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Open Access
BMC Geriatrics
Attitudes towardsdeprescribing
andpatient-related factors associated
withwillingness tostop medication
amongolder patients withtype 2 diabetes
(T2D) inIndonesia: across-sectional survey
study
Monika Pury Oktora1*, Cindra Tri Yuniar2, Lia Amalia2, Rizky Abdulah3, Eelko Hak4 and Petra Denig1
Abstract
Background Deprescribing of preventive medication is recommended in older patients with polypharmacy, includ-
ing people with type 2 diabetes (T2D). It seems that many patients in low-middle-income countries are not willing
to have their medicines deprescribed. This study aims to assess attitudes of Indonesian patients with T2D towards
deprescribing in general and regarding specific cardiometabolic medicines, and factors influencing their willingness
to stop medicines.
Methods Primary care patients with T2D of ≥60 years in Indonesia completed the revised Patients’ Attitudes Towards
Deprescribing (rPATD) questionnaire. Attitudes in general and for cardiometabolic medicines were reported descrip-
tively. Proportions of patients willing to stop one or more medicines when recommended by different healthcare
professionals were compared with Chi-square test. Multiple regression analysis was used to analyse the influence
between patient-related factors and the willingness to stop medicines.
Results The survey was completed by 196 participants (median age 69 years, 73% female). The percentages willing to
stop medicines were 69, 67, and 41%, when the general practitioner (GP), the specialist, or the pharmacist initiates the
process (p-value < 0.001). Higher perceived burden of medicines (p-value = 0.03) and less concerns about stopping
(p-value < 0.001) were associated with a higher willingness to stop medicines if proposed by the GP. Patients using
multiple glucose-regulating medicines were less willing to stop (p-value = 0.02). Using complementary or alternative
medicines was not associated with the willingness to stop. If proposed by their pharmacist, patients without substan-
tial education were more willing to stop than educated patients.
Conclusions Only two-thirds of older people with T2D in Indonesia were willing to stop one or more of their medi-
cines if the GP or specialist recommended this, and even less when the pharmacist proposed this. Attention should
*Correspondence:
Monika Pury Oktora
m.p.oktora@umcg.nl
Full list of author information is available at the end of the article
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Page 2 of 11
Oktoraetal. BMC Geriatrics (2023) 23:21
be given to concerns about stopping specific medicines, especially among patients using multiple glucose-lowering
medicines, who may be more eligible but were less willing to accept deprescribing.
Keywords Deprescribing, Indonesia, Older patients, rPATD, Type 2 diabetes, Survey
Introduction
Medication management in older patients with type 2
diabetes (T2D) is challenging, since comorbidities, poly-
pharmacy, and risk of complications are common in
those patients [1]. Additionally, treatment goals for older
people with diabetes should be individualized consider-
ing the time frame of benefit [2]. American and European
diabetes guidelines have shifted to a more personalized
approach, in which treatment can be deintensified, espe-
cially in older patients [3, 4]. Deprescribing is described
as the process of reducing or stopping medication to
improve patient outcomes in a well-planned process with
supervision of healthcare professional [5]. e concept
of deprescribing glucose-lowering medicines in people
with diabetes is supported, although its implementation
in practice appears to be challenging [6]. Most studies,
however, have been conducted in the United States of
America or European countries.
e process of deprescribing requires interaction
between patients and healthcare professionals (HCPs),
thus the patient’s involvement is considered an important
factor for the success of deprescribing [7]. ere seems
to be a lot of variation in the percentage of patients will-
ing to have medication stopped in general, ranging from
49 to 98%, which may be influenced by the country, set-
ting or population included [8–10]. Patients may have
different attitudes towards deprescribing depending on
the specific medicines involved [11, 12]. In particular,
the patients’ perceived appropriateness to stop certain
cardiometabolic medication may differ between glucose-
lowering, blood pressure-lowering and lipid-lowering
medicines [11]. ere are other factors that may influ-
ence the patient’s attitudes towards deprescribing, such
as their education level and the number of medicines
taken [9, 10]. Previously, it was found that the use of com-
plementary or alternative medicines (CAM) negatively
influenced adherence to using prescribed medicines in
Indonesian patients with diabetes [13]. It is not known
whether this also influences their willingness to stop such
medicines. Furthermore, the healthcare professional and
the healthcare setting may influence patients’ willingness
to have medication deprescribed [9, 10]. It was found that
trust in the healthcare professional is important but lit-
tle is known about the influence of the type of healthcare
professional initiating deprescribing on how patients
would respond. One study in Croatia found that patients
were comfortable with pharmacists’ involvement in
deprescribing process, and that they had a positive opin-
ion on their pharmacists’ competencies regarding depre-
scribing [12]. In addition, patients who perceived more
effective communication with their general practitioner
or pharmacist were more willing to accept deprescribing
[14]. At country level, it was found that patients in low-
middle-income countries (LMIC) may be less willing to
stop medication compared to high-income countries [9].
No previous study has explored the attitudes of Indo-
nesian older people regarding deprescribing of their
medication. Given the rapidly growing number of older
patients with T2D in LMICs who are exposed to polyp-
harmacy, further study is needed to gain insight in their
willingness and particularly their concerns towards
deprescribing. e aims of this study are to assess (1) the
attitudes of Indonesian older people with T2D towards
deprescribing of medicines, (2) their willingness to stop
medicines when recommended by different HCPs, (3)
their specific attitudes towards deprescribing of differ-
ent cardiometabolic medicines, and (4) whether patient-
related factors, including the use of CAM and different
types of medication, are associated with their willingness
to stop medicines.
Methods
Study design, setting, andpatients recruitment
A cross-sectional survey study was conducted among
older outpatients with T2D in Bandung City, West Java
Province, Indonesia, from November 2021 to March
2022. Primary care centers in Bandung were selected
as sampling sites based on managing at least 40 diabe-
tes patients. Potential participants were recruited by
research assistants using convenience sampling among
those who visit the sites to collect their medication at that
time. e sample was expected to be representative for
T2D outpatients living in a large Indonesian city. We con-
ducted an on-site survey using a paper-based question-
naire in Indonesian language. Participants were included
who were: (1) aged 60 years and older, (2) received blood
glucose-lowering medicines, (3) were literate and able to
complete a questionnaire, (4) gave informed consent. e
patients completed the survey by themselves, but when
needed, participants were helped by the research assis-
tants to fill the information on the number and type of
medicines they received. e assistants were pharmacy
bachelor graduates who were instructed not to interfere
or influence the patients’ answers.
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Oktoraetal. BMC Geriatrics (2023) 23:21
A sample size of 195 participants will provide an esti-
mated margin of error of 7% for assessing the attitudes
with a confidence level of 95% assuming that the T2D
population is very large [15].
All procedures in this research involving human par-
ticipants were performed in accordance with the ethi-
cal standards of the institutional research committee,
and the 1964 Helsinki declaration and its later amend-
ments. Informed consent was obtained from all patients
after a full explanation of the aim and procedures of the
research. Ethical approval was obtained from the Ethical
Committee of Universitas Padjadjaran, Indonesia (No.
(191/UN6.KEP/EC/2021). e Checklist for Report-
ing Of Survey Studies (CROSS) [16] was used to guide
reporting (Additionalfile1).
Questionnaire used andoutcomes
Patients’ attitudes towards deprescribing were assessed
using the revised Patient Attitudes Towards Deprescrib-
ing (rPATD) questionnaire [17]. e questionnaire has
been validated to measure patients’ attitudes towards
their medicines and stopping of medicines. We received
permission to use and translate the rPATD question-
naire. We translated the English version of rPATD to
Indonesian following the steps as suggested by ISPOR
Task Force for Translation and Cultural Adaptation Pro-
cess for Patient-Reported Outcome Measures [18]. Initial
translation to Indonesian language was done by two pro-
fessional translators, whose first language is Indonesian
and who are fluent in English. Next, back-translation to
English was done by two professional translators, whose
first language is English and who are fluent in Indonesian
language. e process of checking for differences and
reaching agreement on the translation was performed by
two junior and two senior researchers. e Indonesian
version of the adapted rPATD questionnaire was piloted
among 30 Indonesian people who were prescribed at
least two medications to test for clarity and correct
understanding of the questions. is pilot resulted in
minor language adaptations in four questions. e origi-
nal rPATD questionnaire, the final translated rPATD, the
patient data collection form, and the informed consent
form can be found in Additionalfile2.
e questionnaire has 22 items, with includes two
global statements and four domains each containing five
statements. e two global questions refer to overall sat-
isfaction with medicines and willingness to stop one or
more of their regular medicines when possible. e four
domains include (1) burden of medicines, (2) appropri-
ateness of medicines, (3) concerns about stopping of
medicines, and (4) involvement regarding medication
management. All statements have five-point Likert-
scale answer options, which vary from strongly agree
to strongly disagree [17]. e scores can be summed to
achieve a total score per domain (strongly agree = 5 to
strongly disagree = 1) [17]. Scores for the appropriate-
ness domain need to be reversed. Higher sum scores rep-
resent an higher perceived burden of medicines, higher
perceived appropriateness of medicines, higher concerns
about stopping, and higher involvement regarding medi-
cation management.
To investigate attitudes across different cardiometa-
bolic medicines, the rPATD statements for the ‘appro-
priateness’ and ‘concerns about stopping’ domains were
be amended by changing the word ‘my medicines’ to
a patient’s medicines that could be eligible for depre-
scribing: (1) this glucose lowering-medicine (of note,
this concerned only sulfonylurea), (2) one or more of
my blood-pressure lowering medicines, and (3) one or
more of my lipid-lowering medicines, as done in a pre-
vious study [11]. e research assistants would add the
name of the specific medicines prescribed to the patient
on the form before the patient would complete the
questionnaire.
To assess the patients’ willingness to stop medicines
when recommended by different healthcare profession-
als, the statement about ‘willingness’ was repeated for the
following healthcare professionals: general practitioner,
specialist, and pharmacist.
Patient‑related factors
Patient-related factors included as determinants for
willingness were age, sex, educational level, number of
medicines taken, using more than one glucose-lowering
medicines, using lipid-lowering medicines, using blood
pressure-lowering medicines, and using CAM. All these
data were self-reported. In addition, the sum scores for
each of the four rPATD domains were included in these
analyses.
Data analysis
Data entry was conducted by the research assistants and
all entered data were checked by one of the research-
ers using the original paper questionnaires. Descriptive
analyses were reported for participant characteristics, for
the scores on rPATD global questions (satisfaction, will-
ingness), for the individual statements in four domains
(burden, appropriateness, concerns about stopping, and
involvement), and for the appropriateness and concerns
statements of specific medicines (sulfonylurea, blood
pressure-lowering medicines, and lipid-lowering medi-
cines). e Likert-scale answer options were collapsed
into ‘agree’, ‘unsure’, and ‘disagree’ to align with previous
research [11]. e proportions of patients willing to stop
medicines if the general practitioner (GP), specialist, or
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Oktoraetal. BMC Geriatrics (2023) 23:21
pharmacist, respectively, proposed this were compared
using the Chi-square test.
To test for associations between patient-related fac-
tors and willingness to stop medicines, binary logistic
regression was used with categories of (1) strongly agree
or agree versus (2) unsure, disagree, or strongly disagree
for the willingness scores as was done in similar research
[19].
First, univariate associations between each of the
patient-related factors and the willingness scores were
tested. Next, the variables showing a univariate asso-
ciation with a p-value < 0.20 were included in a multiple
regression analysis. Complete case analyses were per-
formed, excluding those with missing values. A p-value
< 0.05 was considered statistically significant for the final
model with adjusted Odds Ratio (aOR) and 95% con-
fidence intervals (CIs). All statistical analyses were per-
formed using SPSS software (version 28.0; IBM, Armonk,
NY, USA).
Results
Patient characteristics
In all, 240 people from 11 primary care centers were
screened for participating in this study. Of those, 31 were
found ineligible due to an age below 60 years. Of the
remaining 209, 12 people refused to participate and one
did not complete the questionnaire resulting in 196 par-
ticipants (response rate 93.8%).
e median age of participants was 68.6 years (inter-
quartile range [IQR] 64.4–72.2), and the majority was
female (73%). Most were prescribed one to five regu-
lar medicines. is included metformin in 84.2%, blood
pressure-lowering medicines in 67.9%, and lipid-lowering
medicines in 28.1% (in all cases statins). About 33% of the
participants used CAM, often biologically-based such as
herbal therapy (Table1).
Attitudes towardsdeprescribing ingeneral
In general, most participants were satisfied with their
current medicines (94%). Still, 69 and 67% of participants
were willing to stop one of more their regular medicines
if this was recommended by their GP or their specialist,
respectively, whereas only 41% would be willing if their
pharmacist would say it was possible (Table2). is dif-
ference in willingness to stop medication was depend-
ent on the type of HCP who made the recommendation
(p-value < 0.001).
Around a third of participants felt that they were tak-
ing a large number of medicines or were taking too many
medicines (Table3). Few participants were burdened by
inconvenience or costs of the medicines. More than 80%
of participants believed that their medicines were appro-
priate in terms of giving benefits and no harms. On the
other hand, almost half of them would like their doctor to
reduce the dose of one or more of their medicines. Some
opposing attitudes were observed related to the patients’
concerns about stopping medicines. Although few par-
ticipants (6.6%) would feel that their doctor was giving
up on them if he/she recommended to stop a medicine,
many would be worried about missing out on future
benefits if one of their medicines was stopped (76.4%).
Agreement with all ‘involvement’ statements was high
(78.5–96.4%), indicating that most participants believed
they had good knowledge of their medication and would
like to be involved in medication decisions.
Attitudes towardsdeprescribing specic cardiometabolic
medicines
Few participants using sulfonylurea or blood-pres-
sure lowering medicines would like to try stopping
such medication to see how they would feel without it
(14.3%), whereas this was somewhat higher (21.8%) for
lipid-lowering medicines (Fig. 1A). At least one third
would like their doctor to reduce the dose of their sul-
fonylurea (39.1%), blood-pressure lowering medicine
(33.8%), or lipid-lowering medicine (45.5%) (Fig. 1A,
Additional file 3). Most participants would be worried
about missing out on future benefits if their sulfonylurea
(76.1%), blood pressure-lowering medicines (80.5%) or
lipid-lowering medicines (81.8%) were stopped (Fig.1B.,
Additional file3).
Patient‑related factors associated withwillingness
In the univariate models, using more than one glucose-
lowering medicine, using lipid lowering-medicines,
perceived burden of medicines, appropriateness of medi-
cines, and concerns about stopping sum scores were
associated with willingness to stop if proposed by the
GP or specialist (Additionalfiles 4 and 5). Of note, the
strongest associations were seen for the appropriateness
statement ‘I would like my doctor to reduce the dose of
one or more of my medicines’, the concern statement ‘I
would be reluctant to stop a medicine that I had been
taking for a long time’, and the burden statement ‘I feel
that I am taking a large number of medicines’ (Addi-
tionalfile6). When proposed by a pharmacist, patients
with very little education were more willing to stop than
patients with more education (Additionalfile4).
In the multiple regression models, higher perceived
burden of medicines and lower concerns about stop-
ping were associated with a higher willingness to stop,
if this was proposed by the GP or specialist. In addi-
tion, a lower perceived appropriateness of medicines
was associated with more willingness to stop if the GP
proposed this. On the other hand, using more than
one glucose-lowering medicine was associated with
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Oktoraetal. BMC Geriatrics (2023) 23:21
less willingness to stop their medicines if proposed by
the GP. If the proposal to stop the medicines was given
by the pharmacist, participants with the lowest level
of education were more willing to stop the medicines
compared to participants with higher levels of educa-
tion (Table4).
Discussion
Principal ndings andcomparison withliterature
About two-thirds of Indonesian older adults with T2D
were willing to stop one or more medicines in general if
their GP or specialist said it was possible. is willing-
ness was significantly lower when the pharmacist would
Table 1 Patient characteristics (n = 196).
Age (years), median (IQR) 68.6 (64.4–72.2)
Sex, n (%)
Female 143 (73.0)
Male 52 (26.5)
Unknown 1 (0.5)
Number of medicines, n (%)
1–5 169 (86.2)
6–10 15 (7.7)
Missing 12 (6.1)
Cardiometabolic medicines, n (%)
Metformin 166 (84.7)
Sulfonylurea 105 (53.6)
Acarbose 27 (13.8)
Insulin 8 (4.1)
Blood pressure-lowering medicines 133 (67.9)
Lipid lowering-medicines (only statins) 55 (28.1)
Glucose lowering‑medicines, n (%)
Using 1 non-insulin GL medicine 91 (46.4)
Using 2 non-insulin GL medicine 89 (45.4)
Using 3 non-insulin GL medicine 8 (4.1)
Using insulin with/without other 8 (4.1)
Combinations of medicines used, n (%)
GL medicine 50 (25.5)
GL + BP medicine 91 (46.4)
GL + LL medicine 13 (6.6)
G L + BP + LL medicine 42 (21.4)
Education level, n (%)
Primary school/no school 56 (28.6)
Junior high school 33 (16.8)
Senior high school 64 (32.7)
University degree 43 (21.9)
Using CAM, n (%) 64 (32.7)
Type of CAM, n (%)
Skill-based therapy 23 (11.7)
Biologically-based therapy 56 (28.6)
Supernatural therapy 2 (1.0)
Spiritual therapy 1 (0.5)
Number of CAM, n (%)
Using 1 CAM 48 (24.5)
Using 2 CAM 14 (7.1)
Using 3 CAM 2 (1.0)
Abbreviations: IQR interquartile range, GL Glucose-lowering medicines, BP Blood pressure-lowering medicines, LL Lipid-lowering medicines, CAM
Complementary/alternative medicines
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Oktoraetal. BMC Geriatrics (2023) 23:21
propose deprescribing. ere was, however, variation in
how participants perceived appropriateness and concerns
about stopping specific cardiometabolic medicines. Fur-
thermore, participants perceiving more burden of their
medicines and having less concerns about stopping were
more willing to stop their medicines if their doctor would
propose this. Surprisingly, if such a proposal would come
from the pharmacists, participants with very limited edu-
cation were more willing to stop in comparison to those
with higher education.
Table 2 Patients’ responses to global statements
a Overall, I’m satised with my current medicines
b If my [general practitioner] / [specialist] / [pharmacist] said it was possible, I would be willing to stop one or more of my regular medicines’.
c Chi-square comparing willingness across 3 healthcare professional groups: 40.7, p-value < 0.001; Chi-square comparing willingness between general practitioner
and specialist: 1.2, p-value 0.54)
Strongly disagree and disagree
(n, %) Unsure (n, %) Strongly agree
and agree (n,
%)
Satisfaction with medicinesa (n = 196) 9 (4.6) 3 (1.5) 184 (93.9)
Willingness to stop if b,c
General practitioner proposal (n = 196) 55 (28.0) 6 (3.1) 135 (68.9)
Specialist proposal (n = 183) 53 (29.0) 7 (3.8) 123 (67.2)
Pharmacist proposal (n = 195) 105 (53.9) 11 (5.6) 79 (40.5)
Table 3 Patients’ responses and sum scores for the Patients’ Attitudes Towards Deprescribing
Item Strongly
disagree and
disagree (%)
Unsure (%) Strongly agree
and agree (%)
Burden, Mean (SD): 2.27 (0.78)
I feel that I am taking a large number of medicines (n = 196) 64.3 0.5 35.2
Taking my medicines every day is very inconvenient (n = 195) 80.0 1.5 18.5
I spend a lot of money on my medicines (n = 196) 94.9 1.0 4.1
Sometimes I think I take too many medicines (n = 196) 66.3 0.5 33.2
I feel that my medicines are a burden to me (n = 193) 82.9 1.0 16.1
Appropriateness, Mean (SD): 3.71 (0.61)
I would like to try stopping one of my medicines to see how I feel without it (n = 194) 78.4 1.0 20.6
I would like my doctor to reduce the dose of one or more of my medicines (n = 196) 50.5 2.6 46.9
I feel that I may be taking one or more medicines that I no longer need (n = 196) 82.6 2.6 14.8
I believe one or more of my medicines may be currently giving me side effects (n = 195) 87.2 3.1 9.7
I think one or more of my medicines may not be working (n = 195) 87.7 3.1 9.2
Concerns about stopping, Mean (SD): 2.60 (0.62)
I have had a bad experience when stopping a medicine before (n = 194) 83.0 2.6 14.4
I would be reluctant to stop a medicine that I had been taking for a long time (n = 195) 41.5 2.1 56.4
If one of my medicines was stopped I would be worried about missing out on future benefits
(n = 195) 21.5 2.1 76.4
I get stressed whenever changes are made to my medicines (n = 196) 81.2 2.0 16.8
If my doctor recommended stopping a medicine I would feel that he/she was giving up on me
(n = 196) 90.8 2.6 6.6
Involvement, Mean (SD): 3.96 (0.61)
I like to be involved in making decisions about my medicines with my doctors (n = 195) 3.1 0.5 96.4
I have a good understanding of the reasons I was prescribed each of my medicines (n = 195) 3.6 0.5 95.9
I like to know as much as possible about my medicines (n = 195) 19.5 2.0 78.5
I always ask my doctor, pharmacist or other health care professional if there is something I don’t
understand about my medicines (n = 195) 23.6 2.6 73.8
I know exactly what medicines I am currently taking, and/or I keep an up to date list of my medi-
cines (n = 195) 6.7 0.5 92.8
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Oktoraetal. BMC Geriatrics (2023) 23:21
Our findings about the general satisfaction with the
medications and willingness to stop medicines are in line
with previous studies using the rPATD questionnaire
in other Asian countries, where around 80% of older
patients were satisfied with their current medications
and about two-thirds were willing to stop one or more
Fig. 1 (A) Patients’ responses to appropriateness statements for specific medicines (B) Patients’ responses to concerns statements for specific
medicines
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Page 8 of 11
Oktoraetal. BMC Geriatrics (2023) 23:21
of their regular medicines if the doctor said it was pos-
sible [20, 21]. is willingness is, however, much lower
than the 88% willingness observed among primary care
patients with T2D in e Netherlands [11]. In general,
patients from LMICs, including also those from Indo-
nesia in our study, appear less willing to stop medica-
tion compared to high-income countries [9]. Whether
this is due to differences in the healthcare system or cul-
ture is not clear. Contrary to our expectation, we did not
observe any relationship between willingness and the
use of CAM. Another study showed that it is common
for T2D patients in Indonesia to use CAM in addition to
their regular diabetes treatment [22]. is may suggest
that they believe that both are needed, without a clear
preference of using CAM over regular medicines.
e observed difference between e Netherlands and
Indonesia may partly be due to differences in the patient
population. We included patients of 60 years and older
because life expectancy is lower in Indonesia as com-
pared to countries like the Netherlands. Possibly, not all
the participants in our study were people who are eligible
for deprescribing, since patients with lower ages can still
benefit from continuing their current treatment. On the
other hand, we observed no association between age and
willingness within our study population. Of note, almost
half or our participants used only one glucose-lowering
medicine, less than 60% used SU or insulin, and just
over 20% used a combination of glucose-lowering, blood
pressure-lowering and lipid-lowering medication. is
suggests a relatively low need for deprescribing of such
drugs. Nonetheless, around a third of our participants did
feel burdened by a large number of drugs, which is simi-
lar to the findings in the Netherlands [11]. As expected,
people perceiving more burden were more willing to stop
one or more of the medicines if proposed by their doctor.
Surprisingly, people using more than one glucose-lower-
ing medicine were less willing to stop their medicines if
proposed by their doctor, whereas these people would be
more likely the ones who are eligible for deprescribing.
is association became non-significant in the multiple
regression model for the specialist. It might be that par-
ticipants who require more intensive glucose-lowering
treatment would trust the specialist more than the GP for
reducing such medication.
Looking at the attitudes towards deprescribing, we
observed the expected associations between perceived
burden of medicines, appropriateness of medicines,
and concerns about stopping medicines with a patient’s
willingness to stop if a doctor would propose this. How-
ever, we observed no such associations with willingness
if the pharmacist would say that stopping was possible.
is suggests that accepting such proposals from the
pharmacist is not related to the patients’ attitudes
towards deprescribing. Instead, accepting such proposals
appeared mostly related to a patient’s educational level.
In general, we identified that the pharmacist appeared
to be less trusted to propose changes in medication in
Indonesia, particularly among more educated people.
Although pharmacists are allowed to give such recom-
mendations to a GP or a specialist, it might be considered
Table 4 Patient-related factors associated with willingness to stop medicines if the GP, specialist or pharmacist proposes this (multiple
regression analyses)
a Willingness scores are binary categories: (1) strongly agree or agree versus, (2) unsure, disagree, or strongly disagree
b Using one glucose-lowering medicine as reference
c Using no lipid-lowering medicine as reference
d Primary school or no school as reference
Abbreviations: GP General practitioner, aOR adjusted Odds ratio, CI Condence interval
Willingness if GP proposesa
(n= 185) Willingness if specialist
proposesa (n= 173) Willingness if pharmacist
proposesa (n= 183)
p‑value aOR 95% CI p‑value aOR 95% CI p‑value aOR 95% CI
Appropriateness sum score (reversed) 0.03 0.45 0.22–0.93 0.07 0.54 0.27–1.06 – – –
Burden sum score 0.03 1.86 1.06–3.28 0.046 1.72 1.01–2.91 – – –
Concerns sum score < 0.001 0.26 0.13–0.51 < 0.01 0.42 0.23–0.76 – – –
Number of medicines – – – – – – 0.21 0.87 0.71–1.08
Using > 1 glucose-lowering medicineb0.02 0.43 0.21–0.87 0.07 0.53 0.27–1.04 – – –
Using lipid-lowering medicinec0.11 2.00 0.86–4.67 – – – – – –
Education leveld
Junior high school – – – – – – 0.02 0.31 0.12–0.79
Senior high school – – – – – – 0.03 0.44 0.20–0.93
University degree – – – – – – 0.03 0.40 0.17–0.94
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 11
Oktoraetal. BMC Geriatrics (2023) 23:21
inappropriate to make such a suggestion directly to a
patient [22, 23]. A previous study in Indonesia about
patients’ perceptions of the importance of pharmacist
service that can improve medication adherence showed
that most patients preferred regular face-to-face con-
sultation over other more intensive pharmacist services,
like medication reviews [24]. Educational level appeared
to influence the patients’ preference for specific services,
with people with primary education being more in favour
of medication reviews conducted by pharmacists [24].
Of note, a quarter of the patients had never received any
of the pharmacist services, indicating that they may see
the pharmacist mostly as someone dispensing and pre-
paring the medications. is may lead to not preferring
any other pharmacist services than the short face-to-face
consultation when collecting the medication [25]. In a
study conducted in the USA, one in five patients indi-
cated never communicating with the pharmacist, but
when such communication was perceived effective it was
associated with a higher willingness to accept deprescrib-
ing [14]. A study in Singapore found that only half of the
patients felt comfortable with pharmacists being involved
in the deprescribing process in primary care [26], while
more than 70% of patients in Croatia had a positive opin-
ion on pharmacists’ involvement in deprescribing [12]..
In some high-income countries, there is already involve-
ment of the pharmacist in the deprescribing process,
such as taking part in medication reviews that include
the option of stopping certain medication, also giving
guidance on how to taper and stop specific medicines,
and participating in the shared-decision making process
[27–29].
Some variation in attitudes related to the appropriate-
ness of medicines and concerns about stopping was seen
according to the type of cardiometabolic medicines. In
general, it seemed that particularly more of the patients
using lipid-lowering medicines would like to try stopping
or having their doctor to reduce the dose of this medi-
cine. is may in part be related to a lower perceived
need for these medicines and also to differences in per-
ceived disease severity [30]. is is in line with a similar
study comparing appropriateness and concerns of car-
diometabolic medicines in the Netherlands, where statins
were considered less appropriate than blood pressure-
lowering medicines and also in comparison to insulin
[11]. is indicates that patients with T2D may be more
open to stopping statins than their glucose-lowering or
blood pressure-lowering medicines.
is study confirmed that there are no clear and con-
sistent associations of patients’ demographics in rela-
tion to willingness to stop medicines, as was also found
in the previous reviews [8–10]. Sex and age do not seem
relevant, but education and number of drugs used may
influence willingness although not always too the same
extent [8–10]. In our study, the total number of drugs
used appeared to be low, which may explain the lack of
association with willingness. It was suggested before that
the influence of total number of medication might only
be seen among populations that use more drugs [9].
Strengths andlimitations
A clear strength of our study is the high response rate.
Surprisingly, there was a relatively high number of
women participants. A previous survey study among
T2D patients in primary care centers in several big cit-
ies in Indonesia showed a similar pattern with more
women included [31]. It was speculated that this could
be because women in Indonesia are more obedient to
getting their T2D check-ups regularly than men. Par-
ticipants were recruited from 11 primary care centers,
reflecting a broad city population in Indonesia. However,
the results may not reflect the general responses of the
overall Indonesian population since patient attitudes may
be different in more remote areas. We did not adjust for
clustering but observed no clear differences in willing-
ness across the centers (data not shown). Furthermore,
the inclusion of participants was somewhat hampered
due to COVID restrictions in Indonesia during the study
period. When looking at attitudes towards deprescrib-
ing of specific cardiometabolic medicines, we did not
formally tested for differences since our design would
result in a mix of within and between patient compari-
sons. Finally, all patient-related factors were self reported.
Particularly when reporting on the total number of
medicines patients use, recall bias and uncertainty about
which drugs to include may result in an underestimation
of the actual number and type of medicines taken.
Implications forpractice andresearch
Deprescribing of cardiometabolic medicines is still a
new intervention in LMICs. Both patients and HCPs
play a role in implementing successful deprescribing.
When GPs and specialists want to start deprescribing
cardiometabolic medicines among older T2D patients, it
is important that they pay attention to concerns of these
patients, such as being worried about missing out on
future benefits. Also, addressing the perceived appropri-
ateness of specific medicines should be also considered.
is appears particularly important for patients using
more than one glucose-lowering medicine. Tailoring the
deprescribing approach to the individual patient requires
talking with the patient about the medication. Shared
decision making between patients and HCPs is consid-
ered a fundamental part of the deprescribing process
[32]. is may require a change in culture in countries
like Indonesia and may also take more time investment of
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 10 of 11
Oktoraetal. BMC Geriatrics (2023) 23:21
HCPs, which can be problematic especially for countries
that lack funding for such specific program development.
It seems that many patients in Indonesia are not yet
ready for accepting pharmacists to be involved in the
deprescribing process. Currently, there is no regulation
that gives pharmacists a specific task in this process [22,
23]. A lack of trust from patients but also little exist-
ing collaboration of pharmacists with other HCPs may
hamper the realization of medication optimization at
the primary healthcare level in Indonesia. Pharmacists
in Indonesia may also need more training to gain trust.
A qualitative study conducted in Iran concluded that to
gain trust from the patients and establish an effective
relationship with patients, pharmacists need to improve
their communication skills and implement the principles
of professionalism [33]. In addition, collaboration among
HCPs in primary care needs to be enhanced. Developing
mutual trustworthiness, initiating a relationship by con-
ducting good communication during the early stages of
the relationship, and maintaining high-quality pharma-
cist contributions have been mentioned as relevant for a
successful collaboration [34].
Future research could investigate other patients’ char-
acteristics that might be associated with willingness, such
as relationship with the HCPs, frailty, medication adher-
ence, or family support. Furthermore, it would be inter-
esting to conduct research in Indonesia or other LMIC to
explore HCP’s opinions regarding deprescribing in T2D
patients, as has been done in other countries [27, 28].
Conclusion
Only two-thirds of older people with T2D in Indonesia
were willing to stop one of their medicines if proposed by
their GP or specialist, whereas just over 40% were willing
to stop if proposed by their pharmacist. e latter was
particularly lower among more educated people. Further
attention should be given to concerns about stopping
among patients using more glucose-lowering medicines,
who may be more eligible but were less willing for depre-
scribing. Finally, CAM use did not seem to impact the
willingness to stop regular medicines.
Supplementary Information
The online version contains supplementary material available at https:// doi.
org/ 10. 1186/ s12877- 022- 03718-9.
Additional le1. The Checklist for Reporting Of Survey Studies (CROSS)
Additional le2. Patient data collection form, the revised Patient’s
Attitudes Towards Deprescribing (rPATD) questionnaire, and the informed
consent form in English and in Indonesian (as used in the study)
Additional le3. Patients’ responses to appropriateness and concerns
statements for specific medicines
Additional le4. Univariate analyses for associations between patients’
characteristics and willingness
Additional le5. Univariate analyses for associations between sum
scores of revised Patient’s Attitudes Towards Deprescribing domains and
willingness
Additional le6. Univariate analyses for associations between individual
statements of revised Patient’s Attitudes Towards Deprescribing and
willingness
Acknowledgements
MPO would like to thank the Indonesia Endowment Fund for Education
(LPDP) for their support of her PhD program. Financial support from LPDP
has helped many Indonesian students to obtain higher education in order to
build Indonesia development. Authors also would like to express the gratitude
to the research assistants group from School of Pharmacy, Institut Teknologi
Bandung (ITB), Indonesia for their assistance in the conduction of the survey
study.
Authors’ contributions
MPO and PD designed the study concept and methodology. MPO and CTY
conducted the survey. MPO, CTY, LA, and RA worked on project administra-
tion. MPO, CTY, EH, and PD analyzed, investigated data, and interpreted data.
MPO drafted the manuscript. EH and PD reviewed and edited the manuscript.
LA, RA, EH, and PD supervised the research. All authors read the final version,
revised, and approved submission. All authors agree to be accountable for all
aspects of the work.
Funding
This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors. MPO reports grant (scholarship)
to support of her PhD program from Indonesia Endowment Fund for Educa-
tion (LPDP) during the conduct of the study.
Availability of data and materials
The datasets supporting the conclusions of this article are included within the
article and additional files.
Declarations
Ethics approval and consent to participate
Informed consent was obtained from all patients after a full explanation of the
aim and procedures of the research. Ethical approval was obtained from the
Ethical Committee of Universitas Padjadjaran, Indonesia (No. (191/UN6.KEP/
EC/2021).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests
Author details
1 University Medical Center Groningen (UMCG), Department of Clinical
Pharmacy and Pharmacology, University of Groningen, Groningen, The
Netherlands. 2 School of Pharmacy, Department of Pharmacology and Clini-
cal Pharmacy, Institut Teknologi Bandung (ITB), Bandung, Indonesia. 3 Faculty
of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Universitas
Padjadjaran (UNPAD), Bandung, Indonesia. 4 Groningen Research Institute
of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and –Economics,
University of Groningen, Groningen, The Netherlands.
Received: 4 October 2022 Accepted: 27 December 2022
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