigarette use and body mass index (BMI). Alcohol use was assessed with a modified version of ‘Alcohol Use Disorders Identification Test’ consisting of five items (e.g. do you drink alcohol) [12]. A similar strategy was applied for the assessment of cigarette use. For this study, the focus was on use of alcohol and cigarettes in a ‘yes/no’ format. BMI, based on self-reported height and weight, was computed for each older person with the formula kg/m2. Abuse was assessed with 52 questions based on the ‘Conflict Tactic Scales 2’ [13] and on the UK study of abuse/neglect of older people [14]. Psychological abuse comprised 11 questions (e.g. threatened to hit or throw something at you); physical abuse 17 questions (e.g. beat you up); sexual abuse 8 questions (e.g. had sexual intercourse with you against your will); physical abuse with injury 7 questions (e.g. you passed out from being hit on the head); and financial abuse 9 questions (e.g. took or kept power of attorney over you against your will). The participants were asked if they had sustained these acts and how often they had occurred (chronicity). The abuse acts may have occurred once, twice, 3–5, 6–10, 11–20 or >20 times during the past year, did not occur in the past year, but before or never occurred. Additionally, we assessed neglect with 13 questions (e.g. routine housework), where the respondents were asked whether they needed help and received it, needed help but did not receive it, or did not need help. Data were also collected on the perpetrator’s main characteristics (e.g. age) and where the abuse occurred and what were participants’ reactions to the abuse and whether they were affected by it. The focus in the current study was on any kind of violence during the past 12 months. Bivariate analyses of the relationship between refraining from buying prescribed medications, demographics/ socioeconomics, religion, life style and violence were performed by means of χ2 tests. For evaluation of the impact of explanatory variables on the analysed event (binary dependent variable), the Enter model of multiple logistic regression analysis was used. The dependent variable was refraining from buying prescribed medications, and the independent variables were country, age, sex, profession, education, financial support, financial strain, religion and violence. The associations between refraining from buying prescribed medications and the various independent Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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variables were measured by computing odds ratios with the respective 95% confidence intervals (95%CI). Significance level for bivariate and multivariate analyses was set at P < 0.05. Data were analysed using the Statistical Package for the Social Sciences for Windows Version 13.0 (SPSS for Windows 13).
Results Of the 4467 respondents, 1908 (42.5%) were male and 2559 (57.5%) were female. The distribution of respondents by age was: 60–64 years (25.2%), 65–69 years (24.4%), 70–74 years (21.1%), 75–79 years (16.1%) and 80–84 years (12.2%); and by education: cannot read/write (3.1%), without any degree (4.2%), less than primary school (7.5%), primary school/similar (24.4%), secondary school/similar (40.0%), university/similar (19.2%) and other (1.6%). The results showed that 11.9% (n = 531) of respondents had refrained from buying prescribed medications. As shown in Table 1, older interviewees in Germany, Italy and Lithuania more often refrained from buying medications than respondents in other countries (χ2(6) = 448.63, P < 0.0001). Among the age groups, only the youngest people in the study cohort (60–64 years) refrained more often from buying medications (χ2(4) = 13.35, P = 0.0097). Additionally, more women than men (χ2(1) = 14.55, P < 0.0001), and compared to counterparts highly educated (χ2(3) = 21.89, P < 0.0001), middle/ high white-collar workers (χ2(4) = 15.64, P = 0.0035) and work retirees (χ2(4) = 18.34, P = 0.0011) more often refrained from buying medications. Finally, older people who experienced financial strain (χ2(1) = 15.12, P < 0.0001), and were religious (χ2(1) = 5.25, P = 0.0219) and exposed to violence (χ2(1) = 25.93, P < 0.0001) more often refrained from buying medications. There were no other significant differences. As shown in Table 2, refraining from buying medications was strongly associated with people from Germany, Italy, Lithuania and Portugal, and also with people from Greece but with a lower statistical significance (P < 0.05). Moreover, those being in the age interval of 60–64 and 65–69 years, who experienced or were experiencing financial strain, and were or had been exposed to violence were also significantly related to refraining from buying medications with statistically significant values. Conversely, refraining from buying prescribed medications was negatively associated with being male. The model explained 20.7% of the variance in refraining from buying medications.
Discussion Our study revealed that refraining from buying medication was independently linked to being from Germany, Greece, Italy, Lithuania and Portugal; aged 60–64/65–69 years and female; and experiencing financial strain and abuse.
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Table 1: People refraining from buying prescribed medications by demographic/socioeconomic characteristics, religion, life style and abuse Variables
Country (n) Germany Greece Italy Lithuania Portugal Spain Sweden Age groups (n) (year) 60–64 65–69 70–74 75–79 80–84 Sex (n) Female Male Marital status (n) Single Married/cohabitant Divorced/separated Widow/er Living status (n) Alone Spouse/partner Spouse/partner/other† Other† Foreign background (n) Yes No Housing (n) Own Rent Other‡ Education (n) Cannot read/write Primary school/similar Secondary school/similar University/similar Profession (n) At home Blue-collar worker Low white-collar worker Middle/high white-collar worker Armed forces/police Financial support (n) Work pension Social/sickness benefits/ pension Partners income Work Other§ Still working (n) Yes No Financial strain (n) Yes No Religious (n) Yes No Use of cigarettes (n) Yes No Use of alcohol (n) Yes No Abuse (n)¶ Yes No
Number of older people refraining (%) n = 531 (11.9)
Number of older people not refraining (%) n = 3936 (88.1)
120 (22.6) 30 (5.6) 96 (18.1) 205 (38.6) 55 (10.4) 13 (2.4) 12 (2.3)
528 (13.4) 613 (15.6) 532 (13.5) 425 (10.8) 601 (15.3) 623 (15.8) 614 (15.6)
154 (29.0) 136 (25.6) 115 (21.7) 84 (15.8) 42 (7.9)
970 (24.6) 952 (24.2) 846 (21.5) 665 (16.9) 503 (12.8)
345 (65.0) 186 (35.0)
386 (72.7) 29 (5.4)
2214 (56.3) 1722 (43.7) (3935.0) 235 (6.0) 2578 (65.5) 294 (7.5) 828 (21.0) (3921.0) 942 (24.0) 1955 (49.9) 629 (16.0) 395 (10.1) (3923.0) 212 (5.4) 3711 (94.6) (3934.0) 2984 (75.9) 820 (20.8) 130 (3.3) (3932.0) 128 (3.3) 1464 (37.2) 1541 (39.2) 799 (20.3) (3881.0) 601 (15.5) 1114 (28.7) 1078 (27.8) 1046 (26.9) 42 (1.1) (3930.0) 2553 (65.0) 214 (5.4)
45 (8.5) 60 (11.3) 11 (2.1)
582 (14.8) 482 (12.3) 99 (2.5)
96 (18.1) 435 (81.9)
656 (16.7) 3280 (83.3)
380 (71.6) 151 (28.4) (526.0) 469 (89.1) 57 (10.9) (530.0) 70 (13.2) 460 (86.8) 332 (62.5) 199 (37.5)
2477 (62.9) 1459 (37.1) (3913.0) 3344 (85.4) 569 (14.5) (3933.0) 466 (11.8) 3467 (88.2) (3933.0) 2534 (64.4) 1399 (35.6)
166 (31.3) 365 (68.7)
843 (21.4) 3093 (78.6)
35 (6.6) 325 (61.2) 49 (9.2) 122 (23.0) (528.0) 136 (25.8) 253 (47.9) 77 (14.6) 62 (11.7) (526.0) 26 (4.9) 500 (95.1) 408 (76.8) 110 (20.7) 13 (2.5) 8 (1.5) 153 (28.8) 241 (45.4) 129 (24.3) (528.0) 55 (10.4) 163 (30.9) 136 (25.7) 171 (32.4) 3 (0.6)
†For example, daughter; ‡For example, home for older people; §For example, own capital; ¶Any kind of abuse during the past 12 months.
As mentioned earlier, findings from our study suggest the existence of significant differences in refraining from buying Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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Table 2: Factors associated with older people refraining from buying prescribed medications (n = 4095) Independent variables
Country Germany Greece Italy Lithuania Portugal Spain Sweden Age groups (year) 60–64 65–69 70–74 75–79 80–84 Sex Male Female Education Primary school/similar Secondary school/similar University/similar Cannot read/write Profession Blue-collar worker Low white-collar worker Middle/high white-collar worker Armed forces/police At home Financial support Work Work pension Social/sickness benefits/pension Partners income Other† Financial strain Yes No Religious Yes No Abuse‡ Yes No
Older people refraining Odds ratio
95%CI
12.46*** 2.27* 10.20*** 22.91*** 3.69*** 1.00 1.00
6.59–23.53 1.09–4.73 5.33–19.54 12.12–43.31 1.87–7.28 0.43–2.35
2.08*** 1.73** 1.45 1.48 1.00
1.38–3.13 1.16–2.57 0.97–2.17 0.96–2.24
0.72** 1.00
0.58–0.91
0.54 0.51 0.54 1.00
0.24–1.21 0.22–1.17 0.23–1.31
1.01 0.79 1.02 1.26 1.00
0.66–1.55 0.51–1.24 0.63–1.65 0.35–4.57
1.36 1.21 1.25 1.13 1.00
0.56–3.29 0.53–2.76 0.49–3.19 0.47–2.73
1.59*** 1.00
1.27–2.01
0.76 1.00
0.54–1.06
1.64*** 1.00
1.31–2.06
*P < 0.05; **P < 0.01; ***P < 0.0001. †For example, own capital; ‡Any kind of abuse during the past 12 months. 95%CI, 95% confidence interval.
medication by country. The organisation and financing of health-care systems could be one of the reasons in explaining this variation. The lowest rate of refrain was found in Sweden, which should not be surprising as this Nordic country has universal health insurance, where 94% of the health-care system is publicly financed and prescribed medication is subsidised. All residents in Sweden are entitled to free prescribed medicines after spending 1800 SEK (equivalent to $US257) within the preceding 12 months [15]. Nevertheless, Lithuania, which has reported the highest percentage of refrain, has a very similar system for reimbursement of expenditures for medications. The Lithuanian Sickness Fund provides 100% compensation of costs for buying most of the drugs used by older people [16]. In Italy, the states set different rules in reimbursing the cost of medication for older persons. However, a compensation system applies E28
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only to specific groups of medication [17]. It is noteworthy that all ABUEL study’s countries had pharmaceutical benefit schemes. This suggests that financing of health-care system can only partly explain differences in refraining from buying prescribed medications among older persons. A possible explanation of this pattern could be that most of pharmaceutical benefit schemes are more beneficial to older patients than younger ones. This suggests that health-care system’s financing models are more important to young patients than older ones. Results from other studies seem to confirm this. A recent study in Canada revealed that cost-related nonadherence was reported by 26.5% of respondents who had no drug coverage. For people who did have insurance coverage for prescription drugs, only 6.8% reported cost-related non-adherence [18]. In spite of the presence of cost reimbursement mechanisms, patients need to make co-payments (or in some cases to pay full price) for prescribed medications. In addition, studies indicate that chronic diseases require significant proportions of household incomes for buying medications [3]. This suggests that the purchasing power of inhabitants in the particular country can play a major role and be related with the economic situation in the country. Lithuania, which has reported the highest refrain rates, had the lowest gross domestic product (at the time of conducting this study) of all participating countries in the study [19]. It could be that economic factors influenced Lithuanians who decided not to use prescriptions from their doctors. Our hypothesis can be supported by findings from another study which has identified that almost half (48%) of all refraining in Kaunas (Lithuania) was associated with financial issues [7]. This percentage is considerably higher in comparison with more economically developed countries [6]. The above-mentioned findings underline the associations between the economic situation and refraining from buying prescription medications, and are in line with results from our study revealing that the decision not to purchase medications was independently linked to experiencing financial strain. Similar patterns have been noticed in studies from Australia, Canada, New Zealand, United Kingdom and United States [6,18]. Our findings showed that the younger elders (aged 60–64/ 65–69) were at higher ‘risk’ of refrain. Other studies have observed that the oldest elders are less likely to refrain from buying medication (even if they have financial reasons for doing this) [5,6], and this is because they can spend more money for this than those in the younger elder groups [20]. Some studies have emphasised that the chronic nature of health problems among the oldest people in these groups reduces the risk of refraining from buying the prescribed medications [21]. This indicates that the presence of chronic health problems motivates the oldest to follow more precisely physician recommendations and buy the prescription drugs [22]. However, some studies suggest opposite associations [23]. This suggests that more research is needed to explain the link between refraining from buying prescription medications and health status. Australasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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According to our findings, women were more likely to refrain from buying prescribed medications. Many studies indicate that women use medications more often than men [24,25]. For instance, a study in United States has identified that women (aged 65 and over) spent about $1178 on drugs, about 17% more than the $1009 average expenditure by men [26]. One of explanation of this pattern could be that women in general report more bodily distress, and more numerous, intense and frequent somatic symptoms than men [27]. This may cause women to purchase more pharmaceutical products [28] and spend a considerable amount of the household income on them. Other authors explain this sex pattern by arguing that women are central to the process of communication about health and therapies and they appear to draw on a richer repertoire of knowledge, perceptions and attitudes regarding medications [29]. Subsequently, that position leads to reporting higher overall use of medication than men do. Thus, our findings are at odds with these data. An explanation may be that the women decided not to buy some of these prescribed medications in order to save financial resources. However, we need further studies on causes of refrain in order to understand this sex pattern.
Some possible study limitations are noteworthy. First, the samples (women/men) were recruited from urban centres in seven European countries. This could cause results to be different for population samples from non-urban areas and other countries in Europe or elsewhere (e.g. United States). Second, the attrition rate was high, which may have led to the ‘selection’ of women/men with particular characteristics diverging from those of women/men in general. For example, we may have an underrepresentation of women/men with somatic complaints. However, there were no major differAustralasian Journal on Ageing, Vol 33 No 4 December 2014, E25–E30 © 2013 ACOTA
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ences (age/sex) between refusals and non-refusals nor did they differ substantially from the general population in each participating country [11]. Third, the accuracy of the data was dependent on the participants’ subjective assessments of their situations. No objective evaluations (e.g. hospital records) have been performed to corroborate their responses.
Conclusions
The current study suggests that about 12% (n = 531) of older people refrained from buying prescribed medications, with marked variations between countries. Country, age, financial strain and violence were associated with refraining from buying medications. However, more research is needed to explain the association with the country of residence.
Acknowledgements We would like to express our appreciation for the financial support for this initiative by the European Union through the Executive Agency for Health and Consumers (EAHC) which made possible the realisation of the project. We extend also our appreciation to the staff of EAHC, and in particular Dr Guy Dargent, for their help. Furthermore, we would like to express their appreciation to all participating institutions and to the staff involved in ABUEL. Finally, and most of all, all authors appreciate the kindness, efforts and answers of older persons who participated in ABUEL. This study was supported by the EAHC and participating institutions. The study was designed and performed by the ABUEL groups in each participating country.
Our findings showed an association between refraining from buying medication and experiencing abuse. Although many studies have discussed associations between violence and use of health-care services [30], we were not able to find any information regarding the link between abuse and refrain to buy prescribed medications in this study. Thus, our findings may be the first to suggest this association. However, it could be that the abuse is not directly related to refraining from buying prescribed medications. Because of the relative isolation (emotional neglect) of many older people who are mistreated, many victims could face some difficulties in obtaining doctor visits in respect to having money (financial abuse, financial neglect) in order to buy medications. Victims of abuse may also be disabled and thus in need of help for buying medications. In other words, the abuse itself may be the cause of not using medication, for example, physical abuse/neglect including withholding of medication, not providing health care and under-medicating (medical abuse). However, there is a need for more research in order to develop adequate and scientific reliable explanations of association between refraining from buying prescribed medications and abuse.
Limitations
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Key Points • The current study revealed that about 12% of older people in selected European countries refrained from buying prescribed medications. • Country, younger age financial strain and violence were factors associated with refraining. • More research is needed in order to develop adequate and scientific reliable explanations of association between refraining from buying prescribed medications and abuse.
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