European Journal of Epidemiology 16: 19±26, 2000.
Ó 2000 Kluwer Academic Publishers. Printed in the Netherlands.
Sociodemographic factors related to self-medication in Spain
Adolfo Figueiras1, Francisco Caama
no1 & Juan JesuÂs Gestal-Otero1,2
1
Department of Preventive Medicine and Public Health, University of Santiago de Compostela; 2Preventive Medicine Service,
University Hospital of Santiago, Santiago de Compostela, Spain
Accepted in revised form 11 October 1999
Abstract. To identify the sociodemographic factors
associated to self-medication (i.e. use of non-pre-
scription medicines) and undesirable self-medication,
a cross-sectional study was carried out using a sample
(n = 20,311) representative of the population of
adults of 16 years of age and older in Spain. Multi-
variate Cox's regression was used. The prevalence of
self-medication in the sample was 12.7% during the
two weeks preceding the interview. Self-medication is
more prevalent among women, persons who live
alone, and persons who live in large cities. For per-
sons who reported acute disorders, self-medication
prevalence was higher among those with higher
educational levels. The prevalence of undesirable
Key words: Cross-sectional studies, Non-prescription, Prevalence, Proportional hazards models, Self-
medication
Introduction
Self-medication (SM) can be understood as a modern
style of self-care which is becoming increasingly im-
portant in developed countries. Factors such as a
decrease in prescription coverage by the social secu-
rity services, an increase in the use of alternative
remedies, availability of over-the-counter health
products, and an increasing presence of pharmaceu-
tical products in the media, are probably among the
causes of the rise of SM [1, 2]. The World Health
Organization has indicated that SM is acceptable, but
that it must be correctly taught and controlled until it
is fully integrated into social behavior [3].
Despite the increasing relevance that SM is
acquiring in developed countries, there are few
studies which shed light upon the subject [4±6].
When reviewing the available literature, it becomes
clear that previous studies on the sociodemographic
characteristics of SM do not control for potential
confounding variables through the use of multivar-
iate statistical analysis [7, 8], and when they do so,
the results are dicult to interpret [9, 10]. In addi-
tion, the associations between SM and some factors
are generally not strong, which is why the studies do
not always have the sucient statistical power to
detect them.
self-medication in the sample was 2.5% during the
two weeks previous to the interview. Undesirable self-
medication is twice as common among persons older
than 40 years, as compared to persons younger than
27 years. Undesirable self-medication prevalence is
53.0% higher among those who live alone as com-
pared to those who live with their partner (95%
con®dence intervel (CI): 15.2±103.2) and 36.8%
higher among students as compared to full-time
workers (95% CI: 1.9±83.5). People over 40 years of
age, people living alone, and students should be
the priority target populations for public health edu-
cation programs aimed at improving the quality of
self-medication behavior.
Various de®nitions of SM can be found in the
literature. Some authors de®ne SM as the use of
any drug not prescribed by a licensed health prac-
titioner, while others widen their de®nition to in-
clude any alteration to the recommended dose
guidelines undertaken by the patient [11]. Other
authors consider SM any use of medicines which,
although prescribed by a physician, were given due
to direct pressure from the patient [12]. For this
study, we consider SM as the use of any non-pre-
scription medicine. We also noted a lack of studies
evaluating undesirable self-medication (USM) ±
de®ned by us as the use of medicines that, due to
their nature, should not be used without medical
supervision ± and of studies identifying the popu-
lation groups in which USM occurs with higher
frequency. Data on USM would be very useful for
the design of health education programs to improve
medicines use.
The objectives of this study are: to determine the
prevalence of SM and USM in the Spanish popula-
tion over 15 years of age, and to identify sociode-
mographic and medical factors related to SM and
USM. While the study was designed to be explor-
atory, we formulated the preliminary hypothesis that
the prevalence of SM is higher among populations of
higher social and economic status.
20
Methods
Design, sample and data collection
This study has a cross-sectional design, and the study
participants were adults of 16 years of age and older
included in the Spanish National Health Survey of
1993. This sample is comprised of 20,311 persons
distributed in a non-proportional manner throughout
the various regions of Spain. The type of sample used
was multi-stage, strati®ed by clusters, with random
proportional selection of the di€erent units of the
sample in the case of municipal areas, and simple
random sampling in the case of sections. Individual
sampling was carried out through the selection of
routes and quotas of age and sex. Face-to-face in-
terviews were carried out by especially trained inter-
viewers, between 15 February and 3 March 1993. The
data collection instrument was based on the ques-
tionnaire used in the Spanish National Health Survey
of 1987. Details on the methodology of the Spanish
National Health Survey have been published else-
where [13].
Variable de®nitions
Three dependent variables were considered: thera-
peutic drug use (TDU), SM, and USM, all three di-
chotomous. TDU was de®ned as the self-reported use
of any pharmaceutical product in the two weeks prior
to the interview, and SM as the use of any non-pre-
scription medicine, during the two-week period prior
to the interview. Self-medication using drugs from the
following groups: anti-in¯ammatories (for rheuma-
tism); cardiovascular disease drugs; antibiotics; anti-
depressants and tranquilizers; and hypolypemiants
and hypoglucemiants, would not be appropriate
medical practice. Therefore, we de®ned USM as the
reported use of at least one non-prescribed medicine
from any of those drug groups, during the two weeks
prior to the interview. Despite Spanish legislation
requiring dispensation of pharmaceutical products
with the pertinent physician's prescription, it has long
been standard practice that pharmacists can dispense
prescription medicines at their own discretion.
Taking previous studies as a starting point, we se-
lected sociodemographic and medical variables from
the Spanish National Health Survey which could be
related to SM. Some of these variables were analyzed
in the same way as they appeared in the questionnaire
(sex, living arrangements, and education level); others
were recorded by grouping categories (habitat size
(number of inhabitants in the municipality of resi-
dence), and occupation). The age variable was cate-
gorized into quartiles and used in the logistical model
as a dummy variable to avoid assuming linearity in
the age e€ect. The acute disorder and chronic disor-
der variables are dichotomous and were generated
from a group of items in the questionnaire that
evaluated health disturbances. The acute disorder
variable measures the presence of acute disorders
which would have imposed restrictions on free-time
activities during the two weeks prior to the interview
(fever, headaches, diarrhea, fainting, coughing, colds,
¯u, wounds and lesions, urinary irritations, menstrual
problems, etc.). The chronic disorder variable refers
to the presence of chronic disorders which may have
limited the subject's main activity ± work or study ±
in the previous year (hypertension, diabetes, hype-
rcholesterolemia, heart disease, asthma, allergies and
stomach ulcers).
Data Analysis
Univariate (prevalence), bivariate (prevalence ratio
(PR)) and multivariate (adjusted PR) analyses were
performed. Multivariate analysis was ®rst carried out
using logistic regression [14]. We excluded from the
logistic models variables that had no e€ect, and were
not confounders or e€ect modi®ers of the other
independent variables. We used the Hosmer±Leme-
show test to determine the goodness of ®t of the
models to the data [15].
The odds ratios (ORs) obtained by applying lo-
gistic regression to cross-sectional data are prevalence
ORs which are an overestimation of the prevalence
ratio. Thus, once the de®nitive models were deter-
mined, Cox's proportional hazard regression was
applied, taking as an event the presence of the e€ect
(TDU, SM and USM), and assuming an equal ®cti-
tious follow-up period for all the participants. In this
way, and as Lee [16] demonstrated, a non-biased
estimation of the PR and its con®dence interval (CI)
was obtained.
Interactions between independent variables were
analyzed using an additive model. We ®rst calculated
the PRs for each of the combinations of interacting
variables using the jointly unexposed group as a ref-
erence category. Then, we calculated the PR among
those with both exposures that is attributable to their
interaction (proportion attributable to interaction or
AP) [17]. The con®dence intervals for AP were based
on Wald-type statistics using approximate variance
estimators [18].
Results
In the two weeks prior to the interview, nearly half
(44.8%) of the sample under study took some form of
medication, 12.7% self-medicated, and 2.5% self-
medicated in an undesirable fashion. Table 1 shows
the percentages of TDU and SM by therapeutic drug
type. The two most widely used drug groups during
that period were medicines for colds, ¯u, throat or
bronchial infections (14.2% of the sample), and an-
algesics or antipyretics (9.8%). Among those who
self-medicated, these two drug-groups also showed