IntroductionEco-directed sustainable prescribing (EDSP) is an effective upstream way to reduce the environmental footprints of active pharmaceutical ingredients (APIs), a kind of emerging contaminants, from the patients' excretion. EDSP is one of the key steps in the programme of ecopharmacovigilance (EPV), a drug administration route on API pollution.ObjectiveTo assess the attitudes of physicians prescribing medicines regarding EDSP from the perspective of EPV.DesignA cross-sectional study

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... ucted from March 2019 to June 2019.Setting5 government general hospitals in Hubei province, China.Participants405 physicians were randomly selected and 262 valid questionnaires were obtained.Outcome measuresA self-developed questionnaire, which inquired about the participant characteristics, perceptions and attitudes toward API pollution, EPV and EDSP from an EPV perspective, was emailed to collect data from physicians.ResultsMost physicians agreed the existence of APIs in environment, worried about the potential environmental and ecological risks of API residues, supported the effectiveness and necessity of EDSP under an EPV perspective in decreasing environmental exposure of excreted APIs, and showed their willingness to participate in the EDSP practices. Nevertheless, no respondent identified the environmental impacts as the aspects regarding medicines affecting his(her) prescription decision, none was satisfied with knowledge on EDSP and showed confidence toward EDSP. The most important barrier to the effective implementation of EDSP was identified as 'poor awareness of EDSP and EPV'. Most responding physicians (97%) reported that they held the wait-and-see or conservative attitudes towards EDSP practice. The biggest concerns in low-dose prescribing and prescribing of drugs possessing environment-friendly excretion profiles, two EDSP approaches, were the possible negative impact on therapeutic outcomes and too complicated and professional drug evaluation process, respectively.ConclusionsChinese physicians had positive attitudes towards EDSP from the perspective of EPV. However, their environmental consciousness during prescribing and the related education were insufficient.