Abstract

This article aims to assess the prevalence and factors associated with self-medication in adolescents. Cross-sectional study, nested in cohort, with 2,515 adolescents aged 18-19 years born in São Luís-MA. The use of medication in the last 15 days without a medical prescription or by a qualified professional was considered self-medication. Factors associated with self-medication were evaluated using Poisson regression with robust variances and hierarchical selection of variables. Medicines were used in the last 15 days by 48.05% of adolescents. Among these, 70.09% use it without a prescription or indication from another health professional. The most used medications for self-medication were “over the counter” (93.68%). Self-medication was positively associated with female gender (PR: 1.41; 95%CI: 1.25-1.59), screen time ≥5h/day (PR: 1.32; 95%CI: 1.05-1.67) and self-reported diagnosis of allergic rhinitis (PR: 1.19; 95%CI: 1.02-1.39); however, negatively associated with self-satisfaction with health (PR: 0.79; 95%CI: 0.67-0.94) and hospitalization in the previous year (PR: 0.70; 95%CI: 0.50-0.97). Self-medication was common among adolescents and to reduce this practice, greater attention should be given to women, individuals with intense exposure to meshes and allergic diseases.

Key words:
Self-medication; Adolescents; Prevalence; Risk factors

Resumo

O objetivo deste artigo é avaliar a prevalência e os fatores associados a automedicação em adolescentes. Estudo transversal, aninhado a uma coorte, com 2.515 adolescentes de 18-19 anos nascidos em São Luís-MA. O uso de algum medicamento nos últimos 15 dias sem prescrição médica ou de profissional habilitado foi considerado automedicação. Os fatores associados a automedicação foram avaliados usando regressão de Poisson com variâncias robustas e seleção hierárquica das variáveis. Medicamentos foram utilizados nos últimos 15 dias por 48,05% dos adolescentes. Entre estes, 70,09% fazem uso sem receita médica ou indicação de outro profissional de saúde. Os medicamentos mais utilizados na automedicação foram os “over the counter” (93,68%). A automedicação foi positivamente associada ao sexo feminino (RP: 1,41; IC95%: 1,25-1,59), tempo de tela ≥5h/dia (RP: 1,32; IC95%: 1,05-1,67) e diagnóstico autorreferido de rinite alérgica (RP: 1,19; IC95%: 1,02-1,39); porém, negativamente associada a autossatisfação com a saúde (PR: 0,79; IC95%: 0,67-0,94) e hospitalização no ano anterior (RP: 0,70; IC95%: 0,50-0,97). A automedicação foi comum entre os adolescentes e para redução dessa prática uma maior atenção deve ser dada a mulheres, indivíduos com intensa exposição a telas e doenças alérgicas.

Palavras-chave:
Automedicação; Adolescentes; Prevalência; Fatores de risco

Introduction

Self-medication is defined as the use of medicines by the consumer for the treatment of self-recognized disorders or symptoms, or the intermittent or continued use of a medicine prescribed by a physician for chronic or recurrent diseases or symptoms. In practice the self-medication involves the use of medicines by the consumer by indication from family members, especially when it comes to the treatment of children, adolescents or the elderly¹1 World Health Organization (WHO). Guidelines for the regulatory assessment of medicinal products for use in self-medication. Geneva: WHO; 2000..

The practice of self-medication is a growing and global public health phenomenon in general population in both developed and emerging countries²2 Limaye D, Limaye V, Krause G, Fortwengel G. A Systematic Review of the Literature to Assess Self-medication Practices. Ann Med Health Sci Res 2017; 7:1-15.. Especially in adolescence, prevalence of self-medication ranged from 4.0% to 92.0% in different countries³3 Gualano MR, Bert F, Passi S, Stillo M, Galis V, Manzoli L, Siliquini R. Use of self-medication among adolescents: a systematic review and meta-analysis. Eur J Public Health 2015; 25(3):444-450. while in Brazil has been reported frequencies between 10.3% and 52.6%⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181.

5 Silva C, Giugliani ER. Consumption of medicines among adolescent students: a concern. J Pediatr 2014; 80(4):326-332.

6 Moraes ACFD, Delaporte TRM, Molena-Fernandes CA, Falcão MC. Factors associated with medicine use and self medication are different in adolescents. Clinics 2011; 66(7):1149-1155.

7 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660.^-88 Bertoldi AD, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Tracking of medicine use and self-medication from infancy to adolescence: 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2012; 51(6):S11-S15..

Self-medication can bring risks to individuals, such as incorrect self-diagnosis, incorrect choice of therapy, delays in seeking medical advice and correct treatment, possible adverse reactions, dangerous drug interactions, incorrect route or form of administration; inadequate dosage, storage under improper conditions, masking of serious diseases, risk of dependence or abuse⁹9 Alghanim SA. Self-medication practice among patients in a public health care system. East Mediterr Health J 2011; 17(5):409-416..

In adolescents, the practice of self-medication should not be scorned, since adolescence is an essential phase for the formation of habits and behaviors related to lifestyle and health that can impact the current and future morbidity and mortality of these individuals¹⁰10 El Achhab Y, El Ammari A, El Kazdouh H, Najdi A, Berraho M, Tachfouti N, Lamri D, El Fakir S, Nejjari C. Health risk behaviours amongst school adolescents: protocol for a mixed methods study. BMC Public Health 2016; 16(1):1-6.^,1111 Sichieri R, Cardoso MA. ERICA: Study of Cardiovascular Risk Factors in Adolescents (ERICA): results and potentiality. Rev Saude Publica 2016; 50(Supl. 1):2s..

In this context, the issue of self-medication among the adolescents represents a relevant topic in the pharmacoepidemiology. Thus, this study aimed to evaluate the prevalence and associated factors of self-medication among adolescents aged 18 and 19 years in the birth cohort of São Luís, Maranhão, Brazil.

Methods

This is a cross-sectional study nested in a cohort study, with individuals born in 1997/1998 in the city of São Luís. São Luís, capital of the state of Maranhão, is located on an island at the north coast of the state, in the Northeast Region of Brazil. In 2019, São Luís had a population of 1,101,884 inhabitants¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativas da população residente no Brasil e unidades da federação com data de referência em 1º de julho de 2019 [Internet]. Rio de Janeiro: IBGE; 2019 [acessado 2021 mar 18]. Disponível em: https://agenciadenoticias.ibge.gov.br/media/com_mediaibge/arquivos/7d410669a4ae85faf4e8c3a0a0c649c7.pdf. and, according to data from the Brazilian Institute of Geography and Statistics¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). Índice de Desenvolvimento Humano - Brasil/Maranhão/São Luís [Internet]. Rio de Janeiro: IBGE; 2020 [acessado 2021 mar 18]. Disponível em: https://cidades.ibge.gov.br/brasil/ma/sao-luis/pesquisa/37/30255?tipo=grafico., the Municipality’s Human Development Index was 0.768 in 2010.

In the São Luís cohort (1997/1998), one out of every seven live births to mothers living in the city was eligible for the first phase of the study, with delivery performed in ten public and private maternity hospitals from March 1997 to February 1998. The initial sample in the perinatal (N=2,831) corresponded to 96.3% of births in the studied period, excluding non-hospital births and those that occurred in hospitals with less than 100 births per year. Excluding non-residents in São Luís, twins and stillbirths, a final sample of the first phase of the study of 2,443 births was obtained, with 5.8% of losses due to refusals or early discharge¹⁴14 Silva AAM, Coimbra LC, Silva RA, Alves MTSSB, Lamy Filho F, Lamy ZC, Mochel EG, Aragão VMF, Ribeiro VS, Tonial SR, Barbieri MA. Perinatal health and mother-child health care in the municipality of São Luís, Maranhão State, Brazil. Cad Saude Publica 2001; 17(6):1412-1423..

This cohort was followed up at 7-9 years old and again at 18-19 years old. In this article, data from the second cohort follow-up, conducted with participants aged 18-19 years, in 2016/2017 were used. In this follow-up, all individuals included in the initial phase of the study were searched at the Military Enlistment Boards of São Luís, in the 2014 school census and in universities, totaling 687 participants. In order to increase the power of the sample and prevent future losses, the cohort was opened to include other individuals born in São Luís, in 1997. The first search stage took place by means of a drawing using data from the Information on Live Births (SINASC), considering the following criteria for registration: birth in a maternity hospital in the city of São Luís, in 1997. From this list, a random drawing was carried out, obtaining a total of 4,593 born in 1997 in the city of São Luís, from whom it was possible to make telephone or personal contact with 1,133 individuals. In a second stage, 695 volunteers born in the same year were identified in schools, universities and through social media. Thus, the total sample of participants aged 18-19, including both the prospective (original cohort) and retrospective cohort components, was 2,515 adolescents¹⁵15 Simões VMF, Batista RFL, Alves MTSSB, Ribeiro CCC, Thomaz EBAF, Carvalho CA, Silva AAM. Saúde dos adolescentes da coorte de nascimentos de São Luís, Maranhão, Brasil, 1997/1998. Cad Saude Publica 2020; 36(7):e00164519.. In this article, data from the second cohort follow-up, conducted with participants aged 18-19 years, in 2016/2017 were used.

In the follow-up at 18-19 years, data collection took place on the premises of UFMA and was carried out by health professionals who were trained to conduct interviews and operate the instrument used in the research.

Questionnaires were applied by interviewers to collect data from demographic, socioeconomic, lifestyle, health information and self-reported skin color and morbidity variables. Data on the use of illicit drugs, in turn, were obtained through a self-administered confidential questionnaire.

Leisure physical activity was assessed using the Physical Activity Survey, based on an adaptation of the Self-Administered Physical Activity Checklist (SAPAC)¹⁶16 Sallis JF, Strikmiller PK, Harsha D, Feldman HA. Validation of interviewer-and-self-administered physical activity checklists for fifth grade students. Med Sci Sports Exerc 1996; 28(7):840-851..

Screen time was measured by reporting exposure to television, video games, cell phones, tablets and computers in hours/days of the week, except on weekends, as they are considered atypical days.

Regarding data on medication use, the adolescent was asked specifically about the use of medicines in the last fifteen days (yes or no) and, in case of a positive answer, he was asked about the quantity (number) and type of medicine used (drug name), as well as who indicated/prescribed it (doctor, other health professional, mother, family member/friend, nobody (he/she took it on his/her own), other, does not know).

Conventional drugs used with the purpose of preventing, treating or alleviating their symptoms of diseases or health alterations, produced under strict technical control, were considered as medicines¹⁷17 World Health Organization (WHO). World Health Organization model list of essential medicines: 21st list 2019 [Internet]. Geneva: WHO; 2019 [cited 2021 jul 30]. Available in: https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU-2019.06-eng.pdf.^,1818 Brasil. Agência Nacional de Vigilância Sanitária (ANS). O que devemos saber sobre medicamentos [Internet]. Brasília: ANS; 2010 [acessado 2021 jul 30]. Disponível em: https://www.gov.br/anvisa/pt-br/centraisdeconteudo/publicacoes/medicamentos/publicacoes-sobre-medicamentos/o-que-devemos-saber-sobre-medicamentos.pdf/view..

Self-medication, the outcome of the study, was defined how the ingestion of medicines on their own initiative, or on the advice of another person, without consulting a doctor or other health professional qualified to prescribe medication¹1 World Health Organization (WHO). Guidelines for the regulatory assessment of medicinal products for use in self-medication. Geneva: WHO; 2000.. Thus, it was considered self-medication who answered the options mother, family member/friend, nobody (he/she took it on his/her own) or other in the question about who indicated the medications used.

The drugs used by self-medication were classified according to Anatomical Therapeutic Chemical Classification system¹⁹19 World Health Organization (WHO). ATC/DDD Index 2021 [Internet]. Oslo: Collaborating Centre for Drug Statistics Methodology; 2021 [cited 2021 mar 18]. Available in: https://www.whocc.no/atc_ddd_index/.. Through this classification system, the drugs are classified in levels according to anatomical/pharmacological groups (1^st levels) and pharmacological or therapeutic groups (2^nd levels). We also classified the drugs in “over the counter” (OTC) medication using a list of the Brazilian National Health Surveillance Agency²⁰20 Brasil. Agência Nacional de Vigilância Sanitária (ANS). Instruc¸a~o Normativa, nº 11, de 29 de setembro de 2016. Dispo~e sobre a lista de medicamentos isentos de prescric¸a~o. Dia´rio Oficial da Unia~o; 2016.. OTC drugs are drugs approved by health authorities for sale without the requirement of a medical prescription, being indicated to treat self-limited health problems¹1 World Health Organization (WHO). Guidelines for the regulatory assessment of medicinal products for use in self-medication. Geneva: WHO; 2000..

In cases where a specific answer was not obtained regarding the type of drug used, for example when the adolescent did not know to inform the name of the drug, its commercial or generic name, or when only the therapeutic class was mentioned, these data were not considered.

To assess the factors associated with self-medication, a multiple regression analysis model with a hierarchical approach was used. Fuchs et al.²¹21 Fuchs SC, Victora CG, Fachel J. Modelo hierarquizado: uma proposta de modelagem aplicada à investigação de fatores de risco para diarréia grave. Rev Saude Publica 1996; 30(2):168-178., emphasizes the importance of balancing statistically significant associations with biological and social contexts, through theoretical models with a hierarchical approach. The independent variables were selected based on the previous literature on factors associated with self-medication in adolescents²²22 Shehnaz SI, Agarwal AK, Khan N. A systematic review of self-medication practices among adolescents. J Adolesc Health 2014; 55(4):467-483. and organized into levels according to hierarchical conceptual model for the outcome of self-medication in adolescents elaborated by the researchers (Figure 1).

Independent variables were grouped into three blocks, according to the hierarchical conceptual model (Figure 1): Block 1 (distal level) comprised socioeconomic and demographic variables categorized as: sex (male and female), skin color (white/yellow and black/brown), marital status (without partner and with partner), adolescent education (elementary school, high school, pre-university course, technical school and incomplete university graduate), head of household education (uneducated, elementary school, high school, incomplete university graduate, complete university graduate), current job (no and yes), family income (<1 minimum wage, 1 minimum wage and ≥2 minimum wages) - Minimum wages values: BRL 880.00 in 2016 and BRL 937.00 in 2017. Block 2 (intermediate level) was composed of lifestyle variables categorized as : smoking (never smoked, stopped smoking and current smoker), consumption of alcoholic beverages (never, ≤1 time/month, 2 to 4 times/month, ≥5 times/month), use of illicit drugs (never used, just experienced, already used, but stopped, only on weekends/one occasion and use every day/almost every day), physical activity level (sedentary, low, moderate and high), screen time (≤2 hours/day, 2 to 4.9 hours/day and ≥5 hours/day). In block 3 (proximal level) encompassed health-related variables categorized as: self-satisfaction with health (unsatisfied/very unsatisfied, regular and satisfied/very satisfied), hospitalization in the previous year (no and yes) health insurance (no and yes) hyperglycemia/diabetes (no and yes), hypercholesterolemia (no and yes), arterial hypertension (no and yes), allergic rhinitis (no and yes), skin allergy/eczema (no and yes).

Statistical analyzes were performed with the aid of the software Stata version 14.0. To characterize the study population, categorical variables were described using absolute and relative frequencies and quantitative variables using measures of central tendency and dispersion.

The analysis of factors associated to self-medication was performed using Poisson Regression, with robust variances. Initially, a crude analysis was performed, estimating the prevalence ratios of self-medication and the respective 95% confidence intervals. Variables with a P-value less than 0.20 were included in the multivariate analysis, in a hierarchical manner, according to the blocks/levels of the conceptual model.

Firstly, the variables in block 1 were included (Model 1). After, the variables in block 2, adjusted by the variables with P-value<0.20 of the block 1 (Model 2). Finally, variables from block 3 were included, adjusted for the significant variables with P-value<0.20 of blocks 1 and 2 (Model 3). They were considered as significantly associated with self-medication the variables that presented P-value≤0.05 in each regression model. The Akaike criterion was used to compare the models.

The research project was submitted to and approved by the Research Ethics Committee from the University Hospital of Universidade Federal do Maranhão (substantiated opinion No. 1302489 of October 29, 2015), and conducted in accordance with the ethical standards set out in the 1964 Helsinki Declaration and its subsequent amendments. The informed consent form was signed by the study participants.

Results

Among 2,515 adolescents included in this study, 52.45% of whom were female, most of them black/brown, without partner, with high school/pre-university course and family income greater than two minimum wages (Table 1). As for lifestyle characteristics, most adolescents reported never having smoked and never consuming alcoholic beverages, on the other hand, most were sedentary (Table 2). Regarding health characteristics, the majority reported being satisfied/very satisfied with their own health, they were not hospitalized in the previous year and did not have a health insurance. Among self-reported morbidities, the most frequent were allergic rhinitis, skin allergy/eczema and hypercholesterolemia (Table 2).

When asked about the use of medications in the last 15 days, 48.05% of the adolescents reported the use of some type of medication (totalizing 1197 medications), with the average number of medications used among the adolescents being 1.57 (Standard deviation: 0.95). The prevalence of self-medication in the total population (among those who did not take medication and those who did) was 33.36%. Among the adolescents who used any medication in the last 15 days, 70.09% reported using it without a doctor’s prescription or from another health professional, of which 93.68% were OTC (data not shown in table).

Based in ATC classification, the most used drugs without a prescription were: analgesics 34.80% (292), muscle relaxants 21.57% (181), anti-inflammatory and anti-rheumatic drugs 17.64% (148), drugs for functional gastrointestinal disorders 11.08% (93), cough and cold preparations 8.58% (72). In addition, among the drugs used 3.58% (30) represented prescription drugs (antibacterials for systemic use) and 0,84% (7) of medicines subject to special control (antiepileptics, psycholeptics/anxiolytics, psychoanaleptics/ antidepressants and psychoanaleptics/psychostimulants, agents used for attention deficit hyperactivity disorder and nootropics) (Table 3).

In the bivariate analysis, among the socioeconomic and demographic variables, sex, skin color, adolescent education, head of household education level and family income were included in the multiple model (Table 1). Among the lifestyle variables, with the exception of smoking, all were included in the multiple analysis. Among the health-related characteristics, self-satisfied health, hospitalization in the previous year, hyperglycemia/diabetes, hypercholesterolemia, allergic rhinitis and skin allergic/eczema were included in the multiple analysis (Table 2).

In the hierarchical multivariate analysis (Table 4), in block 1, an association was observed between sex and self-medication: female had higher prevalence of self-medication when compared to male (Adjusted PR: 1.41; 95%CI: 1.25-1.59) - Model 1. In block 2, only the variable screen time was significantly associated with the outcome. The prevalence of self-medication was 32% higher among adolescents with screen time ≥5 hours/day when compared to those with ≤2 hours/day (Adjusted PR: 1.32; 95%CI: 1.05-1.67) - Model 2. In block 3, self-satisfaction with health, hospitalization in the previous year and allergic rhinitis were significantly associated with self-medication. The prevalence of self-medication was 21% lower among adolescents satisfied/very satisfied with their own health in relation to unsatisfied/very unsatisfied (Adjusted PR: 0.79; 95%CI: 0.67-0.94). In addition, the prevalence of the outcome was 30% lower among adolescents who were hospitalized in the year prior to the interview (Adjusted PR: 0.70; 95%CI: 0.50-0.97). In the order hand, it was observed higher prevalence of self-medication in the adolescents that reported allergic rhinitis (Adjusted PR: 1.19; 95%CI: 1.02-1.39) - Model 3.

Discussion

In the present study, the prevalence of self-medication in the total population (among those who did not take medication and those who did) and among adolescents who reported using medication in the last 15 days was 33.36% and 70.09%, respectively. Among the drugs used for self-medication, most were OTC drugs, however, prescription drugs and medicines subject to special control were also reported. Self-medication in adolescents aged 18-19 was associated with sex, screen time, self-satisfaction with health, hospitalization in the previous year and allergic rhinitis.

Regarding the prevalence of self-medication, in Brazil, literature has shown very heterogeneous results. Studies based on self-report of self-medication, carried out with Brazilian adolescents of different age groups already showed higher prevalence⁵5 Silva C, Giugliani ER. Consumption of medicines among adolescent students: a concern. J Pediatr 2014; 80(4):326-332.^,66 Moraes ACFD, Delaporte TRM, Molena-Fernandes CA, Falcão MC. Factors associated with medicine use and self medication are different in adolescents. Clinics 2011; 66(7):1149-1155., however, also has been observed lower frequencies ranging 10.3% and 26.7%⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181.^,77 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660.^,88 Bertoldi AD, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Tracking of medicine use and self-medication from infancy to adolescence: 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2012; 51(6):S11-S15.. In the northeast region, in turn, in a study conducted with adolescents from public and private schools in the city of Fortaleza, a prevalence of 20.8% of self-medication was observed⁷7 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660.. However, it is important to highlight that most studies were carried out with adolescents in younger age groups⁵5 Silva C, Giugliani ER. Consumption of medicines among adolescent students: a concern. J Pediatr 2014; 80(4):326-332.

6 Moraes ACFD, Delaporte TRM, Molena-Fernandes CA, Falcão MC. Factors associated with medicine use and self medication are different in adolescents. Clinics 2011; 66(7):1149-1155.

7 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660.^-88 Bertoldi AD, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Tracking of medicine use and self-medication from infancy to adolescence: 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2012; 51(6):S11-S15., and only the study by Bertoldi et al.⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181. evaluated subjects on similar age group to our study, reporting a prevalence of self-medication of 26.7% among adolescents 18 years old.

In this study, the most used drugs by self-medication among adolescents were OTC drugs. This finding corroborates the results of studies in several countries. According to this systematic review of 163 studies published between January 2000 and December 2013, the most used drugs for self-medication among adolescents were pain relievers, followed by vitamins and nutritional supplements, antiallergic agents and remedies for colds and coughs²²22 Shehnaz SI, Agarwal AK, Khan N. A systematic review of self-medication practices among adolescents. J Adolesc Health 2014; 55(4):467-483.. Among Brazilian adolescents’ studies, Silva et al.⁷7 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660. and Bertoldi et al.⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181. also reported a higher frequency of OTC drugs among drugs used for self-medication.

The high frequency of use of OTC drugs for self-medication among adolescents may be related to the easy access to these drugs in drugstores associated with the low use of health services by individuals in this age group²³23 Nunes BP, Flores TR, Duro SMS, Saes MDO, Tomasi E, Santiago AD, Thumé E, Facchini LA. Utilização dos serviços de saúde por adolescentes: estudo transversal de base populacional, Pelotas-RS, 2012. Epidemiol Serv Saude 2015; 24:411-420..

Although OTC drugs are considered safe, the indiscriminate use of these drugs can exacerbate their adverse effects, leading to health complications in individuals. The highest risks in the use of these drugs without professional guidance are related to the excessive frequency of use and their use in high doses Chronic toxicity effects have already been reported with the use of OTC drugs²⁴24 Gunn VL, Taha SH, Liebelt EL, Serwint JR. Toxicity of over-the-counter cough and cold medications. Pediatrics 2001; 108(3):e52..

Despite the low frequency, our study also observed the use of medicines that requires a medical prescription according to the legal provisions of the Brazilian National Health Surveillance Agency. Among adolescents who self-medicated, it was reported the use of antibacterials for systemic use²⁵25 Brasil. Agência Nacional de Vigilância Sanitária (ANS). Resolução de Diretoria Colegiada RDC nº 20, de 5 de maio de 2011. Dispõe sobre o controle de medicamentos à base de substâncias classificadas como antimicrobianos, de uso sob prescrição, isolado ou em associação. Diário Oficial da União 2011; 9 maio. and drugs subject to special control, such as antiepileptics, psycholeptics/anxiolytics, psychoanaleptics/antidepressants and psychoanaleptics/psychostimulants, agents used for attention deficit hyperactivity disorder and nootropics²⁶26 Brasil. Agência Nacional de Vigilância Sanitária (ANS). Portaria nº 344, de 12 de maio de 1998. Aprova o Regulamento Técnico sobre substâncias e medicamentos sujeitos a controle especial. Diário Oficial da União 1998; 19 maio.. These findings are worrying, since the use of medications that require presentation or retention of medical prescription in self-medication directly impacts several important clinical aspects, such as increased risk of developing bacterial resistance to antimicrobials, adverse reactions to medications, masking important symptoms, acute and chronic toxicity, as well as delay in looking for health services²⁷27 Lescure D, Paget J, Schellevis F, Van Dijk L. Determinants of self-medication with antibiotics in European and Anglo-Saxon countries: a systematic review of the literature. Front Public Health 2018; 6:370.^,2828 Ekambi GAE, Ebongue CO, Penda IC, Nga EN, Mpondo EM, Moukoko CEE. Knowledge, practices and attitudes on antibiotics use in Cameroon: Self-medication and prescription survey among children, adolescents and adults in private pharmacies. PloS One 2019; 14(2):e0212875..

Our study observed a higher prevalence of the outcome in females. According to the systematic review carried out by Shehnaz et al.²²22 Shehnaz SI, Agarwal AK, Khan N. A systematic review of self-medication practices among adolescents. J Adolesc Health 2014; 55(4):467-483., the prevalence of self-medication was higher in female adolescents in most countries, including in Brazil⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181.^,88 Bertoldi AD, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Tracking of medicine use and self-medication from infancy to adolescence: 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2012; 51(6):S11-S15.. This association can be explained, in part, by the occurrence of dysmenorrhea and the beginning of sexual life in adolescence, which leads adolescents to make frequent use of medications for the relief of dysmenorrhea symptoms and oral contraceptives. According to Sanctis et al.²⁹29 Sanctis V, Soliman AT, Daar S, Di Maio S, Elalaily R, Fiscina B, Kattamis, C. Prevalence, attitude and practice of self-medication among adolescents and the paradigm of dysmenorrhea self-care management in different countries. Acta BioMed 2020; 91(1):182-192., most adolescents discuss dysmenorrhea with family and friends, and rarely seek medical advice in this situation. As for the use of oral contraceptives, although it is a hormonal method, whose dispensation in the country is still permeated by the formal request for a medical prescription³⁰30 Moura ERF, Silva RMD, Galvão MTG. Dinâmica do atendimento em planejamento familiar no Programa Saúde da Família no Brasil. Cad Saude Publica 2007; 23:961-970., it cannot be ruled out that the acquisition of these drugs by Brazilian adolescents can often take place in commercial pharmacies and drugstores, where the prescription requirement is flexible and prices are relatively low³¹31 Borges ALV, Fujimori E, Kuschnir MCC, Chofakian CBDN, Moraes AJP, Azevedo GD, Santos KF, Vasconcellos MTL. ERICA: sexual initiation and contraception in Brazilian adolescentes. Rev Saude Publica 2016; 50(Supl. 1):15s., which favors self-medication. Another explanation is that, unlike men, who constantly ignore the presence of health symptoms, women tend to better recognize and express their health needs, initiating more curative health actions³²32 Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. J Adv Nurs 2005; 49(6):616-623., which often includes the practice of self-medication.

Another factor positively associated with self-medication in our study was screen time ≥5 hours/day. This association may be related to the effects caused by excessive exposure to screens, simultaneous to the long time spent in inappropriate positions when in front of the screens, such as headaches and muscle pain. In a study with Norwegian adolescents aged 15 and 16, it was found that headaches and muscle aches were common and that half of individuals with severe headaches/migraines self-medicated with analgesics daily or weekly. Among several reasons for feeling pain and discomfort, the adolescents reported the excessive time spent in front of several screens³³33 Lagerløv P, Holager T, Helseth S, Rosvold EO. Self-medication with over-the-counter analgesics among 15-16 year-old teenagers. Tidsskr Nor Laegeforen 2009; 129(15):1447-1450.. In addition, the longer screen time exposes the individual to various advertisements for medications such as OTC drugs, which are most often used for self-medication. The provision of based advertising campaigns, with purely commercial ones, stimulates the indiscriminate and growing consumption of medicines³⁴34 Luchessi AD, Marçal BF, Araújo GFD, Uliana LZ, Rocha MRG, Pinto TDJA. Monitoração de propaganda e publicidade de medicamentos: âmbito de São Paulo. Rev Bras Cienc Farm 2005; 41(3):345-349.. In the study by Silva et al.⁷7 Silva IM, Catrib AMF, Matos VCD, Gondim APS. Self-medication in adolescence: a challenge to health education. Cien Saude Colet 2011; 16(Supl. 1):1651-1660., 34.1% of the evaluated adolescents revealed that they had already been influenced by the media in the purchase of medicines. In this context, advertising becomes harmful when it induces self-medication by people who do not have a critical attitude in receiving medication advertising to recognize the limit of its use within health care³⁵35 Lage EA, Freitas MIDF, Acurcio FDA. Informação sobre medicamentos na imprensa: uma contribuição para o uso racional? Cien Saude Colet 2005; 10:133-139..

Our study also reported an association between Self-satisfied health and self-medication, and similar finding was reported by Bertoldi et al.⁴4 Bertoldi AD, Camargo AL, Silveira MPT, Menezes AM, Assunção MCF, Gonçalves H, Hallal PC. Self-medication among adolescents aged 18 years: the 1993 Pelotas (Brazil) birth cohort study. J Adolesc Health 2014; 55(2):175-181.. Self-rated health affects the use of medications, so poorer self-rated health is associated with a higher frequency of use of different types of medication among adolescents³⁶36 Holstein BE, Hansen EH, Andersen A, Due P. Self-rated health as predictor of medicine use in adolescence. Pharmacoepidemiol Drug Saf 2008; 17(2):186-192.. It is suggested that individuals with poor self-perception of poor health seek medication for immediate resolution of their health problems, often without professional guidance, which favors the practice of self-medication.

We also observed association between hospitalization in the previous year and self-medication. This association may be the result of greater knowledge about the proper use of medicines acquired through counseling received during hospitalization and at hospital discharge. Literature show that advice received during hospitalization seems to assist the patient in better understanding the information received about his medication and requesting additional information, if necessary. In addition, at hospital discharge, the patient is usually referred to the responsible physician in his community, where he should receive additional advice³⁷37 Kerzman H, Baron-Epel O, Toren O. What do discharged patients know about their medication? Patient Educ Couns 2005; 56(3):276-282.. Thus, it is suggested that adolescents who went through the remarkable experience of hospitalization in the last year would be better informed and more aware about the use adequate of medicines, leading them to avoid the practice of self-medication.

Finally, self-reported diagnosis of allergic rhinitis was associated with higher prevalence of self-medication in adolescents. Regarding this finding, literature shows that the use of self-medication medications has been restricted to acute self-limited diseases, including allergic rhinitis³⁸38 Arrais PSD, Fernandes MEP, Pizzol TDSD, Ramos LR, Mengue SS, Luiza VL, Tavares NUL, Farias MR, Oliveira MA, Bertoldi AD. Prevalence of self-medication in Brazil and associated factors. Rev Saude Publica 2016; 50(Supl. 2):13s., which is a common reason for self-medication with OTC drugs³⁹39 Demoly P, Allaert FA, Lecasble M, PRAGMA. ERASM, a pharmacoepidemiologic survey on management of intermittent allergic rhinitis in every day general medical practice in France. Allergy 2002; 57(6):546-554.

40 Maurer M, Zuberbier T. Undertreatment of rhinitis symptoms in Europe: findings from a cross-sectional questionnaire survey. Allergy 2007; 62(9):1057-1063.^-4141 Fromer LM, Ortiz G, Ryan SF, Stoloff SW. Insights on allergic rhinitis from the patient perspective. J Fam Pract 2012; 61(2 Supl.):S16-S22.. Nasal congestion is among the most common symptoms of allergic rhinitis, leading to the frequent use of nasal decongestants by patients. However, the repetitive and prolonged use of intranasal decongestants can result in hypertrophy of the nasal mucosa, leading to “medicated rhinitis”⁴²42 Lockey RF. Rhinitis medicamentosa and the stuffy nose. J Allergy Clin Immunol 2006; 118(5):1017-1018.. Thus, indiscriminate self-medication in the treatment of allergic rhinitis can worsen the condition of the individual.

This study has some limitations. One of them is the possibility of information bias in obtaining data regarding the classification and prescription of drugs used. Many drugs whose individuals did not remember their names or were unspecified notified (eg.: “anti-inflammatories”, “analgesics”) could not be classified according to their therapeutic group, so the frequencies of some drug classes may be underestimated. It is also possible that the prevalence of self-medication is underestimated, as without the specified drug it was not possible to identify the prescriber and another cause would be the fact that self-medication is a behavior that is not socially acceptable.

Another limitation is the possibility of information bias in verifying the use of illicit drugs, which is generally underestimated due to the possible embarrassment in responding to this issue. However, the use of a confidential and self-administered questionnaire to obtain this information may have minimized this bias.

Also, another limitation concerns morbidities. Considering the limited availability of data on morbidities in this research, especially symptomatic ones, the association with health problems with self-medication in adolescents cannot be better explored. Thus, the association with other morbidities not evaluated in this study should not be disregarded. In addition, the morbidities assessed in the present study were self-reported, which is also subject to information bias. However, self-reported morbidities remain one of the most widely used methods in epidemiology and their validity in terms of measuring health problems, already was established in different studies⁴³43 Prinja S, Jeet G, Kumar R. Validity of self-reported morbidity. Indian J Med Res 2012; 136(5):722-724..

On the other hand, this study also has strengths. As far as we know, this is one of the few studies on the subject with northeastern adolescents. In addition, the large sample size stands out, which represents a high statistical power, because the large population sample allows us to better stratify the different pharmacological classes used in the practice of self-medication in these adolescents.

Conclusions

Self-medication, a common practice among the adolescents evaluated in this study, represents a relevant topic in pharmacoepidemiology. The findings of the present study are fundamental for directing and implementing and encouraging health education programs and actions aimed to promoting the rational use of medicines in this age group. Based on the data presented, highlighting that in interventions to reduce this practice, greater attention should be given to women, individuals with intense exposure to screens and allergic diseases.

Acknowledgements

We thank the funding agencies that supported the research in the cohorts included in the study.

References

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