PUBLIC Causes of Refraining From Buying Prescribed Medications Among the Elderly in Kaunas, Lithuania

prescribed medications among the elderly in Kaunas, Lithuania. Material and Methods. The data were collected in a cross-sectional ABUEL study in 2009. A total of 624 filled-in questionnaires (response rate, 48.9%) from the elderly aged 60–84 years living in Kaunas (Lithuania) were received. For evaluation of the impact of explanatory variables on the analyzed event (binary dependent variable), an Enter model of logistic regression was used. Results. The study showed that 32.7% of the respondents refrained from buying prescribed medications. The most common reasons (respondents could select several options) for this decision were financial problems (48.0%), disappearance of problems (40.7%), and fear of side effects (22.5%). Refraining from buying prescribed medications was positively associated with age (OR, 0.85; 95% CI, 0.74 to 0.99). Higher education was associated with a reduced risk of refraining from buying prescribed medications due to financial problems (OR, 0.49; 95% CI, 0.31 to 0.78) and an increased risk of refraining from buying medications due to the disappearance of health problems (OR, 1.75; 95% CI, 1.15 to 2.68). An opposite association with worries about daily expenses was observed. Conclusions. Study has revealed that one-third of the elderly refrained from buying prescribed medications, and the main reasons for this were financial problems and disappearance of health problems.


Introduction
According to the World Health Organization (WHO), the value of resources allocated to medicines is US $440 billion or 15.2% of all global expenditures on health (1). Older people (65 years and more) are the major users of medicines in most developed countries (e.g., United Kingdom) as well as in Lithuania (2,3). Therefore, the use of medicines in the elderly is a growing concern in the international scientifi c literature. Most studies in the fi eld have focused on either medication adherence/nonadherence or accessibility to medications (4)(5)(6)(7)(8). To the best of our knowledge, few studies have evaluated medication nonadherence in Lithuania (9)(10)(11), and only one study has addressed medication use among the elderly (11). The accessibility to medicines is not a common research topic among Lithuanian researchers (12,13). Referred studies investigated the economic accessibility to medicines based on the respondent's self-reported experience associated with fi nancial problems in obtaining necessary medications. However, only Plieskis included older people in his study (12).
The growing number of studies investigating accessibility (economic) to medications has focused on the respondent's refrains from buying the prescribed medications (14)(15)(16). However, we could not fi nd any studies carried out in Lithuania on this topic; therefore, there is a need for further studies in this fi eld, not least in Lithuania.
The aim of this study was to evaluate the causes of refraining from buying prescribed medications among the elderly in Kaunas (Lithuania).

Materials and Methods
Data for this study were collected during the European project "Elder abuse: a multinational prevalence study -ABUEL" (17). The target population for the ABUEL was persons aged 60 to 84 years not suffering from dementia or other cognitive impairments and living in 7 urban communities across Europe. This study refers to the results from the Kaunas sample. Recruitment of eligible participants and data collection were performed from April to July in 2009. Registry-based random sampling was used. The Residents' Register Service under the Ministry of the Interior composed the sample of 1276 individuals. Data were collected by face-to-face interviews, carried out by trained interviewers. More detailed description of sampling, data collection procedures, and study limitations are described in a separate paper (18).
The total number of returned questionnaires was 624 (response rate, 48.9%). The investigated sample was representative of the elderly population in Kaunas (from 60 to 84 years) with regard to the main demographic characteristics (gender and age).
The participants completed a standardized questionnaire with various scales and questions. Self-reported refrain from buying prescribed medications was measured with two multiple-choice questions: "Have you ever refrained from buying prescribed medication and care?" and "What were the reasons for not buying prescribed medications and care?" Data were computed, coded, and analyzed using the Statistical Package for the Social Sciences for Windows, version 11.0 (SPSS Inc.). Descriptive statistics and logistic regression were employed in the statistical analysis. Continuous variables are presented as a mean (standard deviation). For the evaluation of distribution, skewness and kurtosis were calculated. For evaluation of the impact of the explanatory variables on the analyzed event (binary dependent variable), an Enter model of logistic regression was used. The dependent variable was refraining from buying medications. The independent variables were sex, age, education, habitation status, present employment status, worries about daily expenses. The same independent variables were included in logistic regression models for evaluating the chance for identifying the fi nancial problems or the problems disappeared as the reason for not purchasing medications. Risk was measured using odds ratio (OR) and calculating the 95% confi dence interval (CI). Differences in results at the P<0.05 level were considered statistically signifi cant. The Lithuanian State Data Protection Inspectorate and the Kaunas Regional Bioethics Committee granted the permission to perform this study.
The extent of refrain from buying the prescribed medications was evaluated by the age of respondents ( Table 1). The results showed that 32.7% of respondents had refrained from buying prescribed medications. Based on these fi ndings, the highest prevalence of refrain was in the age group of 60-64 years and the lowest in the age group of 80-84 years.
Respondents were asked to name the main reasons (respondents could select several options) for refrain from purchasing prescribed medications (Table 2). Financial problems (48.0%), disappearance of health problems (40.7%), fear of side effects (22.5%), and negative experience from other medications (17.6%) were the most common reasons for refraining. As shown in Table 2, the causes differed by age. The elderly in the age groups of 60-64, 65-69, and mainly 80-84 years were more likely to identify fi nancial problems as the main reason compared to those aged 70-74 and 75-79 years. Those aged 70-74 years reported refraining from acquiring of medications mainly due to the disappearance of health problems. The remaining reasons (fear of side effects and negative experience from other medications) pertain mainly to older people aged 80-84 years.
Logistic regression reveled that only age was associated with a decreased risk of refraining from buying prescribed medications (OR=0.85) ( Table  3). The identifi cation of fi nancial problems as the reason was associated with economic deprivation (OR=2.95) and higher education (OR=0.49). Daily worries about expenses (OR=0.65) were associated with a decreased risk of the identifi cation of the problems disappeared as the reason for not buying the prescribed medications, while an opposite association was observed with education (OR=1.75).

Discussion
Our fi ndings revealed that every third older (aged 60-84 years) person refrained from buying the prescribed medications. The most common reason was fi nancial problems. Similar studies from other countries support the existence of refraining from buying drugs due to fi nancial aspects. The reported underuse of medicines due to costs in older age varies from 3% in the Australia, Canada, New Zealand, the Netherlands and 8% in Germany to 9% in the United States (16). It should be mentioned that the prevalence in these studies was calculated for all participants, whereas in our study, the prevalence was calculated only for those who refrained from buying the prescribed medications. In our study, the underuse due to fi nancial problems of the whole participants would be 15.2%. Overall, our results showed that the elderly in Lithuania are more likely to refrain from buying medicines due to economic reasons than their counterparts in Australia, Canada, Germany, the Netherlands, New Zealand, the United States, and the United Kingdom.
Logistic regression showed that age was independently associated with a decreased risk of refraining from buying prescribed medications. However, age was not signifi cant for the identifi cation of fi nancial problems as the main reason of this decision. Studies have shown that economic problems become a less important factor for refraining from buying drugs in older age (15,16,19). However, our fi ndings do  not support this fi nding. The explanation could be that the referred studies compared older respondents with middle-aged. The infl uence of age on refraining from buying the prescribed medications can be explained from two aspects: economic and health. According to some authors (20), older people are less likely to refrain from buying medications due to fi nancial problems because they can spend more money for this than younger ones. Is this explanation relevant to the elderly in Lithuania? According to the Department of Statistics, the average salary in 2008 was at least two times higher than old-age pension (21). However, the cited authors (20) emphasized that younger people had more expenses (i.e., costs for children's education) than older ones. On the other hand, the Lithuanian Sickness Fund provides 100% reimbursement for buying most of the drugs used by the elderly (22). It is noteworthy that data for this study were collected during the economic crisis in Lithuania (23,24). It might be that "hard times" could have a negative impact on the economic accessibility to medications. On the other hand, it should be mentioned that the Lithuanian Government cut old-age pensions only from the year 2010 (25). Therefore, we think that the infl uence of crisis on respondents' answers is very limited. However, further investigations on this issue are needed.
As to the health aspects, some studies have emphasized that the chronic nature of health problems among older persons reduces the risk of refraining from buying the prescribed medications (7). The presence of chronic health problems causes older people to follow the physician's recommendations more precisely and to buy the prescribed drugs (26)(27)(28)(29).
Our study has revealed that higher education was associated with a reduced risk of refraining from buying medications due to fi nancial problems. This is in line with other surveys showing a positive impact of education on the utilization of health and health care services (30)(31)(32). According to Graham, the education, among other factors, is related to higher material living standards and better accessibility to health, which ensure better health (33). However, it is agreed that that the level of education is directly associated with better health within the population. This could be explained by better health literacy of more educated people. According to Zagurskienė and Misevičienė (34), more educated patients demand more information about their health status, treatment procedures, and use of medications. It might be that better educated respondents were more likely to adhere to the recommendations of physicians and, thus, did not refrain from buying the prescribed medications. The adherence to medication use in the elderly is described in the scientifi c literature (35) and will not be discussed in this paper. However, our results have revealed that education was associated with an increased risk of refraining from buying the prescribed medications due to the disappearance of health problems. This association and the scientifi c literature show that more educated respondents have better health and that their health problems are not so serious. However, for the confi rmation of this explanation, a more detailed study that would evaluate association between the use of medications and self-rated health, somatic complaints, diagnosed diseases, and quality of life is needed.
These considerations, and mainly when referring to the fi nancial problems, are very crucial with regard to the aging population in Europe, to the fact that the elderly people aged 65 years and more are a growing part of society and are the greater consumers of medications (36) and are also at high risk of poverty (about 13 million in 25 EU Member States) (37). In the light of this context, the objective of "poverty reduction and social inclusion of the elderly is to be monitored" (37), keeping in mind the recommendations of the European Medicines Agency with regard to the strategy of geriatric medicines, which aims to take into account the needs of older people in the development of new medicines, ensuring their safety and effective use in the elderly, mainly "frail" patients (38).