Abstracts

Introduction

The pattern of drug use, including self-medication, has been widely investigated in national and international epidemiological studies, in different population segments¹1 Oliveira MA, Francisco PMSB, Costa KS, Barros MB. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saude Publica 2012; 28(2):335-345.

2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658.

3 Balamurugan E, Ganesh K. Prevalence and pattern of self medication use in coastal regions of South India. BJMP Br J Med Pract 2011; 4(3):a428.

4 Arrais PSP. Medicamentos: consumo e reações adversas: um estudo de base populacional. Fortaleza: Edições UFC; 2009.

5 Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saude Publica 2004; 38(4):557-564. ^{- 6}6 Sans S, Paluzie G, Puig T, Balañá L, Balaguer-Vintró I. Prevalencia del consumo de medicamentos en la población adulta de Cataluña. Gac Sanit 2002; 16(2):121-130..

The factors associated with drug use and self-medication, identified in some studies, have revealed differences according to subgroups. Regarding the consumption in adult population, studies have pointed to an increasing use of drugs with increasing age, among women²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 7}7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746.

8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238. ^{- 9}9 Loyola Filho AI, Uchoa E, Guerra HL, Firmo JOA, Lima-Costa MF. Prevalência e fatores associados à automedicação: resultados do Projeto Bambuí. Rev Saude Publica 2002; 36(1):55-62., those with greater purchasing power⁷7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746.

8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238.

9 Loyola Filho AI, Uchoa E, Guerra HL, Firmo JOA, Lima-Costa MF. Prevalência e fatores associados à automedicação: resultados do Projeto Bambuí. Rev Saude Publica 2002; 36(1):55-62.

10 Bertoldi AD, Barros AJD, Wagner A, Dennis RD, Hallal PC. A descriptive review of the methodologies used in household surveys on medicine utilization. BMC Med Res Methodol 2008; 8:222. ^{- 11}11 Paniz VMV, Fassa AG, Facchini LA, Bertoldi AD, Piccini RX, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Rodrigues MA. Acesso a medicamentos de uso contínuo em adultos e idosos nas regiões Sul e Nordeste do Brasil. Cad Saude Publica 2008; 24(2):267-280., among the most educated⁸8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238. ^{, 12}12 Ribeiro AQ, Rozenfeld S, Klein CH, César CC, Acurcio FA. Inquérito sobre uso de medicamentos por idosos aposentados, Belo Horizonte, MG. Rev Saude Publica 2008; 42(4):724-732., those that have a higher number of chronic diseases²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 7}7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 9}9 Loyola Filho AI, Uchoa E, Guerra HL, Firmo JOA, Lima-Costa MF. Prevalência e fatores associados à automedicação: resultados do Projeto Bambuí. Rev Saude Publica 2002; 36(1):55-62. ^{, 11}11 Paniz VMV, Fassa AG, Facchini LA, Bertoldi AD, Piccini RX, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Rodrigues MA. Acesso a medicamentos de uso contínuo em adultos e idosos nas regiões Sul e Nordeste do Brasil. Cad Saude Publica 2008; 24(2):267-280., among others. As for self-medication, a study performed in Bambuí verified that, for the adult population (18 years and older), there is a higher prevalence among men, younger subjects (between 18 and 39 years) and those who reported spending on drugs in the last year. Lower prevalence was observed among those who reported one or more medical appointments⁹9 Loyola Filho AI, Uchoa E, Guerra HL, Firmo JOA, Lima-Costa MF. Prevalência e fatores associados à automedicação: resultados do Projeto Bambuí. Rev Saude Publica 2002; 36(1):55-62..

Drug use has been the subject of constant attention among health care professionals and managers because, while they are necessary for the cure or control of diseases, they may also represent health risks when not rationally used⁴4 Arrais PSP. Medicamentos: consumo e reações adversas: um estudo de base populacional. Fortaleza: Edições UFC; 2009.. Among these risks, we highlight the nonuse of the drug in a timely manner, which can lead to delays in diagnosis and therapeutics, adverse interactions with other drugs, bacterial resistance, drug toxicity and poisoning¹³13 Naves JOS, Castro LLC, Carvalho CMS, Merchan-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Cien Saude Colet 2010; 15(Supl. 1):1751-1762. ^{, 14}14 Sá MB, Barros JAC, Sá MPBO. Automedicação em idosos na cidade de Salgueiro-PE. Rev Bras Epidemiol 2007; 10(1):75-85..

Considering that there are differences between men and women in relation to the risk of becoming ill, in the perception of signs and symptoms, in seeking health services and in health care, which vary due to the biological, socio-economic and behavioral factors of the gender¹⁵15 Obermeyer CM, Price K, Schulein M, Sievert LL, Anderton DL: Medication use and gender in Massachusetts: results of a household survey. Health Care Women Int 2007; 28(7):593-613. ^{, 16}16 Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Cien Saude Colet 2005; 10(1):35-46., we must pay attention to the singularities in the profile of drug use in each of these groups.

Comparative studies between men and women point out that, although women report higher prevalence of morbidities¹⁷17 Barros MBA, Francisco PMSB, Zanchetta LM, Cesar CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003- 2008. Cien Saude Colet 2011; 16(9):3755-3768., men are more vulnerable to severe chronic diseases, which cause limitations and are important causes of death¹⁶16 Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Cien Saude Colet 2005; 10(1):35-46. ^{, 18}18 Verbrugge LM, Wingard DL. Sex differentials in health and mortality. Women & Health 1987; 12(2):103-145.. Besides that, men seek primary care services in a lower proportion than women¹⁹19 Figueiredo WS. Assistência à saúde dos homens: um desafio para os serviços de atenção primária. Cien Saude Colet 2005; 10(1):105-109., most commonly going to emergency rooms, to union clinics and to pharmacies for curative care, resulting in self-medication²⁰20 Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Cien Saude Colet 2002; 7(4):687-707.. Consequently, they are more subject to procedures that could be avoided if preventive measures and the search for health care were carried out early²¹21 Brasil. Ministry of Health. Portaria nº 1944, de 27 de agosto de 2009. Institui no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Atenção Integral à Saúde do Homem. Diário Oficial da União 2009; 28 ago..

Few Brazilian studies have investigated the use of drugs considering the male and female subgroups separately. Thus, the objective of this study was to verify the factors associated with drug use in adults, with an emphasis on the differences between men and women, in the adult population in the city of Campinas, São Paulo, Brazil, in 2008.

Methods

Population-based, cross-sectional study carried out from 2,476 records of non-institutionalized adults (20 years and older), residents in the urban area in the city of Campinas in the period of 2008 and early 2009. The study used data from the health survey of the city of Campinas (ISACamp), performed by the Collaborating Center on Health Situation Analysis (CCAS) of the Department of Public Health of the School of Medical Sciences, University of Campinas (UNICAMP).

In the survey, the sample was obtained by means of probability sampling, by conglomerates and in two stages, considering the census sectors as primary unit. Thus, in the first stage, 50 census sectors were drawn with probability proportional to size, given by the number of households in the sector. In the second stage, households were selected by systematic randomization applied to the households that had been prepared for each of the selected sectors.

The number of persons to compose the sample was obtained considering the situation corresponding to the maximum variability for the frequency of events studied (P = 0.50), 95% confidence coefficient in the determination of confidence intervals (z = 1.96), sampling error between 4 and 5 percentage points and design effect equal to 2, amounting to 1,000 individuals in each age group, namely: adolescents (10 to 19 years), adults (20 to 59 years) and elderly (60 years and more). Sample size was fixed at 1,250 for 80% response rate. To achieve this sample size in each domain, after update in the field of the maps of the sectors randomized and preparation of the list of addresses, 2,150, 700 and 3,900 households were selected, independently, for adolescents, adults and the elderly, respectively. In this research, in each household, all residents were interviewed in the age group selected for that address. The sampling design for the ISA-Camp 2008 survey has been described in detail by Alves²²22 Alves MCGP. ISA-Campinas 2008/09: plano de amostragem. [cited 2013 Set 10]: [about 4 p.]. Available from: http://www.fcm.unicamp.br/fcm/sites/default/files/plano_de_amostragem.pdf
http://www.fcm.unicamp.br/fcm/sites/defa... .

The information was obtained through structured questionnaire previously tested in pilot study and applied in household interviews conducted by interviewers trained and supervised. To ensure the quality of the data collected, partial second interviews, performed by telephone or in person, were conducted on random sample of 5% of the participants and showed no discrepancy in relation to the original information.

In this study, we used the survey's data relating to subjects of 20 years or older and the dependent variable was the use of at least one drug in the three days preceding the survey, investigated by the questions: (1) Have you used any drug in the last three days? (2) How many drugs? Which ones?

For the identification of drugs, we requested the presentation of the drug packaging and/or the medical prescription to minimize errors in data annotation by the interviewer. Subsequently, the drugs were coded according to the Anatomical Therapeutic Chemical Code (ATC-2009)²³23 World Health Organization (WHO). ATC/ DDD Index 2009 [on line]. [cited 2013 Apr 12]. Available from: http://www.whocc.no/atcdddindexdatabase/
http://www.whocc.no/atcdddindexdatabase/... . For the identification of the composition of drugs, we used the "Dicionário de Especialidades Farmacêuticas" (DEF 2008/2009)²⁴24 DEF - Dicionário de Especialidades Farmacêuticas 2008/2009. 37ª ed. São Paulo: Epub; 2009.. For the drugs whose names the interviewee was unable to point out or to provide packing/prescription, we assigned an unidentified code; for products that were not in the ATC, we created codes to identify them, and, for those who did not present a specific code in the ATC, we used the code to the extent that was possible to identify the group, class or therapeutic action.

In the analysis of the factors associated with drug use according to gender, we excluded the records relating to the interviews that related the use of only contraceptives (n = 63), as this is a group of drugs unique to women and whose logic differs from the use of other drugs⁸8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238.. The following sets of independent variables were selected:

· Demographic and socio-economic: age group, marital status, self-reported color/race, education (in years of study), household income per capita (in minimum wages), job and number of residents in the household.

Health-related behaviors: abusive use of alcohol, assessed by the Alcohol Use Disorder Identification Test (AUDIT)²⁵25 Dawson DA, Grant BF, Stinson FS, Zhou Y. Effectiveness of the derived alcohol us disorders identification test (AUDIT-C) in screening for alcohol use disorders and risk drinking in the USD general population. Alcohol Clin Exp Res 2005; 29(5):844-854., composed of ten questions and which identifies the risk of alcohol abuse/addiction when its score (0-40 range) equals to eight or more²⁶26 Lima CT, Freire ACC, Silva APB, Teixeira RM, Farrel M, Prince M. Concurrent and construct validity of the AUDIT in an urban Brazilian sample. Alcohol Alcohol 2005; 40(6):584-589.; frequency of alcohol consumption categorized into: no consumption, consumption up to once a week and consumption two or more times a week; smoking categorized into smoker, former smoker and non-smoker; practice of physical activity in the context of leisure (active - individuals who practiced at least 150 minutes per week, distributed, at least, in three days; inadequately active - those who practiced less than 150 minutes or more than 150 minutes, but in less than three days a week, and inactive - those who did not dedicate any time to leisure physical activity during the week); body mass index (BMI = Kg/m²⁾, calculated based on the weight and height data and cut-off points proposed by the World Health Organization²⁷27 Organización Mundial de la Salud (OMS). El estado físico: uso e interpretación de la antropometría. Genebra: OMS; 1995. (Serie de Informes Técnicos, 854). for the adult population: underweight (BMI < 18.5 kg/m²⁾, eutrophy (18.5 kg/m² < BMI < 24.9 kg/m²⁾;overweight (25.0 kg/m² < BMI < 30.0 kg/m²⁾ and obese (BMI > 30 kg/m²⁾; and sleep time (in hours).

· Indicators of health conditions and use of health services: health self-assessment, number of chronic diseases (considering hypertension, diabetes mellitus, cardiovascular disease, tumor/cancer, rheumatic disease/arthritis/osteoarthritis, osteoporosis, asthma/ bronchitis/emphysema, tendinopathy/Cumulative Trauma Disorders, circulatory problems and others), morbidity in the 15 days prior to the survey, common mental disorder (CMD) evaluated based on the Self Reporting Questionnaire (SQR-20) with cutoff point 7/8²⁸28 World Health Organization (WHO). A user's guide to the Self Reporting Questionnaire. Geneva: WHO; 1994., number of health problems (symptoms/complaints) (frequent headache/migraine disorders, back pain/column problem, hypersensitivity, emotional problem, dizziness/vertigo, insomnia, urinary problem), search for health service or health care professional for health-related issues in the last 15 days, hospitalization in the past year and membership in health plan.

In the data analysis, we initially verified the association between the various variables and drug use according to gender using the Pearson's chi-square testwith a significance level of 5%. Then, considering the effect of age on the greater drug use²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 5}5 Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saude Publica 2004; 38(4):557-564. ^{, 7}7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 8}8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238. ^{, 29}29 Rocha CH, Oliveira APS, Ferreira C, Faggiani FT, Schroeter G, Souza ACA, DeCarli GA, Morrone FB, Werlang MC. Adesão à prescrição médica em idosos de Porto Alegre, RS. Cien Saude Colet 2008; 10(1):105-109., prevalence ratios (PR) were calculated adjusted for age and 95% confidence intervals. The multivariate analysis was performed by means of Poisson regression²⁹29 Rocha CH, Oliveira APS, Ferreira C, Faggiani FT, Schroeter G, Souza ACA, DeCarli GA, Morrone FB, Werlang MC. Adesão à prescrição médica em idosos de Porto Alegre, RS. Cien Saude Colet 2008; 10(1):105-109., for both genders, obeying the following hierarchical model: in the first stage, we included the socio-demographic characteristics associated with the use of drugs. In the second stage, in addition to the variables in the first set that maintained significance after being adjusted by the other variables of the same hierarchical level, we added those related to health-related behaviors associated with use, remaining in the model only those that had significance in the adjusting for confounding factors belonging to the same hierarchical level and at the higher level. In the third stage, we introduced the variables relating to health conditions, use of health services and subjective health evaluation, given their importance as trigger for the search for medical assistance or other alternatives to improve/recover the health condition⁷7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746.. Therefore, we included in the models the variables that showed significant association with drug use in the simple analysis (p < 0.20) and, in the final model, remained those that showed a p < 0.05 value, adjusted by the variables of higher levels and at the same level³⁰30 Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21..

Data analyses were performed with the program Stata 11.0, whose procedures for analysis of population surveys incorporate the various aspects of the complex sampling design³¹31 Kish L. Survey sampling. New York: John Wiley and Sons; 1965..

The research project was approved by the Ethics Committee of the University of Campinas.

Results

Of the adults interviewed by the survey with answers to the question about drug use in the three days preceding the survey, 94.2% (95% CI: 90.8 - 97.6) of men and 96.9% (95% CI: 95.4 - 98.3) of women responded in person to the interview. The other interviews were answered by a family member or responsible, due to the impossibility arising from the individual's health problems. The average age of the study population was 41.6 years (95% CI: 40.3 - 42.9) and 43.7 (95% CI: 42.4 - 45.0) for men and women, respectively. Regarding drug use, 45.4% (95% CI: 41.3 - 49.4) of men and 68.0% (95% CI: 63.5 - 72.5) of women reported having consumed at least one drug in the three days preceding the survey.

Excluding the specific usage of contraceptives, according to the criteria adopted, the prevalence of use among women (n = 1,350) was 64.6% (95% CI: 59.8 - 69.2) and the average number of drugs used by the adult population investigated in this study (n = 2,413) was 1.5 (95% CI: 1.3 - 1.6) for women and 0.9 (95% CI: 0.8 - 1.0) for men.

Table 1 presents the prevalence of drug use, by gender, according to socio-demographic variables. We observed that, in the simple analysis, age group, education and job were associated with drug use for both genders (p < 0.05). Marital status was associated only with men and, in relation to household income per capita and number of people in the household, there was an association only for women (p < 0.05). After adjusting for age, higher prevalence of drug use was verified in women who did not have any jobs at the time of the survey, in the limit of statistical significance (PR = 1.13; 95% CI: 1.00 - 1.29). Women showed a higher prevalence of drug use than men, except for the age group of 80 years or more and among the persons with less education.

With regard to health-related behaviors in the male adult population, we observed significantly higher prevalences of drug use among those who stopped smoking and those overweight. Regarding the women, greater use was verified among those who no longer smoke, the obese and those who reported a short sleep pattern (up to 6 hours). Underweight women showed lower prevalence of drug use after adjusting for age (PR = 0.66; 95% CI: 0.46-0.95) (Table 2). In assessing the prevalence ratio between the genders, we observed that the prevalence of drug use for women were not higher than those for men only for those who abused alcohol, those insufficiently active and in those underweight.

Table 3 presents the prevalence of drug use according to health condition and use of health services. All variables concerning health conditions were significantly associated with drug use in the analysis stratified by gender, as well as the search for health service or health care professional in the past 15 days. Among men, hospitalization in the previous year was also associated with drug use. The magnitudes of associations evaluated by means of prevalence ratios adjusted for age, in general, show the greater magnitude of associations among men. For the set of variables analyzed, women showed higher prevalence of drug use, compared to men, for at least one of the categories considered (Table 3).

The hierarchical multiple regression analysis results are presented in Tables 4 and 5. For the male adult population, among the socio-demographic variables, age group above 40 years and no job remained statistically associated with drug use. Of the variables from the set concerning health-related behaviors, only former smokers had higher prevalence of drug use, after adjustment by the variables of the same set, and by those that remained from the set of socio-demographic characteristics. In the set integrated by health conditions, use of health services and subjective health evaluation, the following variables remained positively associated: presence of one or more chronic disease, presence of two or more health problems (symptoms/complaints) and search for health service or health care professional in the past 15 days, when adjusted among each other and for the variables that persisted in the previous sets (Table 4).

In relation to the female population, among the socio-demographic variables, only the age group older than 40 years remained statistically associated with drug use, after adjustment by the variables of the same set. For the health-related behaviors, former smokers, obese and those who reported a short sleeping pattern presented higher prevalence, and underweight women showed a lower prevalence of drug use, after adjustment by the variables of the same set and by the age groups. In the set related to health conditions, use of health services and subjective health evaluation, the following variables remained positively associated: presence of one or more chronic disease, presence of two or more health problems (symptoms/complaints) and search for health service or health care professional in the past 15 days, when adjusted among each other and for the variables that were kept in the previous sets (Table 5).

Discussion

The prevalence of use of at least one drug in the three days preceding the survey was of 45.4% and 64.6% among adult men and women residing in Campinas, respectively. In the research on drug use, we should consider the recall period, as the prevalence of use depends on the period evaluated. The literature does not point an ideal period, as this choice depends on what is being recorded and the ability of the respondent population to recall¹⁰10 Bertoldi AD, Barros AJD, Wagner A, Dennis RD, Hallal PC. A descriptive review of the methodologies used in household surveys on medicine utilization. BMC Med Res Methodol 2008; 8:222.; however, regardless of this period, the accuracy of the respondent for drug use decreases with increasing age, number of drugs prescribed for chronic use and also can vary depending on the drug used³²32 Van den Brandt PA, Petri H, Dorant E, Goldbohm RA, Van de Crommert S. Comparison of questionnaire information and pharmacy data on drug use. Pharm Weekbl Sci 1991; 13(2):91-96..

The increased use of drugs by women compared to men is consistent with the results obtained in many other epidemiological investigations²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 5}5 Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saude Publica 2004; 38(4):557-564.

6 Sans S, Paluzie G, Puig T, Balañá L, Balaguer-Vintró I. Prevalencia del consumo de medicamentos en la población adulta de Cataluña. Gac Sanit 2002; 16(2):121-130.

7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{- 8}8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238. ^{, 12}12 Ribeiro AQ, Rozenfeld S, Klein CH, César CC, Acurcio FA. Inquérito sobre uso de medicamentos por idosos aposentados, Belo Horizonte, MG. Rev Saude Publica 2008; 42(4):724-732. ^{, 15}15 Obermeyer CM, Price K, Schulein M, Sievert LL, Anderton DL: Medication use and gender in Massachusetts: results of a household survey. Health Care Women Int 2007; 28(7):593-613. ^{, 33}33 Pelicioni AF, César CLG. Uso de medicamentos: In: César CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo: Inquérito multicêntrico de saúde no Estado de São Paulo - ISA-SP. São Paulo: USP; 2005. p. 199-212. and is independent of type of use (prescribed or over-the-counter)⁷7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746.. In one of the first Brazilian research studies to analyze the profile of population-based drug consumption, held in the city of Ribeirão Preto (SP) in the 70s, there was already a greater drug usage by women with higher rates of morbidity, drug consumption and medical appointments, which sharply contrasted with the greater male mortality³⁴34 Barros MBA. Saúde e classe social: um estudo sobre morbidade e consumo de medicamentos [thesis]. Ribeirão Preto: Universidade de São Paulo; 1983.. There are several aspects that make women more prone to drug use, among them stand out their greater concern with health, their performance in the health care of their family members, early and more frequent search for health services, probably due to greater opportunity for care (the incorporation of attention to women's health into national health policies date from the early 20th century)³⁵35 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Integral à Saúde da Mulher/Princípios e Diretrizes. Brasília: MS; 2004. (Série C. Projetos, Programas e Relatórios). .

In addition, the existing specific programs³⁵35 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Integral à Saúde da Mulher/Princípios e Diretrizes. Brasília: MS; 2004. (Série C. Projetos, Programas e Relatórios). are disseminated and directed to the problems that affect women in every stage of life (such as in the menstrual period, symptoms and effects of estrogen deficiency) and contribute to a greater chance of drug use during adulthood, factors that may partially explain the greater use in this group. In the study conducted by Pedro et al.³⁶36 Pedro AO, Pinto-Neto AM, Costa-Paiva L, Osis MJ, Hardy E. Procura de serviço médico por mulheres climatéricas brasileiras. Rev Saude Publica 2002; 36(4):484-490. in Campinas about the search for medical services among menopausal women revealed that, for the major complaints (menstrual irregularity, climacteric symptoms and urogenital symptoms), all women were medicated and almost all followed the prescription indicated.

Pelicioni and César³³33 Pelicioni AF, César CLG. Uso de medicamentos: In: César CLG, Carandina L, Alves MCGP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo: Inquérito multicêntrico de saúde no Estado de São Paulo - ISA-SP. São Paulo: USP; 2005. p. 199-212., based on data from a home health survey carried out in four areas of the State of São Paulo (ISA-SP), observed increased drug use in the higher age groups and a higher prevalence among women compared to men, considering the same period used in the present study, which was also verified by Costa et al.²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. with health survey data in the State of São Paulo (ISA-SP) and by Perrone et al.³⁷37 Perrone AMF, Molina MC, Bertonha MEAM, Nativio J, Barros MBA. Use of drugs. In: Barros MBA, César CLG, Carandina L, Goldbaum M, organizadores. As dimensões da saúde: inquérito populacional em Campinas, SP. São Paulo: Aderaldo & Rothschild; 2008. p. 218-229. on the analysis of ISA-SP data disaggregated for the city of Campinas. This trend, also observed in the present study, is consistent in the literature and, possibly, is due to the higher prevalence of co-morbidities with advancing age³⁸38 Bardel A, Wallander MA, Svärdsudd K. Reported current use of prescription drugs and some of its determinants among 35 to 65-year-old women in mid-Sweden: A population-based study. J Clin Epidemiol 2000; 53(6):637-643.. In this study, we could observe that the increasing drug use according to age groups occurs differently in relation to gender and that only for the elderly there were no differences in the prevalence ratio according to gender.

The average number of drugs consumed by the adult population of Campinas was similar to that observed for studies performed with the same period recorded²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 37}37 Perrone AMF, Molina MC, Bertonha MEAM, Nativio J, Barros MBA. Use of drugs. In: Barros MBA, César CLG, Carandina L, Goldbaum M, organizadores. As dimensões da saúde: inquérito populacional em Campinas, SP. São Paulo: Aderaldo & Rothschild; 2008. p. 218-229..

Marital status and education among men, as well as education, household income per capita, job and number of people in the household among women, who had association with drug use in the simple analysis, lost their significance after the adjusted analysis, as verified in other studies⁶6 Sans S, Paluzie G, Puig T, Balañá L, Balaguer-Vintró I. Prevalencia del consumo de medicamentos en la población adulta de Cataluña. Gac Sanit 2002; 16(2):121-130. ^{, 8}8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238.. Studies indicate the importance of the socio-economic level and, specifically, the monthly family income as determinants of drug consumption⁵5 Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saude Publica 2004; 38(4):557-564.

6 Sans S, Paluzie G, Puig T, Balañá L, Balaguer-Vintró I. Prevalencia del consumo de medicamentos en la población adulta de Cataluña. Gac Sanit 2002; 16(2):121-130.

7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{- 8}8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238., which was not verified in this study for the variables analyzed.

Among men, there was a higher prevalence of drug use in those who did not have a job at the time of the research. In a study performed in Catalonia with adult population of 25 to 64 years, there was higher drug consumption among retired men, but not among the women⁶6 Sans S, Paluzie G, Puig T, Balañá L, Balaguer-Vintró I. Prevalencia del consumo de medicamentos en la población adulta de Cataluña. Gac Sanit 2002; 16(2):121-130.. Moreover, in relation to job, some studies have found higher prevalence of drug use and self-medication among the unemployed, students and housewives⁷7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 39}39 Joaquim MR. Automedicação versus indicação farmacêutica [thesis]. Faro: Universidade do Algarve; 2011. ^{, 40}40 Figueiras A, Caamaño F, Gestal-Otero JJ. Sociodemographic factors related to self-medication in Spain. Eur J Epidemiol 2000; 16(1):19-26.. In this study, drug use was not evaluated according to prescription, but when comparing genders, drug consumption without medical or dental indication showed no statistical difference (data not presented).

With regard to health-related behaviors, we observed higher prevalence of drug use among men and women who stopped smoking. The same trend was observed for point estimates in the study of Bardel, et al.³⁸38 Bardel A, Wallander MA, Svärdsudd K. Reported current use of prescription drugs and some of its determinants among 35 to 65-year-old women in mid-Sweden: A population-based study. J Clin Epidemiol 2000; 53(6):637-643., without, however, achieving statistical significance. The higher prevalence of use could be partially explained as these persons constitute a group with worse health conditions, resulting from the effect of smoke exposure, which may have even motivated the abandonment of smoking⁸8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238.. Evidence shows smoking as part of the chain of causality of almost 50 different diseases, including cardiovascular diseases, cancers and respiratory diseases⁴¹41 Instituto Nacional do Câncer (INCA). Tabagismo um grave problema de saúde pública. [cited 2013 May 5]. Available from: http://www1.inca.gov.br/inca/Arquivos/ t_Tabagismo.pdf
http://www1.inca.gov.br/inca/Arquivos/ t... .

Also among women, underweight was inversely associated with use, and obesity and short sleep pattern had higher prevalence of drug use. Bardel, et al.³⁸38 Bardel A, Wallander MA, Svärdsudd K. Reported current use of prescription drugs and some of its determinants among 35 to 65-year-old women in mid-Sweden: A population-based study. J Clin Epidemiol 2000; 53(6):637-643., in a study with Swedish women of 35 to 65 years in Sweden, and Bertoldi, et al.⁸8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238. verified that prevalences of drug use were significantly higher among the obese, as verified in the present study; however, in both studies, the category underweight (BMI < 18.5) was not considered. The association between obesity and chronic morbidities, such as diabetes mellitus, hypertension and cardiovascular diseases (data not shown), consistent with health surveys conducted elsewhere⁴²42 Gigante DP, Moura EC, Sardinha LMV. Prevalência de excesso de peso e obesidade e fatores associados, Brasil, 2006. Rev Saude Publica 2009; 43(Supl. 2):83-89. ^{, 43}43 Calza S, Decarli A, Ferraroni M. Obesity and prevalence of chronic diseases in the 1999-2000 Italian National Health Survey. BMC Public Health 2008; 8:140., may partially explain this finding. In this study, among women who had the desire to lose weight, the use of medications for weight loss was rarely mentioned.

In this study, sleep duration equal to less than 6 hours was positively associated with drug use among women. Epidemiological studies have observed that the pattern of short or long sleep is associated with increased morbidity⁴⁴44 Lima MG, Francisco PMSB, Barros MBA. Sleep duration pattern and chronic diseases in Brazilian adults (ISACAMP, 2008/09). Sleep Med 2012; 13(2):139-144.

45 López-García E, Faubel R, León-Muñoz L, Zuluaga MC, Banegas JR, Rodríguez-Artalejo F. Sleep duration, general and abdominal obesity, and weight change among the older adult population of Spain. Am J Clin Nutr 2008; 87(2):310-316. ^{- 46}46 Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, Punjabi NM. Association of usual sleep duration with hypertension: the sleep heart health study. Sleep 2006; 29(8):1009-1014.. Changes in sleep duration can be peculiar symptoms of diseases, but the use of medicines can also change the sleep pattern. In this sense, it is not possible to clarify the cause-and-effect relationship of this association in a cross-sectional study, due to the possibility of reverse causality, which highlights the need for studies to find, from the pharmacological point of view, what is the relationship between the specific drugs used and their association with the sleep pattern in more detail.

In relation to health conditions and the use of health services, for the presence of chronic disease, which is the main determinant of drug use in both genders²2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 7}7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 9}9 Loyola Filho AI, Uchoa E, Guerra HL, Firmo JOA, Lima-Costa MF. Prevalência e fatores associados à automedicação: resultados do Projeto Bambuí. Rev Saude Publica 2002; 36(1):55-62. ^{, 11}11 Paniz VMV, Fassa AG, Facchini LA, Bertoldi AD, Piccini RX, Tomasi E, Thumé E, Silveira DS, Siqueira FV, Rodrigues MA. Acesso a medicamentos de uso contínuo em adultos e idosos nas regiões Sul e Nordeste do Brasil. Cad Saude Publica 2008; 24(2):267-280., the magnitudes of associations were higher among men.

In this study, health problems (symptoms/complaints) often referred to by the adult population were considered in the analysis with the objective of scaling their importance and magnitude given the indicators traditionally used in studies on drug use, and, for both men and women, they were significantly associated with drug use. The health problems mentioned by the population determine the drug use for a real need and the symbolic function of the drugs. Also, in addition to cultural and behavioral factors that partially explain the use, the need motivated by advertisements promoted by the pharmaceutical industry and primarily related to non-prescription drugs heavily contribute to the use⁴⁷47 Lefèvre F. A função simbólica dos medicamentos. Rev Saude Publica 1983; 17(6):500-503.. We stress that when handling these problems/complaints - which may harbor other more serious health problems that require specific care and/or treatment - non-prescription drugs are often used (self-medication) and the drugs commonly used in these cases belong to the group of analgesics, antipyretics and NSAIDs (data not presented). Information based on scientific evidence and knowledge in pharmacology enables the pharmacist to take actions that can improve the practice of self-medication subsidizing the proper use of these drugs³⁹39 Joaquim MR. Automedicação versus indicação farmacêutica [thesis]. Faro: Universidade do Algarve; 2011. ^{, 48}48 Wannmacher L. Tratamento de enxaqueca: escolhas racionais. In: OPAS. Uso racional de medicamentos: temas selecionados - 6. Brasília: OPAS; 2011. p. 55-65.. In this sense, the pharmacist has the important role of providing sufficient information to ensure the responsible self-medication.

The search for health services or a health care professional in the 15 days before the survey was significantly associated with drug use. Studies indicate a high proportion of drug prescription for respondents who seek health care⁵5 Coelho Filho JM, Marcopito LF, Castelo A. Perfil de utilização de medicamentos por idosos em área urbana do Nordeste do Brasil. Rev Saude Publica 2004; 38(4):557-564. ^{, 7}7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 15}15 Obermeyer CM, Price K, Schulein M, Sievert LL, Anderton DL: Medication use and gender in Massachusetts: results of a household survey. Health Care Women Int 2007; 28(7):593-613. ^{, 49}49 Loyola Filho AI, Uchoa E, Lima-Costa MF. Estudo epidemiológico de base populacional sobre uso de medicamentos entre idosos na Região Metropolitana de Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica 2006; 22(12):2657-2667.. The medicalization of society is a complex phenomenon related to socio-cultural, political and scientific transformations based on the incorporation of standards of conduct of biomedical origin, on the general culture, and on the redefinition of human experiences associated with medical problems⁴⁷47 Lefèvre F. A função simbólica dos medicamentos. Rev Saude Publica 1983; 17(6):500-503.. Excess drug use cannot be attributed solely to medical action, but to the reduction of sickness caused by a problem in the "human machine", disregarding the social, behavioral, cultural and psychological determinants related to the health-disease process⁴⁷47 Lefèvre F. A função simbólica dos medicamentos. Rev Saude Publica 1983; 17(6):500-503. ^{, 50}50 Tesser CD, Barros NF. Medicalização social e medicina alternativa e complementar: pluralização terapêutica do Sistema Único de Saúde. Rev Saude Publica 2008; 42(5):914-920.. However, the medical care, commonly classified by the user as quick, superficial and impersonal, often has been summarized to the prescription of the best drug suited to the symptoms⁷7 Arrais PSP, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saude Publica 2005; 21(6):1737-1746. ^{, 39}39 Joaquim MR. Automedicação versus indicação farmacêutica [thesis]. Faro: Universidade do Algarve; 2011..

Among the limitations of this study, the three-day recall period may underestimate the prevalence of use, since, the longer is the period (15 or 30 days), the greater will be the likelihood of an eventual use of a drug. The continuous-use medication can also be counted in any length of period. However, we must consider that a longer period could also generate a memory bias in relation to drugs of sporadic use, commonly used by the adult population and without medical prescription, promoting an understating especially about the pharmaceuticals used for minor illnesses¹1 Oliveira MA, Francisco PMSB, Costa KS, Barros MB. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saude Publica 2012; 28(2):335-345. ^{, 2}2 Costa KS, Barros MBA, Francisco PMSB, Cesar CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados: um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(4):649-658. ^{, 8}8 Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saude Publica 2004; 38(2):228-238.. We should also consider that this study used data from a comprehensive health survey, which may lead to different results than the ones obtained from a specific survey on this theme.

Even though the period remembered when obtaining information is an important methodological aspect in comparative approaches, we observed a high prevalence of drug use in the adult population of Campinas, which is also influenced by the availability and quality of medical care services, among other factors not assessed in this study.

The differences observed in the prevalence and magnitude of drug use reflect the specificities of the subgroups evaluated with regard to socio-demographic characteristics, health-related behaviors, health status and service use. In this study, the findings showed some differences in determinants of drug use in relation to gender, revealing the greater importance of obesity and the short sleep pattern among women. They also revealed that, despite the higher prevalence of drug use among women for almost all variables considered, the growing trend of drug use according to age groups and an increase in the number of chronic diseases was more markedly noted among men. This allowed us to identify the importance of health problems/complaints often referred to by the population, regarding the use of drugs and health-related behavior, especially among adult women in Campinas.

Studies that include the identification of drugs that are being used by specific population groups may contribute to the knowledge about the profile of medical prescription and self-medication, as well as a more detailed investigation with regard to the appropriateness of use, given the morbidities.

Acknowledgements

To the National Council for Scientific and Technological Development (CNPq) for funding the research and the scholarship productivity M. B. A. Barros and the Ministry of Health and the Department of Health of Campinas for financial support for the survey (Unicamp Partnership/Funcamp). São Paulo Research Foundation (FAPESP) for the PhD scholarship for TF Bastos and the scholarship postdoctoral for PMSB Francisco.

References

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