In Canada, the prevalence of oral diseases is very high among people on social assistance. Despite great need for dental treatment, many are reluctant to consult dental professionals, arguing that dentists do not welcome or value poor patients. The objective of this research was thus to better understand how dentists perceived and experienced treating people on social assistance.This descriptive qualitative research was based on in-depth semi-structured interviews with 33 dentists practicing in Montreal, Canada. Generally organized in dentists’ offices, the interviews lasted 60 to 120 minutes; they were digitally recorded and later transcribed verbatim. The interview transcripts were coded with NVivo software, and data was displayed in analytic matrices. Three members of the research team interpreted the data displayed and wrote the results of this study.Dentists express high levels of frustration with people on social assistance as a consequence of negative experiences that fall into 3 categories: 1) Organizational issues ; 2) Biomedical issues ; 3) Financial issues (they are not lucrative patients). To explain their stance, dentists blame people on social assistance for neglecting themselves, and the health care system for not providing adequate coverage and fees. Despite dentists’ willingness to treat all members of society, an accumulation of frustration leads to feelings of powerlessness and discouragement.The current situation is unacceptable; we urge public health planners and governmental health agencies to ally themselves with the dental profession in order to implement concrete solutions. The burden of oral diseases is high among underprivileged people in North America and constitutes a serious public health issue ,2. Yet, Several factors could explain this disturbing situation: the dental care pathway for people on social assistance depends on how they define oral health , oral ilFor their part, many dentists in North America seem reluctant to treat people on social assistance. Indeed, in the United States, dentists’ participation rate in the Medicaid program remains low  for variWe used a descriptive qualitative research design based on open-ended, semi-structured interviews. Qualitative methodologies are indeed indicated for exploring complex phenomena about which little is known . The fleWe conducted this study in Montreal, Canada, a multicultural city with 1.6 million inhabitants  and almoWe recruited the dentists by sending a written invitation  and a subsequent telephone call to plan an interview. In the written invitation as well as during the phone call, we informed them that they had no obligation to participate and could take the time they needed to decide on whether to participate or not. We stopped recruiting when we obtained data saturation, “the point at which additional data does not improve understanding of the phenomenon under study”  and simpExperienced interviewers collected data between 2004 and 2007 through in-depth, semi-structured interviews. Generally organized in participating dentists’ offices, the interviews lasted 60 to 120 minutes; they were digitally recorded and later transcribed. Before each interview, the participants were invited to read a consent form approved by the academic ethics committee of McGill University’s Faculty of Medicine. We encouraged them to ask questions about the research and their rights as participants prior to signing the consent form.Researchers used an interview guide that focused on dentists’ experiences with people on social assistance. This guide was designed to help interviewers identify the problems and difficulties faced by dentists. In order to obtain more in-depth information on the topics discussed, researchers used “probing” techniques : when neWe performed a thematic analysis, a “method for identifying, analysing and reporting patterns (themes) within data” . The anaThe debriefings were conducted between the interviewer and the main researcher after each interview. They served to summarize the main findings, identify emerging hypotheses, and prepare subsequent interviews. Coding of the interview transcripts was carried out using NVivo software. We used an initial list of codes inspired by the research questions, but refined this list throughout the coding. The process involved cutting the transcripts into meaningful segments and assigning codes to the segments. We then examined the codes and their corresponding passages through an iterative process, grouping them into broad themes and displaying them in analytic matrices, as recommended by Miles . We finaTo improve the rigor and credibility of our results, three members of the research team conducted this process, checking and validating their analysis. In particular, they coded initial transcripts separately and then compared their findings; for each instance of coding disagreement they discussed their interpretations, refined the codes, and undertook coding again until agreement was reached. Furthermore, the researchers carefully pondered the analytic matrices while comparing their interpretation of the results. Again, when confronted with divergence, they discussed the data until jointly able to agree upon an interpretation.A total of 33 dentists, 21 men and 12 women, participated in the study  Organizational issues; 2) Biomedical issues; 3) Financial issues . This case is particularly frustrating to them because patients on social assistance are generally unable to pay the fees and instead opt for extractions, a procedure that is fully covered by the government.Even if I offer to let them pay bit by bit, it doesn’t work at all. [The patients say] “No, I don’t have any money”. The government reimburses extractions, [so] it doesn’t cost them anything. [CB1].Each time a patient needs a root canal and it’s not paid for by social assistance, well, obviously, they never have it done. So then, we have to extract teeth, often even those of children, of adolescents. To remove permanent teeth. That, I would have to say, has been my worst experience. [CL11].A perceived lack of motivation in people on social assistance is the other major barrier to the provision of appropriate care. According to our dentists, many patients do not consider oral health as a priority and consequently neglect themselves. Furthermore, despite high treatment needs, they do not consult a dentist often enough and tend to interrupt their episodes of care.Most of the time, I find they’re not motivated enough. Their [oral] hygiene is very poor. Even though dental services are free, not everyone takes advantage of them. [CL4].Dentists consequently feel powerless, emphasizing how challenging it is to perform adequate treatments and, more generally, to improve this clientele’s oral health. These patients, according to them, are not receptive to their recommendations and generally fail to improve oral hygiene and dietary habits. In addition, people on social assistance sometimes ask for treatments, such as multiple extractions, that dentists do not recommend, which is a source of conflict and misunderstanding. In brief, dentists perceive treating people on social assistance as an uphill battle, which makes some conclude that they are wasting their time with these patients.When someone comes to you and says,“This tooth hurts, it’s swollen”, you look at the rest of the mouth and, yikes, you wonder where to start; that’s not pleasant. That’s what we see with people on social assistance. [CL21].It’s as if I’m wasting my time talking to a wall. [CL7].Feeling constrained to emergency treatments or very basic care, some dentists conclude that there are two types of dentistry: dentistry for the poor and dentistry for everyone else. “Dentistry for the poor” is seen as a devaluation of their competencies and constitutes a source of frustration; not only does it lessen dentists’ satisfaction with their work, but dentists also point out that it has negative impacts on the oral health of people on social assistance.So we can’t apply everything we’ve just learnt in school, and therefore we’re forced to practice two kinds of dentistry: dentistry for our regular clientele and dentistry for our welfare clientele. It’s frustrating for the dentist. [CL9].Dentists argue that treating people on social assistance is not lucrative because government payment rates—which do not follow the fee guide produced by the dental association—are too low. For some procedures, the fees do not even cover the expenses related to the materials and the staff’s salary.I like doing good quality work but, unfortunately, with the fees that social assistance gives us, I mean, we’re talking 12 dollars for an extraction and 5 dollars for the second one, that barely pays for the anesthesia and your muscle power. And that is if it’s an easy extraction. So even for restorations, exams, cleanings, everything is really a lot less. So, if we want to do a good cleaning, then what the government pays is not much. [CL7].Most dentists perceive this situation as inherently unfair. They argue that, even though the choice of treatments is limited for people on social assistance, they will not compromise the quality of the procedures they perform, nor can they reduce the cost of the materials and the equipment that are used. Feeling underpaid, some dentists conclude that they subsidize the government.That’s what’s frustrating for a dentist. I’ll perform an extraction that, to my mind, is worth the price I would charge you, say, but when I perform the same extraction for a person on social assistance I’ll get paid maybe a fourth of what it’s worth. So it’s frustrating. Of course it’s the person on assistance who suffers the consequences in the sense that we’re maybe frustrated… [CL2].Another reason why dentists do not perceive people on social assistance as lucrative patients is related to missed appointments. Missed appointments not only represent “lost wages”, as dentists are not paid for work they cannot perform, but also prevent them from treating “regular patients” who would pay better fees.You know that [insurance for those on social assistance] pays about a third of the standard rate of the Dental Association. […] I don’t mind. But when they miss their appointments, then I pay for it three times over. I am already only getting a third as it is and then… I lose a regular patient that could have had that spot, stuff like that. [AL6].In brief, dentists perceive people on social assistance as a potential threat to the financial sustainability of dental practices, and some express their relief at having only a small number of such patients. A few, moreover, express concern that this clientele could compromise their financial stability.But I can’t of course complain because I don’t have many of them. So if I have one once in a while I don’t mind treating them, but if I had ten a day I’d be stressed out. It would annoy me. [CL2].Our study provides an in-depth and unique understanding of dentists’ perspective concerning patients on social assistance: 1) dentists seem to perceive patients through an interpretive filter that distinguishes three important dimensions: organizational, biomedical, and financial  helping current  and futuIn addition, we suggest addressing current limitations of the health care system by improving coverage and fees. It is worth noting that, in the United States, augmented Medicaid payment rates are associated with dentists’ increased participation in the program as well as increased utilization of dental services by Medicaid recipients ,34.Several successful programs in the United States, such as Access to Baby and Child Dentistry (ABCD)  and HeadIn conclusion, we would emphasize the common goals uniting our research with the principles upheld by the American Dental Education Association , who staThe authors declare that they have no competing interests.CB originated the study, directed all aspects of its implementation, and led the writing of this article. CL, PA and LR assisted him. CL and AL organized the interviews and the analyses. All authors interpreted findings and reviewed drafts of the article. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/464/prepub


Globally, around 20,000 facilities have been designated Baby-Friendly. In Austria, however, only 16% of the maternity units have received BFHI-certification. Internationally, few studies have investigated facilitating or hindering factors for BFHI implementation. The need to extend BFHI-certification rates has been investigated previously, but little is known about Using a qualitative approach,  professionals’ perceptions of the selection, installation, as well as facilitators of and barriers to the BFHI were investigated. 36 semi-structured interviews with persons responsible for BFHI implementation  were conducted in three Austrian maternity units. Data were analyzed using thematic analysis.Interviewees mentioned several motives for selecting the BFHI, including BFHI as a marketing tool, improvement of existing services, as well as collaboration between different professional groups. In each hospital, “change agents” were identified, who promoted the BFHI, teamed up with the managers of other professional groups and finally, with the manager of the unit. Installation of BFHI involved the adoption of project management, development and dissemination of new standards, and training of all staff. Although multiple activities were planned to prepare for actually putting the BFHI into practice, participants mentioned not only facilitating, but also several hindering factors. Interpretations of what facilitated or impeded the operation of BFHI differed among and between professional groups.Successful implementation of the BFHI in Austria depends on a complex interplay of multiple factors including a consensual “bottom-up” selection process, followed by a multifaceted installation stage. Even these activities may be perceived as a hindrance for non-BFHI-certified hospitals. Findings also suggest that despite active preparation, several barriers have to be overcome when BFHI is actually incorporated into routine practices. BFHI seems to pose a great challenge to health professionals’ work routines and, thus, clear structural changes of such routines as well as ongoing monitoring and support activities are required. The advantages of breastfeeding for infants and their mothers are well known ,2. To prIn addition to the Ten Steps, the International Code of Marketing of Breast-Milk Substitutes (in the following referred to as the Code) has to be observed and, since 2009, depending on national decisions the criteria for mother-friendly care must also be included ,4. CurreIn Austria, as in many other European countries, initiation of breastfeeding is high . 93.2% oGenerally, there is a mandatory statutory insurance system and hospital care is publicly funded in Austria. Nationwide, there are 79 maternity units, from which insured women can make a selection. Hospital owners are mainly public authorities, such as municipalities, provinces, and social insurance companies or private bodies, such as religious orders. In addition, there are a few private, for-profit hospitals where women can give birth at their own expense. In 2012, there were 78,952 births in Austria. In the last ten years, this number of births has been quite constant . By contWhile in the early years, UNICEF Austria supported the BFHI and BFHI-certification was carried out by a few individuals, since 2010, it has been coordinated and carried out by a specialized BFHI division of the Austrian Health Promoting Hospitals Network. This division also determined that the criteria for mother-friendly care have to be fulfilled by Austrian maternity units to gain BFHI-certification  the installation of BFHI at the unit-level, and (3) facilitators of and barriers to BFHI operation. We further pursue the question of how the facilities have overcome the different barriers.Following these stages of implementation, our paper aims to illuminate how health professionals in Austria perceived (1) the In this study, a qualitative approach , includiThe study took place in three hospitals/maternity units in an urban area of Austria. Of these, two were publicly owned and one privately (by a religious order), but each unit had public access for women with the obligatory health insurance. The three maternity units together had around 6,000 births per year and nearly all mothers were in-patients. Only 254 (4.3%) had out-patient births in 2012, i.e. mothers gave birth in the hospital and were discharged after a few hours as there were no complications. Further supervision was provided by a midwife and a pediatrician at home. Two hospitals had been BFHI-certified during the last two years and one hospital was preparing for its first BFHI-certification at the time our study took place. According to the BFHI division of the Austrian Health Promoting Hospitals Network, since 2010, BFHI-recertification would be demanded after four years.Participants were recruited using purposive sampling  to ensurData were collected between August and December 2013 with two researchers being present at each interview. Each interview was held in the hospital in which the interviewee worked and lasted approximately one hour. The main themes of the interview guide followed the logical models of program implementation in organizations ,27. An oData were analyzed using thematic analysis . This waEthical approval was obtained from the relevant Ethics Committee prior to the commencement of the study (EK 13-188-VK_NZ). All participants were provided with written information about the content and the purpose of the study. As noted above, except for one participant, all gave written consent to record the data. The participants’ confidentiality and autonomy were protected at all stages.The results are presented in accordance with the themes investigated: (1) Selection of BFHI, (2) Installation of BFHI, and (3) Facilitators of and barriers to BFHI operation. Concerning the barriers to BFHI operation, also data on how maternity units overcame each barrier will be emphasized. While most themes were consistent across all three sites, a few only emerged for one or two hospitals, but appeared to be important. These will be highlighted in the text.On the whole, interviewees of all sites mentioned multiple motives for becoming a Baby-Friendly hospital, ranging from BFHI-certification as a marketing tool, to improvement of existing services, and improvement of collaboration among professional groups . Likewise, other respondents emphasized that BFHI-certification was a “calling card” (Nurse 6) for the hospital as there are only a few designated maternity units in Austria. They explained that BFHI was particularly important for a positive corporate image of a maternity unit.Several participants also noted that BFHI-certification was a credible quality label and would, therefore, support maternity units in fulfilling mothers’ or parents’ expectations of high-quality service delivery on maternity units.Another motive to become Baby-Friendly was the improvement of existing services and work procedures on maternity units. Typically, the improvement of existing services referred to aspects such as encouraging the close relationship between mother and baby as well as not separating mother and baby, but also involved a paradigm shift. This paradigm shift was described as moving from having the staff rather than the mother care for the baby to empowering the mother to care for her baby herself. As a pediatrician said: “[…] from an active person who cares for the baby to a coach for the mother” (Physician 6). Working according to the BFHI criteria was seen as an enhanced form of supporting and caring for mothers and their babies.A number of participants also noted that BFHI would be of benefit for interdisciplinary collaboration on the unit. They emphasized that on maternity units, multiple professional groups, such as nurses, physicians, including gynecologists, pediatricians and anesthesiologists, but also midwives, had to interact in multiple working processes. Yet, interviewees felt that there was often room for improvement in inter-professional collaboration. Through BFHI, participants expected to achieve an “interdisciplinary convergence” . Interviewees indicated that BFHI was not just expected to improve existing services on the unit, but also to change health professionals’ practices and patterns of collaboration.Apart from motives, all participants were asked to describe who promoted the BFHI on their unit and how the decision to become Baby-Friendly came about  located on the maternity unit. Analysis revealed that change agents were personally convinced about the content and advantages of the BFHI as such, but also about the benefits of BFHI-certification for the hospital. Another characteristic of the change agents was that they were also able to influence the managers of the other relevant professional groups. In all cases, the nurse unit manager was among the change agents. One nurse unit manager pointed out: “[…] I, myself, promoted this project. I’ve really been the engine to push it forward and to get the managers of the other professional groups on board” (Nurse 9). Participants emphasized the importance of the presence of some change agents to facilitate the move from advocating the BFHI to an organizational decision to become BFHI-certified.To decide upon seeking BFHI-certification, participants typically referred to the relevance of the managers of different professional groups. These included the manager of midwives, the nurse unit manager, the manager of pediatricians, as well the manager of the whole maternity unit, who was, in all hospitals, a gynecologist. Analysis showed that consensus among all managers of the professional groups as well as the manager of the unit was required to move towards a decision about whether to become Baby-Friendly. In one hospital, the manager of the unit explained that, during a weekend meeting with all relevant managers, basic points about the BFHI had been agreed upon. In the other two hospitals, participants said that an agreement to become a Baby-Friendly hospital was made during a regular team meeting. The manager of one of these units clarified: “[…] we have a strategic meeting with all managers of the professional groups and there we decided to do it [become BFHI-certified].” (Physician 3)For the formal decision to pursue BFHI-certification, the consent of the hospitals’ top management was characteristically required. The quality manager noted: “[…] the order is given by top management. […] yet, the input often comes from the bottom.”  In one hospital, some interviewees emphasized that, for long time, it was only the lack of consent by one member of the top management that prevented the decision to earn BFHI-certification from being made.All interview participants were asked which steps were taken next to prepare for and support the operation of the BFHI in the next stage. Data analysis showed (a) project management, (b) development and dissemination of new standards, and (c) training of all health care staff . The project group met at least once a month over a period of one to two years.To facilitate project group meetings, participants said that top management and the managers of the professional specialties had agreed that meetings could take place during work time. Yet, a number of participants felt that meetings were rather intensive and time-consuming and dedicated work time was insufficient: “[…] it’s the meetings as such, and sitting together, and preparing these meetings which require a lot of time and effort” (Physician 13).In addition to the project group, several sub-groups were created to work on particular aspects/themes required by the BFHI. A nurse in the hospital preparing for its first BFHI-certification explained: “We’ve a sub-group which works on breastfeeding, a group working on breastfeeding statistics, a group working on training and workshops, a group working on bonding [skin-to-skin contact] […]” (Nurse 9). By comparison, the other two hospitals had fewer sub-groups. Here, sub-groups elaborated on multiple aspects of the BFHI.As with the project group, meetings of sub-groups could take place during work time. Considering the composition of sub-groups, most interviewees emphasized that it depended on the particular topic. However, several highlighted the fact that representation of all relevant professional groups was ensured. Participants in a management position further noted that the purpose of the multiple sub-groups was not merely the elaboration of new work procedures manifested in the new standards, but that sub-groups were also thought to be a means to gain staff commitment on the unit. This was expected to facilitate BFHI operation later on. However, this part of the agenda was enacted differently by the three hospitals. While two hospitals mainly searched for fellow travelers, staff members who were convinced about the content and benefits of the BFHI, one hospital deliberately addressed resisters: “We also try to involve the so-called detractors in our sub-groups and thus to let them participate in the preparation of the project” (Physician 11).A main task of the sub-groups was the development of standards which included a description of new BFHI-related work procedures as well as distribution of responsibilities. Besides the required written breastfeeding policy (Step 1) a couple of additional standards, e.g. standardizing skin-to-skin contact after cesarean sections or documentation forms for breastfeeding statistics, were prepared. Interviewees repeatedly emphasized that the development of the new standards depended on inter-professional agreement. This was considered a basic prerequisite for successfully putting BFHI standards into practice for two reasons. First, inter-professional agreement on new standards was thought to prevent professionals from feeling disregarded. Second, it was expected that this strategy of developing new standards would reduce the risk of failure once the standard became adopted in daily routines: “We’ve tried to learn from the failures of other hospitals, which had forgotten about particular professional groups. I really tried to include everyone. For example, having a young anesthesiologist […] on board would be helpful, especially to inform and get commitment from his colleagues” (Nurse 9).Once new standards were defined, these standards had to be conirmed by the manager of the maternity unit. To facilitate the dissemination of the new standards, interviewees referred to the usage of multiple sources. In particular, dissemination took place during intra-professional team meetings: “First of all, it was discussed in every team meeting. It [the BFHI] was a key issue in every team meeting” (Nurse 8). Employees were also informed face-to-face by members of the sub-groups or project group and standards were propagated in written form (e.g. via mail). Most participants felt that multiple dissemination sources helped to ensure that every employee working on the maternity unit recognized and became familiar with new work procedures. Interviewees further explained that after dissemination of new standards, every employee was expected to work according to those standards from that time onwards: “[…] innovations are spread via e-mail and every employee is expected to read it [the e-mail] because from that time onwards working according to the innovation is compulsory” (Midwife 8).Step 2 of the international BFHI-certification requirements requires mandatory training for health care staff to implement BFHI.The Austrian BFHI certification authority has defined the scope of training as 20 hours for midwives and nurses, 10 hours for physicians and four hours for nursing assistants working in the maternity unit. Therefore, the hospitals implemented comprehensive internal and external training programs. A nurse explained it as follows: “We had a schedule for all trainings. For all employees we had a two week training which was quite intensive […]” (Nurse 5).To contain costs, participants of all sites emphasized, as did this nurse, that internal resources were used. Moreover, to keep costs low, experts from other hospitals, already BFHI-certified, were invited to give an “in-house” training/workshop: “A lot of training was provided on site by persons who were familiar with the BFHI. However, we also invited people from other hospitals [already BFHI-certified] to share their experience with our staff” (Nurse 2). Interviewees noted that internal training was cheaper than sending all staff to external training. However, data showed that midwives and nurses often fulfilled their training requirement by participating in the basic course offered by the European Institute for Breastfeeding and Lactation (EISL).Some staff also took the training towards the International Board Certified Lactation Consultant (IBCLC) examination. Although the training towards IBCLC examination goes far beyond the Austrian training requirements, most participants mentioned the importance of this training. They felt that this training could facilitate BFHI because IBCLC-certified staff had expert knowledge on lactation and lactation problems.All three hospitals supported staff in gaining IBCLC-certification by covering costs. Cost coverage was possible as long as IBCLC-training was considered within the strategic planning of the hospital. However, some participants commented that cost coverage was not endless and pointed out: “In the beginning, costs were partly refunded but some day, of course, management said that we’ve already done that much… it’s enough” (Nurse 8).Thematic analysis of the data has resulted in several facilitators of and barriers to putting BFHI into practice  Another function of IBCLC-certified staff was the care for mothers with breastfeeding problems. One nurse said: “We particularly pay attention that IBCLC-nurses take it [mothers with breastfeeding problems] over from non-IBCLC-certified employees” (Nurse 7). Some IBCLC-nurses commented critically that supporting colleagues and taking care of mothers with breastfeeding problems often meant an additional work load for themselves because they had no dedicated working time for this assistance. In one hospital, IBCLC-nurses were relieved from regular duties on the unit and were appointed to concentrate on supporting colleagues and mothers on lactation.Most interviewees assessed support by the managers of all professional groups, as well as the manager of the maternity unit, as facilitating the BFHI. The quality manager noted: “It’s the manager of the unit, the nurse unit manager, the manager of midwives who should or even have to facilitate the project […]” .Some interviewees felt that the managers of each professional group were required to convince their colleagues. A nurse pointed out: “Support from the manager of the unit. He has to stand behind us. Especially in case some physicians oppose the program, he’s needed to reprimand these physicians” (Nurse 6). A pediatrician supported this by providing a reverse example. This person explained that on the maternity unit, the manager of midwives had not given her support and consequently putting the BFHI into practice had been challenging, if not almost impossible in the past.Almost all referred to the relevance of a commitment to facilitate BFHI during daily routines and emphasized that this was an ongoing process. Interviewees stressed that a lot of time and effort was required to get a critical mass of staff members on board. Interviewees emphasized that to put BFHI into practice on the unit level, over hundred staff members had to be involved. Resistance and concerns of staff should be minimized through multifaceted persuasive efforts. A nurse remembered: “It took a long time to convince me that it’s [BFHI] worthwhile. […] Yet in the end I was even involved in committing other colleagues” (Nurse 8). Many interviewees felt that achieving commitment and acceptance from staff was a “bumpy road” (Nurse 6).To achieve commitment, all hospitals conducted activities, in addition to those set during the installation stage. It was explained that presenting the evidence of health benefits through breastfeeding to staff, showing positive outcomes of Baby-Friendly practices already implemented, e.g. by breastfeeding statistics, as well as ongoing discussions during team-meetings, helped to increase commitment. Analysis also showed that two hospitals had a kick-off meeting in the beginning. One nurse unit manager pointed out: “It started with a huge kick-off meeting for the whole hospital. It’s really important, really important that all know what you’re doing. Everybody needs to be informed […]” (Nurse 5).Several participants felt that working according to BFHI standards needed more work time in particular situations. Often they either referred to the intensive support of breastfeeding and, thus, the increased communication efforts in daily work with mothers, or to skin-to-skin contact after cesarean section. With respect to skin-to-skin contact after cesarean section, participants pointed out that midwives had to stay in the theatre for a while. In the past, the midwife could return directly to the labor room or maternity unit and fulfill other tasks. A nurse unit manager noted particularly: “It’s not that easy. In times of staff shortages, no one wants to carry additional duties. That’s really challenging” (Nurse 9). Thus, required working time and increased workloads were seen critically, not least in combination with staff shortages. As a response, the two hospitals already BFHI-certified had tried to rearrange work procedures and responsibilities to enable staff to fulfill BFHI standards.Many participants saw persisting in old patterns as a major factor leading to resistance against the required changes. At all sites, this type of resistance rose with the number of years a staff member had worked on the maternity unit, especially among midwives and nurses. A midwife explained: “I’ve worked like that the past 25 years and I want continue doing so […]” (Midwife 2). A nurse unit manager similarly explained that older colleagues were more resistant because they considered the BFHI to be unnecessary “new rubbish” (Nurse 3). Several older midwives explained that they were used to bathing the baby directly after birth and to rapidly filling out the birth certificate. Yet, as a consequence of Step 4, writing the birth certificate could only be finished much later and as one midwife said “It [skin-to-skin contact] really disturbs established sequences” (Midwife 2). A gynecologist supported the relevance of old patterns and confirmed that younger midwives were more likely to adopt BFHI practices because they were familiar with these practices due to their recent education. Moreover, young midwives were thought not to have developed particular work patterns that would impede BFHI.Others had the impression that former work practices were inadequate. Therefore, the acceptance of the BFHI standards would generate cognitive dissonance. A nurse unit manager explained: “[Colleagues] are concerned that care they’ve delivered so far isn’t ideal anymore […] and everything they’ve done in the past has been wrong or poorly carried out” (Nurse 3). Another nurse unit manager mentioned that one of her colleagues felt very guilty once she had finished BFHI training. Following the input from the training, this colleague felt that she must have done everything wrong in the past, even with respect to her own child.To overcome old patterns, interviewees mentioned that, especially in the beginning, BFHI-related activities were discussed during regular team meetings. Some change agents referred to the importance of reassuring especially older colleagues, that they have probably always worked on the basis of the most up-to-date information available and that the BFHI merely adds some new insights. Other activities, to facilitate operation of the BFHI included face-to-face conversations among individual employees as well as obtaining feedback from mothers for whom BFHI-related practices had worked out well: “[…] and of course we’ve tried to gain feedback from mothers. Those where it [the BFHI] really worked out” (Physician 6). Finally, letting employees experience for themselves the success of BFHI was considered facilitating.Many participants commented that personal experiences of some staff hindered the BFHI operation, especially their personal experiences with breastfeeding or formula feeding. A nurse unit manager explained that she gave formula to her own child in the beginning and later started breastfeeding. She emphasized that breastfeeding worked quite normally. Others scrutinized BFHI and mentioned: “[…] I’ve not breastfed my own children and still, I’ve amazing kids” (Nurse 8). These participants explained that they felt some tension between their own experiences and what was required by the BFHI.To overcome this barrier, convinced staff tried to discuss successful cases during team meetings. A lot of communication with resistant staff and trying to commit employees helped to reduce personal experiences as a hindrance for BFHI operation.Another considerable barrier was the lack of physician buy-in. This was particularly the case among anesthesiologists and gynecologists. The physicians themselves, as well as nurses and midwives, indicated that physicians were more likely to resist or at least were indifferent with respect to the BFHI. A nurse unit manager explained: “Especially among gynecologists […] there were some who refused it [BFHI]” (Nurse 9). A pediatrician spoke about the indifferent position of some colleagues and pointed out that their perception of responsibility was mixed.In contrast to physicians, midwives and nurses already considered themselves as being responsible for BFHI operation. A midwife commented: “[BFHI] particularly applies to and involves midwives and nurses because they most directly interact with the women” (Midwife 2).Analysis in the BFHI-certified hospitals showed that to facilitate BFHI, midwives and nurses advised physicians to refer to IBCLC-certified staff rather than giving wrong or contradictory responses to mothers with breastfeeding problems during their unit rounds. Nevertheless, midwives and nurses also emphasized that physicians could not be totally relieved from BFHI-related duties. Statistics as well as reports of success stories were used to convince physicians: “Once I had experienced some success on my own, I got committed to the program. From that time onwards, I worked according to the BFHI and I’ve to emphasize that others noticed my behavior as well” (Midwife 7). Moreover, a nurse unit manager commented that informing the manager of the unit about problems with physicians would help.Participants debated the compatibility of the BFHI criteria with the provision of care oriented towards the needs of the mother. It was mainly midwives and gynecologists who were skeptical. Some of them had the feeling that BFHI, in particular the Ten Steps, focused too much on the baby and the needs of the mother were often neglected. A midwife expressed her concern as follows: “However, Baby-Friendly isn’t equal to mother-friendly” (Midwife 10). Others said that some colleagues supposed that meeting the BFHI criteria put pressure on mothers. Especially with respect to breastfeeding (Steps 5 and 8) and the ban on pacifiers (Step 9) there were multiple biases. A pediatrician mentioned: “[…] concepts such as ‘breastfeeding Taliban’ are circulating as well as ideas that infants aren’t allowed to use a pacifier, pacifiers are removed and mothers are forced to breastfeed” (Physician 10).Although biases about the operation of BFHI requirements existed, interviewees indicated that the benefits of breastfeeding were beyond question. Yet, defining boundaries between promoting breastfeeding and starting to force mothers to breastfeed was considered a great, but solvable challenge. “We’ve the duty to implement it [BFHI] in a manner that women feel valued and their autonomy is guaranteed […]” (Physician 11).By contrast to midwives and gynecologists, several pediatricians and some nurses felt that the BFHI was rather supportive to the care provided on maternity units. These interviewees felt that BFHI enabled staff to focus more precisely on babies’ needs, which was considered to be of primary importance. Pediatricians and nurses emphasized that babies were not able to vocalize their own needs, whereas mothers were able to do so: “The problem is that infants [as compared to mothers] have no voice. The baby can’t say it wishes breast-milk and wants as much skin-to-skin contact as possible with the mother” (Physician 10). One nurse unit manager also felt that BFHI criteria helped to improve care for the baby: “Looking at it from a baby’s perspective, multiple aspects become less absolute […] Babies can’t tell their moms ‘Stay here, don’t leave me’. Nobody would leave a two year old child alon.” (Nurse 5).Overcoming these issues appeared to be quite difficult because this barrier largely refers to differences originating from employees’ professional education and orientation. However, again participants emphasized that referring to successful cases and discussing concerns and problems during team meetings helped to break down this barrier. Moreover, BFHI advocates indicated that optimal care for babies and their mothers are not in conflict.Interviewees stressed that the BFHI care-chain was often interrupted within the same professional group during handing over of services or due to different working patterns of shifts. A pediatrician explained: “In particular, mostly at the end of the night when everybody is worn out and tired, giving formula is a lot easier than providing alternatives which are rather energy-consuming” (Physician 10).Analysis also revealed that the BFHI care-chain is interrupted because of inter-professional discontinuation. Several participants were concerned that professional groups did not collaborate in an integrative or coordinated manner in terms of BFHI requirements. Especially anesthesiologists, as well as some pediatricians and gynecologists, asserted their right to work in accordance with their particular professional standards, which could differ from the Baby-Friendly procedures agreed upon in the hospital. Anesthesiologists often refused skin-to-skin contact after cesarean section because this constrained them in continuously monitoring the mother. Similarly, the manager of one maternity unit explained how pediatricians impeded continuous skin-to-skin contact after cesarean section: “In the beginning pediatricians felt that they first had to do vital checks on the baby and afterwards return the baby” (Physician 7). In another hospital, a pediatrician constantly determined the use of supplementary formula feeding by referring to pediatric guidelines. Yet, colleagues pointed out that, in many cases, the reasons for providing formula were not in accordance with the defined medical indication of BFHI.Midwives and nurses emphasized that collaboration between their professional groups was less well-implemented and mothers were quickly handed over from the labor room to the maternity unit: “For example we pass the child over from the labor room to the unit only saying ‘breastfeeding yes/no’ […] yet specifying which positions have already been shown would make much more sense” (Midwife 10).laissez faire about formula feeding: “[…] I hope that formula feeding becomes more difficult because of documentation. I expect that colleagues will decide more consciously whether to give a bottle because they’ve to document reasons for it” (Midwife 10). Furthermore, a nurse explained that in her hospital they had temporarily introduced a documentation book to monitor skin-to-skin contact after cesarean section: “[…] We used a documentation form because we wanted to see what is happening and why mother and baby could be in bonding [skin-to-skin contact] or not” (Nurse 2). A midwife in another hospital commented similarly: “It’s the manager of midwives who sometimes does ‘inspection rounds’ on the unit. Similarly, she controls documentation forms in the records of mother and child. If she finds something suspicious, we’ll discuss it during the next team meeting. However, not every midwife is controlled every day” (Midwife 8).To improve the hand-over of mothers and babies, nurses and midwives said that sharing information had to be intensified between their professional groups and new ways of informing colleagues about the care already given had to be found. In one hospital, a seal for mothers’ records as well, as those of the babies, was introduced to document “informed primary weaning” (Physician 10) meaning that a woman has made a conscious decision not to breastfeed her baby. Another strategy how to overcome intra- and inter-professional discontinuation was additional documentation of e.g. reasons for formula feeding in the care record. As a consequence of the additional documentation, several interviewees hoped that other colleagues would be less Language barriers as well as illiteracy among mothers repeatedly impaired the BFHI. Interviewees from all professional groups felt that educating mothers about breastfeeding (Step 3) was especially challenging: “The problem is, especially among women from Turkey, that they can’t read [German]. You give them an information folder, they smile at you and you think, great they’ve understood, but they just can’t read [German]” (Midwife 2).As a response, maternity units had developed multilingual information materials, on the one hand, and, on the other hand, information was translated on the unit either by staff speaking the particular language or by relatives, often husbands: “For example, we’ve a colleague who is IBCLC-certified and her mother tongue is Turkish” (Midwife 4).Another factor was expectations of mothers and their relatives. Interviewees from different professional groups often referred to Step 4 (skin-to-skin contact) of the Ten Steps. A pediatrician explained that skin-to-skin contact after natural birth was often interrupted because parents wanted to know the weight and length of their baby: “[…] coming back after 10 minutes you already find the baby on the scale because the mother wanted to know the birth weight” (Physician 6). Interviewees further explained that BFHI was impeded because some mothers brought their own formula. Several women, especially those with a different cultural background, believed that their babies would starve without formula. Some participants pointed out that, although from their professional perspective, giving formula to the baby was not necessary, it still happened. Interviewees said that trying to talk to the mother and to convince her not to give formula was a challenging endeavor: “[…] probably I can’t convince them [that formula is unnecessary] because they just don’t listen to me but rather listen to their own mothers or mothers-in-law. These are the ‘teachers’ in such cultures […]” (Nurse 2).The aim of this study was to investigate health professionals’ perceptions of the different stages of BFHI implementation. Analysis revealed that in Austria multiple motives and prerequisites on maternity units themselves have to be present to become a Baby-Friendly hospital. Furthermore, the sub-categories under installation, as well as the facilitators of and numerous barriers to BFHI operation, have shown the complexity maternity units have to deal with.Considering why organizations invest in health promotion, Pelikan provides two general reasons: (1) the decision can be orientated towards the purpose and function (purposive orientation) of a health promotion intervention for the organization or (2) towards the fact, that a health promotion intervention is in line with values and beliefs of the organization  . In relaThe achievement of different steps or milestones before a program can be put into practice has been emphasized by logical models of program implementation in organizations ,27. Our Looking at the operation of the BFHI, our findings, like previous BFHI studies ,21,36-38Additional monitoring and documentation: Our data indicated that, in addition to the breastfeeding statistics that are required by the BFHI [the BFHI ,13, our Process evaluation/self-evaluation: Participants emphasized that it was not merely monitoring of outcomes that facilitated BFHI, but also the exchange with colleagues about putting BFHI into daily routines that was considered helpful. As with the additional monitoring and documentation, process evaluation facilitated self-reflection among employees and, as a consequence, supported them to find alternative strategies to solve particular problems.Continuous commitment process: Our findings suggest that besides individual readiness for change [r change ,20,21,37r change ,41, partDifferentiation and specialization: To facilitate BFHI operation, participants emphasized that e.g. breastfeeding counseling should not be provided by every employee. Rather they suggested that employees with expert knowledge in breastfeeding counseling should be referred to by colleagues. Findings of training options offered showed that our hospitals trained a number of employees far beyond the official BFHI-requirements. In contrast to findings of Nickel et al. [l et al. , it appeStructural changes of work procedures: This aspect strongly relates to the previous one. Our participants noted that mere differentiation and specialization does not automatically translate into overcoming implementation barriers, as was also shown by Nickel et al. [l et al. . Our intMultilingual information and translation services: Analysis has shown that also mothers and relatives – in particular their attitudes and expectations – can be a hindrance to successful BFHI operation. Additional information materials, which were translated into multiple languages, as well as verbal translation of information, facilitated the operation stage.Barriers related to employees’ personal and professional attitudes as well as mothers’ and relatives’ attitudes are particularly difficult to overcome because an organization cannot directly change these. Analysis revealed that structural support and additional resources accomplished during the installation stage fell short in facilitating change and additional activities would be required to overcome barriers resulting from individuals’ attitudes. Yet, as these attitudes can only be influenced indirectly, attempts to change individuals’ attitudes imply complex and continuing activities. In our settings, activities that were meant to overcome individuals’ attitudes and to facilitate BFHI as part of daily work routines as well as physician buy-in involved:The strengths of this study are that multiple professional groups from different maternity units participated. The qualitative approach provided valuable insights into health professionals’ experiences and perceptions regarding the selection, installation and, ultimately, the operation of BFHI. However, the study settings were limited to one urban area of Austria and participation was voluntary. Thus, participants were only those who were interested in the study and who may have had more positive perceptions of the BFHI than non-participants.Current circumstances – without strong external support and incentives provided by the government – make a considerable increase in BFHI-certification rates unlikely to be realized. Our findings suggest that becoming a Baby-Friendly hospital requires a complex interplay of factors during the several stages of implementation. Moreover, hospitals seeking BFHI-certification may benefit from distinct and intensive investments in planning and preparation before BFHI is actually put into practice. Extensive information for staff but also for mothers and their relatives, continuous participation of health professionals as well as room for open debate before and during the operation stage may be basic activities to facilitate BFHI implementation in other hospitals. If these activities are continuously adjusted or even expanded during the operation of the BFHI, BFHI-certification could potentially increase and a sustainable BFHI implementation could be achieved.


In South Korea, the Health Insurance Review and Assessment Service manages the Prescribing Analysis System (PAS) to evaluate the appropriate use of medication. To achieve the system’s goal of changing prescribing behavior, it is critical to understand how physicians respond to the PAS. This study analyzes the opinions of South Korean physicians about the PAS, the way it is used, and factors affecting prescribing behavior.A qualitative, exploratory approach was used, with four focus groups of physicians from different specialties. A semi-structured guide was used to explore their opinions. Transcripts of the discussions were analyzed by the authors, who independently considered content using uniform categories. Common themes were extracted and used to gather results and draw conclusions.Physicians acknowledged some positive aspects of the PAS but, overall, had mainly negative impressions of the system, and particularly, the evaluation reports that it generates. They reported that their prescribing behavior was affected by predisposing factors, including experiential, environmental and psychological factors. Physicians reported that their negative perceptions regarding the regulations were primarily influenced by concerns about maintaining their autonomy and expertise. However, their strong resistance to these perceived infringements on their independence may be considered inconsistent in relation to their professional autonomy as there was an equally strong concern about market competition. Physicians’ objections to the PAS are more likely to have been caused by deeply rooted distrust of the government agency in charge of the system.Interestingly, we found that physicians’ strong resistance to perceived violations of their autonomy seems somewhat inconsistent and contradictory. While they are very positive about new information or printed materials provided by pharmaceutical representatives, they are less enthusiastic when it comes to governmental guidelines or standards. Similarly, they appear to willingly accept situations in which they believe they should comply with patients’ demands as a means of surviving in a competitive market. It is notable that physicians’ negative perceptions of PAS seemed to be aggravated by suspicion and distrust regarding the purpose of this program.Because of widespread beliefs in professional autonomy, market competition, and a deep-seated distrust of the system, it would be difficult for the government to persuade physicians to change their prescribing behaviors using only the PAS. Successful implementation of the PAS will not only require its improvement as a policy tool, but also the creation of a social consensus regarding the PAS. According to the World Health Organization (WHO), rational use of drugs means that patients receive medication appropriate to their individual clinical needs in the right dosage for an adequate period of time at the lowest possible cost . To imprHowever, physicians’ behavior has not necessarily changed since the introduction of these systems. Worldwide, approximately two-thirds of all prescriptions for antibiotics prescribed by physicians are known to be for the treatment of respiratory tract infections (RTIs) . AccordiAntibiotic prescription abuse is also a serious issue in South Korea. In 2000, the total antibiotic prescribing rate was 57.9 % . In 2002In this research, we aimed to understand the impact of the PAS on physician behavior, and whether it has the potential to reduce pharmaceutical misuse or abuse and manage pharmaceutical expenditure by reducing unnecessary and inappropriate prescriptions. We attempted to identify factors affecting physicians’ prescribing patterns, examined their perceptions of the PAS, and assessed the system’s strengths and limitations. Our research questions were: 1) What factors do physicians report as affecting prescribing behavior? 2) What are physicians’ perceptions of the PAS? 3) Do physicians perceive the program to be effective? If not, what are the main reasons? and 4) Are there ways to improve the current system to make it more effective?We conducted focus group interviews on May 7–14, 2009. Four medical specialty areas were identified as having the most outpatient visits and prescriptions in the Seoul and Kyungki-do areas: internal medicine, otorhinolaryngology, pediatrics and primary care. We recruited 28 physicians across the specialties and geographical areas, and 27 agreed to participate in the study. They were divided into four focus groups by specialty, each consisting of six to seven physicians. In each focus group, participants’ ages ranged from 39 to 56 with an average age of 40. There were two females and 25 males. The gender distribution of primary care physicians in South Korea is 86 % male and 14 % female. Six participants worked in the Kyungki-do area, and the rest in Seoul  determinants of prescribing behavior; 2) perceptions and attitudes toward the PAS; 3) PAS indicators; 4) feedback methods used by the PAS; and 5) overall opinions and comments about the system.Interviews were conducted at a research center with videotaping facilities. Two of the authors, who are health policy researchers and familiar with government decision-making processes, moderated the focus group discussions as facilitators. Other researchers participated in the focus group as observers.The study was approved by the Health Insurance Review and Assessment Service’s (HIRA) Institutional Review Board. Informed consent was obtained from the participants at the beginning of each session. Pseudonyms were used in data analysis to protect participants’ anonymity.Focus group interviews were videotaped and transcribed verbatim by a professional transcriber. All four researchers monitored the interviews and, upon completion of each one, wrote reflective notes and memos. The researchers conducted hour-long sessions for debriefing and discussion, following the completion of each group interview.The four resulting transcripts were coded by all four authors. We used open-coding of transcripts to identify key words, phrases, and statements. As far as possible, the codes and categories were created for consistency in reflecting emerging ideas, rather than merely describing topics. In the initial line-by-line coding process, researchers tried to observe data analytically without preconceived assumptions. Through iterative reading, we identified repeated and notable words, phrases, and patterns among the participants’ responses. Several common themes emerged from the first stage of ‘interpretive’ reading, while others emerged during, or as a result of, several additional rounds of reading. We then collapsed the codes and categorized them into themes by similarity of meaning within our research questions. Disagreements and differences in describing, synthesizing, and explaining the data were resolved by continuous discussions. Emerging codes, categories, and themes were entered into matrices by specialties to enable comparisons and contrasts within and among groups.The South Korean government adopted the PAS in 2001 to reduce misuse and abuse of prescription medicines, and to promote proper usage, by improving each institution's autonomous management of medication. There are indicators to measure performance in three categories, including antibiotic prescription, injection frequencies, and the medication cost per day of use, which have been tracked and recorded since 2001. Later additions include the number of items per prescription (2003), the proportion of high-priced prescriptions (2003), and the duplication rate of NSAIDs (2005) . Their behavior was also affected by patient demands, market trends, and information from seminars or pharmaceutical companies .“Physicians prescribe antibiotics according to what they learned and what they think works. Physicians have their own background for their decisions.” (G1-a)“My training was in the respiratory system. As I was taught, I now prescribe inhalants often.” (G1-b)Participants indicated that the most important determining factor was their professional judgment, based on clinical training and accumulated personal experience. They stressed that physicians observe the effects of antibiotics many times in their clinical practice. They emphasized that what they learned during their training is strongly ingrained, so it would be hard for them to be open to other inputs.“Otolaryngologists prescribe antibiotics more often than other specialties. Pediatricians don’t prescribe antibiotics as much. It is because we have many patients who need antibiotics. We have a higher proportion of patients with infections.” (G2-a)Participants also argued that diagnosis and prescription may differ for the same symptom or disease, depending on the prescribing physician’s specialty. For example, for symptoms resembling a common cold, prescribing decisions depend on the physician’s specialty—primary care, pediatrics, or otorhinolaryngology—resulting in different diagnoses and treatment.Participants were concerned that the PAS could result in a uniformity that disregards differences between specialties.“Maintaining a good relationship with my patients is the most important issue for me. If it is ruined, then nothing works out. I have no other choices.” (G4-a)Regardless of their specialties, participants acknowledged that patient demands were another important factor that affected their prescribing behavior. The participants suggested that, to patients, quick recovery or restoration to health is most important, and this affects patients’ choice of clinics and physicians (‘physician shopping’). Physicians worried that if these expectations were not met, patients could make claims against them. They also asserted that quick recovery is a critical factor in building trust between physicians and patients.“My injection prescription rate is in the highest range. However, the mean age of my patients is 75 years old. If I refuse to prescribe injections, they get angry. Some cry. Others complain that I don’t respect them. What can I do? Female elderly patients don’t come back if I say ‘no’ to them.” (G4-b)“Nurses in my clinic told me that I was notorious among patients. When I was in the bottom 20th percentile [in terms of prescribing injections], patients didn’t come back. So I made some changes. Then the number of female elderly patient visits increased. My score now is around the 40th to 50th percentile.” (G4-c)Participants admitted that they kept records of patients’ preferences for injections or antibiotics in medical records, and prescribed according to preferences. In particular, geriatric patients were known to prefer injections; therefore these were more frequently provided.“Competition between private clinics is very intense. In the case of GPs, patients don’t wait for us just as they do in university hospitals. If they don’t feel better within one or two days, they just go to see another physician. That’s why GPs tend to prescribe high-priced drugs, antibiotics, injections, or steroids more often in the initial treatment.” (G4-d)“When I first opened the clinic, I followed what I learned from my school or guidelines from doctors’ associations or HIRA. After one year of practice, the number of patient visits fell to one third. There are so many GPs in my town. If I say injections are not necessary for the patients, they go to another clinic up the road.” (G4-e)“Mothers insist on branded medicines, even if I prescribe generic drugs. For example, if I prescribe generic drug A to a child, the mother will ask me to prescribe B from company C instead.” (G3-b)These opinions seem to contradict the participants’ previous comments that they prescribe according to their own expertise and professionalism. It seems that, in practice, physicians’ expertise and autonomy do not always take precedence over patient demands. Participating physicians stated that prescribing antibiotics is unavoidable because patients choose physicians who will provide their preferred treatment. Physicians’ prescribing behavior is very affected by patient demands, especially when they work in a competitive medical market. Abundant information available through the internet and mass media appears to influence patients, so that they make direct requests for specific medication. Both an otorhinolaryngologist and a primary care physician pointed out that market competition caused difficulties for them. They reported that it is often very tiring and time-consuming to persuade patients asking for antibiotics or injections that this medication is not appropriate for their condition. In a competitive market, adhering to government guidelines makes their work difficult.Those who said patient demands played a huge role in their prescribing behaviors argued that patient education is vital to changing prescribing practices. Physicians argued that the government should start a campaign of patient education on the appropriateness of particular medication for various illnesses.s also influences the prescribing behavior of physicians. Our analysis indicated that physicians’ prescribing behavior is often influenced by pharmaceutical companies’ marketing strategies. Patients often prefer brand name drugs that they have learned about from TV advertisements, while physicians rely on pharmaceutical companies’ marketing materials. In general, participating physicians showed a low level of trust in bioequivalence tests conducted in South Korea between generic and branded drugs.Information from seminars, academic conferences, or pharmaceutical companieRegardless of their specialty, participants in all four groups made some positive remarks about the PAS. They reported that the system has been helpful in enabling them to compare their own prescribing behavior with others. Participants also acknowledged the over-use of antibiotics and injections in South Korea. Most of them, including those who had a negative attitude toward the PAS, agreed that changes are necessary. Several participants said that if the program is based on relevant indicators and employs correct data, it has the potential to change physicians’ prescribing behavior.Overall, participants stressed more negative than positive aspects of the PAS. They described it as another ‘top-down’ managerial intervention by the government. They also had strong suspicions about its purpose. The strongest criticism of the system was whether it was designed to improve the quality of medical services or reduce pharmaceutical expenditure. Most of the participants seemed to assume that its main purpose was to reduce pharmaceutical expenditures, while bolstering the financial security of the National Health Insurance Corporation. Participants therefore expressed antagonistic attitudes toward the use of indicators that measure how often physicians prescribe lower-priced drugs, asserting that these indicators may promote prescription of ‘cheap’ drugs and degrade the quality of medical services.“I feel like they are forcing us to prescribe cheap drugs. It is not about improving the quality of medical services but all about drug cost savings. It may help to cut out unnecessarily prescribed drugs, but they excluded all the complex medicines from the positive list. What can I do if I need to prescribe complex medicines for the patient?” (G2-b)“I am not sure if what they want is appropriate pharmaceutical prescriptions or cost savings.” (G3-a)Many participants said that it is beneficial to be known as someone who prescribes high-priced medicines. They do not want to be known as physicians who are more concerned about cost savings than effective treatment.“Auditing intimidates me. I feel I am monitored all the time, which makes me very uncomfortable. I am stressed out. I worry that I may get into trouble.” (G2-c)“When I received the report from HIRA, it was like receiving a silent threat.” (G4-d)Our analysis revealed deeply rooted distrust of the PAS and of HIRA, the agency in charge of the PAS. Study participants reported experiencing unpleasant pressure from, and dissatisfaction with, PAS. Most participants used negative terms such as “threat”, “daunting”, and “pressured” when they described the PAS.“In the end, it is all about partnership. If they are not ready to listen to physicians, it is really a serious problem…whenever we hear that there is a problem, their answer is simple. ‘It’s already been decided.’” (G3-a)This well-established distrust seems to come from a lack of effective communication between HIRA and physicians.“I’m not sure what the word ‘appropriateness’ really means here. I made the decision based on my professional judgment of patients’ conditions and status, so this is a matter between a physician and his/her patient. It is not a matter in which a third party should interfere. The government often thinks that everybody should perform in the same way according to the standardized guidelines, but there are cases that are far from the standard. In my view, only my patient and I can decide what is an appropriate treatment for a specific situation.” (G4-c)Similar to the findings of most studies on physicians’ attitudes toward any controlling mechanism –15, nega“The biggest problem with this system is that it may unify all the medical services to a single standard. The system forces us to just follow standardized medical practice guidelines, provided by HIRA, even when they are not consistent with newly published information.” (G1-a)Most of the participants believed that the PAS forces them to prescribe treatment based on rules, and that one result of this single-standard system is a lower quality of medical services.“For J06 laryngotracheobronchitis, a steroid should be prescribed. However, from J00 to J06, they fall under the same category of the PAS. Physicians have pointed this out many times but it hasn’t changed yet.” (G3-a)“Statistics or indicators are all about controlling physicians. Ranking physicians from 1 to 100 does not make sense at all.” (G2-d)All participants pointed out that, to improve the PAS, valid indicators should be developed and applied. They complained that current indicators do not accurately reflect the quality of medical services. Participants felt that they were evaluated unfairly, based on distorted data. They also argued that the PAS should only check whether physicians meet the criteria or not, rather than ranking them.“[with the current system] there is no way to differentiate between main and sub diagnoses. Some patients may need two or three injections for different diagnoses. When a hypertensive patient came to me because of a nosebleed, I had to register ‘hypertension’ as the diagnosis.” (G2-e)Participants also pointed out that the current system, which allows physicians to register only the main diagnosis when they process claims, gives them an incentive to distort claims.“Is there any penalty for those who get low scores?” (G1-c)“Many physicians don’t know which one  is a high-priced drug or what the exact purpose is [of collecting data regarding the] prescribing rates of high-priced drugs.” (G2-b)Most of the participants did not have sufficient understanding of the evaluation indicators and how they are calculated. They expressed vague fears about receiving the PAS results because they had not been clearly informed about the penalties for a low score. This indicates that the purpose, evaluation criteria, and implementation methods of the PAS are not effectively communicated to physicians.Participants also complained that they did not know where to find such information.“I don’t think ‘evaluation’ is the right term for this system. The term implies that they investigate who did right and who did wrong. The name should be changed to ‘trend research’ or something like that.” (G1-a)“The result should not be open to the public. Can you explain to me what an upper or lower respiratory system is? Releasing results to the public, most of whom don’t have medical expertise, can distort the image of the whole healthcare system.” (G3-c)Regardless of their specialty, most of the participants were hostile to the PAS’ use of the term “Notice” and suggested that the title of the “Grade Report” should be changed to a more neutral one such as “Reference” or “Results”. At the same time, they said that publishing results openly to those without the appropriate medical knowledge to properly evaluate the information, is an unwelcome challenge to their medical expertise.Participants also had critical opinions of the report format and the evaluation cycle. They preferred graphs and figures to numerical values. Many suggested that evaluations should be conducted once, in the fourth quarter, or perhaps twice a year. For the PAS to be effective in changing physician behavior, they suggested that better feedback methods should be developed. Most physicians do not understand the recommendations which accompany the PAS results. They also thought that there should be appropriate incentives to motivate physicians to change their prescribing behavior. Physicians would be motivated to do so if they could expect positive evaluations and encouragement through rewards such as an excellent clinic certification.This study was conducted to understand how South Korean physicians perceive the PAS. A total of 27 participants from internal medicine, otorhinolaryngology, pediatrics, and primary care were interviewed to identify factors determining physicians’ prescribing behavior, and the effects of the PAS on this, together with their response to the program. Like previous studies on factors affecting prescribing behavior –19, we fMost of the participants in this study had negative perceptions of the PAS, stemming from a belief that the reports were distorted by inadequate data collection or interpretation. This result is similar to findings in the study of Jones et al. , which fPhysicians’ negative perceptions of government policy seemed to come from various sources, including concerns about violations of their autonomy and expertise, suspicion about the program’s intention and purpose, distrust of HIRA, dissatisfaction with notification methods, and concerns about the publication of results. Physicians worried that the current PAS would not only promote conformity to a single standard but would also lower the quality of medical services. Moreover, as a highly autonomous and professional group, participants strongly objected to a system which results in them being evaluated and compared with others in terms of prescriptions written, or rates of injections of antibiotics , 27.Interestingly, we found that physicians’ resistance to perceived violations of their autonomy were often inconsistent and contradictory. While they were very positive about new information or printed materials provided by pharmaceutical representatives, they were less enthusiastic about government guidelines or standards. They appear willing to comply with patient demands as a means of surviving in a competitive market. Physicians’ inclinations to readily accept patient demands in making prescribing decisions has been reported in previous studies . In an iCare is necessary when interpreting physicians’ comments that they had no choice but to comply with patients’ requests for antibiotics, injections, or high-priced drugs. A qualitative study conducted with 8 physicians and 42 patients in North Rhine, Germany, showed that physicians tended to over-assume patient demand for antibiotics . In SoutIt is notable that physicians’ negative perceptions of the PAS seemed to be aggravated by suspicion and distrust about the purpose of this program. The most appropriate prescription would be a cost-effective one that provides high quality medical care at low cost. Participants, however, seemed to believe that improvement in the quality of care is only the stated purpose, with cost reduction being the real goal. Physicians expressed a deeply rooted distrust of HIRA, the body in charge of the system. They believed that HIRA’s role is to reduce medication costs by scrutinizing their claims and often rejecting their requests for reimbursements. In fact, the PAS is meant to encourage physicians to improve their practice autonomously, by providing information on their prescribing behavior. PAS is therefore entirely separated from HIRA’s reimbursement review process. Physicians continued to use negative terms such as “threat”, “daunted”, and “pressured” to characterize the PAS, associating the system with their distrust of HIRA.Since this study was conducted in 2009, there have been several changes in government policy, including P4P (Pay for Performance), which was implemented in 2011; targeted acute myocardial infarction (AMI); and caesarean section delivery. In October 2010, the South Korean government introduced a prescribing incentive scheme to reduce physicians’ prescribing rates, and an online, computerized, prospective drug utilization review (pDUR) has been in operation since December 2010. This seems to have had some effect on overuse and misuse of medicines. Policies that target antibiotic prescription rates for upper respiratory tract infections, overuse of injections, and polypharmacy (the number of medications prescribed ≥6), were implemented in July 2013. Despite this ongoing introduction of new policies, any change in physicians’ prescribing behavior has yet to be shown. Findings from studies that have examined the effectiveness of these policies are not consistent , 31. DesOverall, the results from our study indicate that forming a social consensus on the purpose of the PAS is the most critical prerequisite. Physicians do not agree that they are responsible for cost containment. Participants in our study felt that maintaining the quality of service was the most important issue. They view the PAS as a system that forces physicians to focus on cost rather than quality. Without narrowing such gaps in perceptions and eliminating deeply rooted suspicions, any government efforts will continue to fail.For HIRA to regain the trust of physicians, it must listen to them more proactively and have open channels for receiving comments and inquiries. Physicians place a higher priority on their professional autonomy and on market competition than on government surveillance. If change is to happen, this cannot be overlooked.