title: Improving appropriate polypharmacy for older people in primary care: selecting components of an evidence-based intervention to target prescribing and dispensing.
abstract: BACKGROUND
  The use of multiple medicines (polypharmacy) is increasingly common in older people. Ensuring that patients receive the most appropriate combinations of medications (appropriate polypharmacy) is a significant challenge. The quality of evidence to support the effectiveness of interventions to improve appropriate polypharmacy is low. Systematic identification of mediators of behaviour change, using the Theoretical Domains Framework (TDF), provides a theoretically robust evidence base to inform intervention design. This study aimed to (1) identify key theoretical domains that were perceived to influence the prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists, and (2) map domains to associated behaviour change techniques (BCTs) to include as components of an intervention to improve appropriate polypharmacy in older people in primary care.
  
  
  METHODS
  Semi-structured interviews were conducted with members of each healthcare professional (HCP) group using tailored topic guides based on TDF version 1 (12 domains). Questions covering each domain explored HCPs' perceptions of barriers and facilitators to ensuring the prescribing and dispensing of appropriate polypharmacy to older people. Interviews were audio-recorded and transcribed verbatim. Data analysis involved the framework method and content analysis. Key domains were identified and mapped to BCTs based on established methods and discussion within the research team.
  
  
  RESULTS
  Thirty HCPs were interviewed (15 GPs, 15 pharmacists). Eight key domains were identified, perceived to influence prescribing and dispensing of appropriate polypharmacy: 'Skills', 'Beliefs about capabilities', 'Beliefs about consequences', 'Environmental context and resources', 'Memory, attention and decision processes', 'Social/professional role and identity', 'Social influences' and 'Behavioural regulation'. Following mapping, four BCTs were selected for inclusion in an intervention for GPs or pharmacists: 'Action planning', 'Prompts/cues', 'Modelling or demonstrating of behaviour' and 'Salience of consequences'. An additional BCT ('Social support or encouragement') was selected for inclusion in a community pharmacy-based intervention in order to address barriers relating to interprofessional working that were encountered by pharmacists.
  
  
  CONCLUSIONS
  Selected BCTs will be operationalised in a theory-based intervention to improve appropriate polypharmacy for older people, to be delivered in GP practice and community pharmacy settings. Future research will involve development and feasibility testing of this intervention.
authors.affiliation: School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK. cathalcadogan@rcsi.ie.|School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland. cathalcadogan@rcsi.ie.
authors.forename: Cathal A
authors.initials: CA
authors.lastname: Cadogan
authors.affiliation: School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK. cristinryan@rcsi.ie.|School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland. cristinryan@rcsi.ie.
authors.forename: Cristín
authors.initials: C
authors.lastname: Ryan
authors.affiliation: School of Health Sciences, City University London, London, UK. Jill.Francis.1@city.ac.uk.
authors.forename: Jill J
authors.initials: JJ
authors.lastname: Francis
authors.affiliation: Department of General Practice, Queen's University Belfast, Belfast, UK. g.gormley@qub.ac.uk.
authors.forename: Gerard J
authors.initials: GJ
authors.lastname: Gormley
authors.affiliation: Centre for Public Health, Queen's University Belfast, Belfast, UK. P.Passmore@qub.ac.uk.
authors.forename: Peter
authors.initials: P
authors.lastname: Passmore
authors.affiliation: School of Population Health, University of Auckland, Auckland, New Zealand. n.kerse@auckland.ac.nz.
authors.forename: Ngaire
authors.initials: N
authors.lastname: Kerse
authors.affiliation: School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK. c.hughes@qub.ac.uk.
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Hughes
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D004777:Environment; D005260:Female; D058005:General Practitioners / Q000523:psychology*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D010595:Pharmacists / Q000523:psychology*; D019338:Polypharmacy; D011320:Primary Health Care / Q000458:organization & administration*; D024382:Professional Role; D011582:Psychological Theory; D058996:Quality Improvement; D020377:Self Efficacy; D012931:Social Environment; D012944:Social Support