Barriers and facilitators to deprescribing in primary care in Brazil: a qualitative study of pharmacists’ perspectives mapped to the Theoretical Domains Framework

Abstract

Objective:

To identify the main Barriers and facilitators to deprescribing from the perspective of primary care pharmacists in Brazil.

Methods:

In this qualitative secondary analysis, we analyzed brief written responses collected during a training session on medication deprescribing. Data were elicited through a SWOT (Strengths, Weaknesses, Opportunities, and Threats)-based structured activity and analyzed using qualitative content analysis. Emerging categories were subsequently interpreted through the Theoretical Domains Framework.

Results:

Responses were categorized into barriers (related to healthcare professionals, service structure, patients, and the healthcare model) and facilitators (advances in evidence, benefits of deprescribing, availability of resources, management support, and favorable attitudes among professionals and patients). These categories were mapped to Theoretical Domains Framework domains, including Beliefs about Consequences, Environmental Context and Resources, Social Influences, and Social/Professional Role and Identity.

Conclusion:

Implementing deprescribing in Brazil faces challenges but prospects are also promising. Adopting interprofessional approaches, educating patients, involving management, and investing in resources to strengthen primary health care are essential to optimize clinical outcomes and reduce health-related costs.

INTRODUCTION

Deprescribing is the process of reducing or stopping medications under the supervision of a healthcare professional when the harms outweigh the benefits. It has been widely discussed as a strategy to reduce harms and costs and increase quality of life.^1,2

Excessive and inappropriate use of medication, along with the inherent risks to human health, are decisive factors in the discussion of deprescribing.³ Access to medical care and medicines does not guarantee health or a better quality of care, as inadequate assessment (and, consequently, inappropriate prescription, dispensing errors, and self-medication) can result in ineffective and risky treatments.⁴ Potential outcomes can include exacerbation of chronic conditions or development of symptoms related to adverse drug cascade events, leading older adults to seek health services again, increasing health costs, and the complexity of care in the health system.^5,6

Polypharmacy, characterized by the routine use of multiple medications to treat various comorbidities, has been growing worldwide. When inappropriate, polypharmacy is a cause for concern, especially in aging populations, who face chronic illnesses and physiological changes that increase the risk of adverse reactions from previously safe medications.⁶ A heavy burden of inappropriate medications in older adults is associated with adverse outcomes, such as falls, hospitalizations, and mortality, in addition to impairing treatment adherence and, due to adverse reactions, increasing the use of health services.⁶

Therefore, implementing deprescribing in clinical practice requires careful clinical assessment, planning, and partnership between the healthcare team, patients, and their families/caregivers.^1,2 This assessment considers several variables, including the patient’s illnesses, risk-benefit profile of medicines, personal beliefs, and opinions of other healthcare professionals.¹

Studies have demonstrated the importance of identifying Barriers and facilitators to embedding deprescribing in the clinical context,⁷ including the development and adaptation of tools to validate deprescribing.⁸ On the other hand, the debate on deprescribing in Brazil has only started to gain prominence in the last decade, and it has been poorly incorporated into clinical practice.

Qualitative studies investigating Barriers and facilitators to deprescribing have increasingly adopted theoretical frameworks to guide data interpretation. The Theoretical Domains Framework (TDF), which synthesizes behavior change theories into 14 domains, has been widely used in implementation research to identify determinants of healthcare professional behavior in the deprescribing context.^9,10 The TDF domains — including Knowledge, Skills, Beliefs about Consequences, Environmental Context and Resources, Social Influences, and Social/Professional Role and Identity — provide a structured lens for understanding why health professionals adopt or resist changes in practice.⁹ Despite growing international evidence, most studies have been conducted in high-income countries,⁷ and there is a gap regarding the deprescribing context in low- and middle-income countries, including Brazil.

Given the importance of understanding the factors that affect deprescribing and the aim of ensuring the safety and effectiveness of treatment, this research seeks to identify the main barriers and facilitators to deprescribing from the perspective of primary care pharmacists in Brazil, using the TDF as a theoretical lens to interpret the findings.

METHODS

This study was reported in line with established recommendations for qualitative research reporting, drawing on relevant COREQ items¹¹ where applicable to the secondary analysis of brief written responses collected during an educational activity. The qualitative secondary analysis was conducted using brief written responses collected during the “Medication Deprescribing in Primary Care”, an educational activity promoted by the Ministry of Health as part of the VII Brazilian Congress on the Rational Use of Medicines. This was a one-off, thematic capacity-building event dedicated specifically to medication deprescribing in primary care, rather than a routine or recurring course. It was delivered in person over two afternoons and was open to primary care pharmacists working in the public health system, who enrolled voluntarily through the official platform. The training comprised a theoretical component, covering deprescribing concepts, supporting evidence, and available tools, and a practical component, in which participants applied these concepts by delineating a deprescribing project for their own service using a SWOT analysis.^12,13

The training participants included 84 primary care pharmacists from different cities in Brazil. The training was structured into theoretical and practical components. At the end of the theoretical segment, participants were encouraged to develop a deprescribing project, analyzing strengths, opportunities, weaknesses, and threats associated with deprescribing in the context of their health services using SWOT Analysis.¹³

SWOT analysis was used as a structured reflective activity to elicit participants’ perceptions of strengths, weaknesses, opportunities, and threats related to deprescribing within their health service contexts.¹⁴

Pharmacists used mobile phones and laptops to answer a structured online form. The resulting dataset was analyzed using qualitative content analysis.¹⁵ The analytical process included pre-analysis, exploration of the material, and interpretation of the findings.

Pre-analysis involves organizing the material for analysis, operationalizing it, and systematizing the main ideas for subsequent phases. Initially, we performed a preliminary reading of all responses to establish the first contact with the material. Next, we conducted a more detailed reading to begin coding and grouping participants’ responses, selecting study categories and subcategories, and conducting subsequent analysis in line with the objectives established at the beginning of the research and based on identified similarities. One author carried out the initial coding, followed by a second review by another author to enhance the analytic consistency of the subcategory definitions.

The responses, derived from the SWOT Analysis, were grouped into two broad categories. Specifically, participants’ responses related to Threats and Fragilities were consolidated under the “Barriers” category, while responses referring to Opportunities and Strengths were allocated to the “Facilitators” category. Subsequently, responses in each category were grouped into subcategories based on the similarity of the statements.

To provide a theory-informed interpretation, the categories and subcategories that emerged from the inductive content analysis were subsequently mapped to the domains of the TDF.^9,10 The TDF comprises 14 domains derived from behavior change theories, offering a comprehensive structure for understanding the determinants of professional behavior. Two authors independently mapped each subcategory to the most relevant TDF domain(s), and disagreements were resolved through discussion.

The secondary data used in this study are general and do not identify participants, ensuring preservation of their anonymity and the confidentiality of their personal information. Data were collected during a public training event, and the analysis focused exclusively on the participants’ opinions about deprescribing in their health services. In accordance with Resolution 510/2016 of the Brazilian National Health Council, which exempts research using publicly available data or data that do not allow participant identification, submission to an Ethics Committee was not required.

RESULTS

We gathered responses from the 84 pharmacists who took part in the course, 70 of whom were women (83.3%).

Because data were collected through an online form, responses were generally brief. Based on similarities across participants’ statements, the ‘Barriers’ category was subdivided into four subcategories, while the ‘Facilitators’ category was subdivided into six subcategories (Table 1).

Table 1.

Barriers and facilitators to deprescribing in Brazil.

Subcategory	Central idea	TDF Domain(s)
Barriers
Barriers related to healthcare professionals	Resistance of health professionals to deprescribing; concerns about uncertainty; reluctance to change established processes.	Beliefs about Consequences; Social/Professional Role and Identity
Barriers related to the structure of health services	Reduction of public investment in health; work overload; insufficient infrastructure and human resources.	Environmental Context and Resources
Barriers related to patients and families	Patients’ cultural and belief habits; lack of health literacy; difficulty in changing the culture of medicalization.	Social Influences; Knowledge
Emphasis on physician- and medicine-centered healthcare model	A health model centered on the physician that favors the culture of medicalization.	Social/Professional Role and Identity
Facilitators
Advances in medicine and scientific evidence	Increase in publications and discussions; development of algorithms that assist the process.	Knowledge; Beliefs about Consequences
Benefits provided by deprescribing	Reduced costs and adverse effects, improved adherence, and reduced adverse clinical outcomes.	Beliefs about Consequences
Existence of resources	Increase in human resources due to the presence of residents and medical students.	Environmental Context and Resources
Favorable aspects related to management	Management interest in strategies that promote patient safety and reduce polypharmacy and costs.	Goals; Reinforcement
Favorable attitudes among health professionals	Engagement of pharmacists and other professionals in improving patient care and implementing deprescribing in primary healthcare.	Social/Professional Role and Identity; Intentions
Favorable attitudes among patients	Participation of users and family members in managing their drug therapy.	Social Influences

TDF: Theoretical Domains Framework.

Source: The authors.

Barriers among healthcare professionals included reluctance to change established prescribing practices and uncertainty about the clinical consequences of stopping medicines. Barriers related to the service structure focused on underfunding, work overload, and inadequate infrastructure. Regarding patients, pharmacists emphasized low health literacy and a strong culture of medicalization.

When mapped to the TDF, the barrier subcategories aligned with the following domains: Beliefs about Consequences and Social/Professional Role and Identity (barriers related to healthcare professionals); Environmental Context and Resources (barriers related to service structure); Social Influences and Knowledge (barriers related to patients); and Social/Professional Role and Identity (physician-centered model). The facilitator subcategories mapped to: Knowledge and Beliefs about Consequences (evidence and benefits); Environmental Context and Resources (existence of resources); Goals and Reinforcement (management); Social/Professional Role and Identity and Intentions (professionals); and Social Influences (patients).

DISCUSSION

Despite the inherent challenges, deprescribing was generally well received by participants, who identified both important barriers and relevant facilitators. These findings have important implications for clinical practice and emphasize the need for rational medication management and continued patient safety promotion. Mapping findings to the TDF provided a structured interpretation of the behavioral determinants underlying these barriers and facilitators.

Many participants manifested resistance to the deprescribing process, motivated by concerns associated with uncertainty about the results, fear of not controlling health conditions after cessation of medications, and the perception that prescribing is safer than withdrawing medications.⁷ Due to a culture of “medicalization” of healthcare, the training process for healthcare professionals is highly focused on diagnosis and prescription, which can contribute to numerous barriers to implementing deprescribing in clinical practice. This situation may be aggravated by the scarcity of evidence-based guidelines for deprescribing, particularly in Brazil.^7,8 Within the TDF, these findings relate to the domains of Beliefs about Consequences and Social/Professional Role and Identity. Professionals’ fear of adverse outcomes following deprescribing reflects negative beliefs about its consequences. At the same time, prescribing-focused training shapes their professional identity in ways that make deprescribing feel foreign to their role.^9,10 Similar patterns have been identified in studies using the TDF, where healthcare professionals expressed uncertainty about their role in initiating deprescribing.^16,17

The participants’ responses also highlighted barriers related to the structure of services due to reduced investments in the Brazil,^18,19 an essential factor for implementing changes in clinical practice. This reduction in financial resources affects the quality of services, the availability of medicines, equipment, and qualified professionals, and the implementation of deprescribing, which depends on access to updated information and decision-support systems.⁷ In addition, work overload, cited by respondents as an obstacle to the implementation of deprescribing, is a problem that has been documented previously in the primary care setting.²⁰ These findings correspond to the TDF domain of Environmental Context and Resources, consistent with evidence from international studies, in which limited consultation time and lack of structured protocols have been identified as key environmental barriers.^7,16

Successful implementation of deprescribing requires an understanding of organizational dynamics and involves overcoming challenges, such as resistance to change and limited resources in health services. These challenges suggest difficulties in translating evidence and training into routine deprescribing practices within primary care services.

Regarding patients, an important barrier was the persistent belief that prescribing is the solution to most health problems, a perception rooted in broader historical and sociocultural processes.¹ There is strong resistance and skepticism when the possibility of effective cessation is raised. Such behaviors have been formed throughout the patient’s life, with previous experiences and relationships with healthcare professionals reported as significant influences.²¹ At the same time, some patients expressed satisfaction with ongoing pharmacotherapy, not seeing a need to reduce use, especially those who had already been using medications for years.^7,22 From the TDF perspective, these findings align with the domains of Social Influences and Knowledge. Social norms and relationships with providers shape patients’ attachment to medications, while low health literacy limits their engagement in shared decision-making.⁹

The emphasis on models of care centered on the physician and on medication, which participants identified as a barrier, highlights a culture in which every consultation must end with a prescription.^7,23,24 It is also important to consider sociocultural elements and their interference with evidence-based practices. The context in which patients and healthcare professionals interact, the relationships that have been formed, and the level of patient engagement involve their beliefs, customs, and values. Therefore, deprescribing can be hindered by the hegemonic culture of medicalization in the population.²⁵ An approach aimed at establishing a relationship of care, trust, and credibility between older patients and their caregivers increases the chances of successful medication deprescription.²⁶ This culture of medicalization relates to the TDF domain of Social/Professional Role and Identity, since both prescribers and patients operate within a system that equates good care with medication prescription.

An interprofessional approach to patient care may optimize outcomes¹ by integrating different perspectives, identifying treatment redundancies, and supporting more informed decisions focused on patients’ real needs.^1,27

Regarding facilitators, recent studies demonstrating that deprescribing can significantly improve community health and reduce costs associated with higher levels of health care^5,6 may contribute to its implementation in practice. These publications include medication reviews, educational interventions, prescribing practice audits, and deprescribing guidelines and algorithms.^5,27–29 Within the TDF, the availability of evidence and tools aligns with the domains of Knowledge and Beliefs about Consequences, suggesting that exposure to scientific evidence can reshape professionals’ views of the expected outcomes of deprescribing.

Deprescribing may support a more holistic approach to chronic disease management. It reduces exposure to medicines when the risks outweigh the benefits and favors a more personalized approach tailored to each patient’s needs.^1,2 Thus, it responds to the challenges of the current context of increasing demands on patients with multiple comorbidities.

Some participants’ statements highlighted the interdependence and importance of human, structural, material, and financial resources in strengthening primary care and ensuring it plays a crucial role in promoting health and preventing disease. The presence of residents and medical students in health services can significantly enhance teams’ ability to address and resolve users’ health problems, thereby positively impacting work processes. This aligns with the TDF domain of Environmental Context and Resources, reinforcing that the availability of human and material resources acts as an enabling condition for deprescribing.

In the management field, responses from course participants indicate that deprescribing can be supported by managers interested in ensuring safety and reducing costs in health services. The receptiveness of managers to innovative services also suggests adaptable leadership oriented towards continuous improvement. However, managers need positive indicators and examples to understand the context and identify the impacts of the proposed solutions.³⁰ In TDF terms, management support relates to the domains of Goals and Reinforcement, as institutional endorsement can create incentives and prioritize deprescribing within organizational agendas.

In general, pharmacists expressed a favorable attitude toward promoting deprescribing. This may be due to their in-depth knowledge of medications. Considering that deprescribing should be planned with the patient, the participants’ statements suggest an opportunity to implement it; they believed patients could respond positively to deprescribing when properly informed and involved in the process.

It is noteworthy that most studies investigating barriers and facilitators to deprescribing have been conducted in high-income countries.⁷ This study provides an original contribution by describing the perspectives of primary care pharmacists in Brazil, a middle-income country with a universal public healthcare system (SUS) that faces unique structural and cultural challenges. The barriers identified here, particularly those related to underfunding, work overload, and a deeply rooted culture of medicalization, reflect the specific context of the Brazilian primary care system and add to the international evidence base.

Although our study focused on primary care, the same barriers and facilitators are highly relevant to transitions of care. Medications appropriately started during hospitalization, such as insulin regimens intensified during an acute decompensation, may become unnecessary or harmful once the precipitating condition resolves, predisposing older adults to events such as hypoglycemia after discharge. Primary care teams are well positioned to perform early post-discharge medication reviews and deprescribing, emphasizing that the determinants identified here extend across the continuum of care.

Systematic, structured deprescribing protocols could help primary care teams maintain patient safety and consistency by standardizing how potentially inappropriate medications are reviewed and tapered. International examples already exist, such as the Canadian deprescribing.org class-specific, evidence-based guidelines with decision-support algorithms, and adapting them to the Brazilian context could help overcome the uncertainty and lack of local guidance reported by our participants.³¹

This study has some limitations. First, the data were based on short written responses, offering a broader overview of the topic, rather than an in-depth exploration. However, participation from 84 respondents provided a broad and diverse set of perspectives. Additionally, the post-hoc mapping of findings to the TDF, rather than its use as an a priori analytical framework, may have limited the depth of theoretical interpretation. The data were collected from pharmacists attending a training event, which may introduce selection bias, as these participants may have been more interested in deprescribing than the general primary care pharmacist population. On the other hand, the sample size and geographic diversity of respondents from across Brazil enhance the diversity of perspectives captured in the analysis.

CONCLUSION

This study identified important barriers and facilitators to implementing deprescribing in primary healthcare in Brazil. The results highlight the need for interprofessional approaches, patient education, and awareness to overcome cultural barriers, as well as for integration of deprescribing training at the undergraduate and postgraduate levels and for inclusion of this approach in clinical protocols and guidelines. The application of the TDF enabled a theory-informed interpretation of the findings, revealing that behavior change interventions targeting professional identity, beliefs about consequences, and environmental resources may be particularly relevant for advancing deprescribing in the Brazilian context.

Future research should employ the TDF prospectively in the design of interview guides to achieve greater depth in exploring the behavioral determinants of deprescribing. Implementation studies are needed to evaluate specific strategies for overcoming the identified barriers in the Brazilian public healthcare system. Studies with broader participant profiles, including physicians, nurses, and patients, would complement these findings.

Data availability statement

The data underlying this study are not publicly available because they are derived from brief written responses collected during an educational activity.