ABSTRACT:

Objective:

To estimate the prevalence, investigate factors associated with the use of medication according to prescription, identify the main pharmaceuticals consumed through self-medication, and the reason for this use among adult men.

Methods:

This cross-sectional population-based study with stratified clustered two-stage sampling was conducted in Campinas, São Paulo, Brazil, in 2008/2009.

Results:

Of the 1,063 men, 45.3% reported using at least 1 drug in the last 3 days. From them, 32.9% reported using exclusively prescribed medication, and 11.2% reported self-medication. The results revealed different profiles among subgroups. Positive associations with the use of prescription medication was found for age (40 - 59 and ≥ 60 years), failure to perform paid work, body mass index (25 - 30 kg/m²⁾, having sought health services over the last 15 days, dental care in the last year, morbidity, and chronic diseases. Lower use of prescription medication was found among men who reported doing physical activities in their leisure time. Independent and positive associations with the use of nonprescription medications in the 15 days prior to the survey were found for reported morbidity and frequent headaches/migraine. Furthermore, there was an independent and inverse association for hospitalization within the last year. Over-the-counter medications consumed by men were dipyrone, paracetamol, acetylsalicylic acid, and diclofenac.

Conclusion:

The findings of this study provide information that can guide actions aimed at promoting the rational use of medication in a poorly investigated population subgroup regarding this topic.

Keywords:
Medication use; Prevalence; Men's health; Self-medication; Pharmacoepidemiology; Epidemiological surveys

INTRODUCTION

Men constitute the population subgroup with the highest risk of death¹1. Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Ciênc Saúde Coletiva 2005; 10(1): 35-46.. The gender differences in the risk of becoming sick are modified according to lifestyle and biological, socioeconomic, cultural, and behavioral factors¹1. Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Ciênc Saúde Coletiva 2005; 10(1): 35-46.^,22. 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.. Still, health perception can vary owing to factors connected to the social experiences of the individual, access to health services, the form in which people notice symptoms, evaluate the gravity of the sickness, and decide what to do regarding their health problems³3. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Ciênc Saúde Coletiva 2002; 7(4): 687-707.^,44. Gomes R, Nascimento EF, Araújo FC. Por que os homens buscam menos os serviços de saúde do que as mulheres? As explicações de homens com baixa escolaridade e homens com ensino superior. Cad Saúde Pública 2007; 23(3): 565-74.. Sawyer et al.⁵5. Sawyer DO, Leite IC, Alexandrino R. Perfis de utilização de serviços de saúde no Brasil. Ciênc Saúde Coletiva 2002; 7(4): 757-76. analyzed the user profile for health services in Brazil and found that, when sick, younger men initially seek pharmacies and emergency services.

Excess mortality among male is reported in various places around the world. In Brazil, Laurenti et al.¹1. Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Ciênc Saúde Coletiva 2005; 10(1): 35-46. investigated the profile of morbidity and mortality among men and found higher mortality for all ages and for all cause groups. In Campinas, São Paulo, a similar pattern was observed, with significant inequality in mortality in relation to gender, a fact that is partially explained by male behavior, which is molded by sociocultural factors⁶6. Belon AP, Barros MB, Marín-Léon L. Mortality among adults: gender and socioeconomic differences in a Brazilian city. BMC Public Health 2012; 12: 39.. Regarding health conditions and the use of services, despite the female excess morbidity, men are more vulnerable to severe chronic illnesses, which impose limitations and are an important cause of death¹1. Laurenti R, Mello Jorge MHP, Gotlieb SLD. Perfil epidemiológico da morbi-mortalidade masculina. Ciênc Saúde Coletiva 2005; 10(1): 35-46.^,77. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem: princípios e diretrizes. Brasília: Ministério da Saúde; 2008..

In 2008, after identifying that men present low access to the actions for health promotion and prevention and that they access the health system for specialized care, the Ministry of Health implemented a National Policy for Integral Attention to Men's Health. This policy was created with the intention of promoting health actions that reduce morbidity and mortality owing to preventable causes, considering the male singularity in the sociocultural, political and economic contexts and the different levels of development and organization of the local health systems. One of its guidelines is to give full attention to the quality of life and education as important strategies in the promotion of behavioral changes⁷7. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem: princípios e diretrizes. Brasília: Ministério da Saúde; 2008..

Medication is a necessary therapeutic instrument, responsible for the increase in the population's life expectancy and quality⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46.. Its use is influenced by sociodemographic and cultural factors, morbidity profile, characteristics of the pharmaceutical market, and the government policies⁹9. Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saúde Pública 2004; 38(2): 228-38.^,1010. Arrais PSD. Medicamentos, consumo e reações adversas: um estudo de base populacional. Fortaleza: Edições UFC; 2009.^,1111. Oliveira LCF, Assis MMA, Bardoni AR. Assistência Farmacêutica no Sistema Único de Saúde: da Política Nacional de Medicamentos à Atenção Básica à Saúde. Ciênc Saúde Coletiva 2010; 15(Suppl 3): 3561-7.. As a form of self-care in search of health, self-medication is understood as the selection and use of medication for health maintenance, illness prevention, and treatment of noticed sicknesses and symptoms, without the prescription, guidance, or follow-up of a doctor or dentist¹²12. Brasil. Ministério da Saúde. Portaria nº 3.916, de 30 de outubro de 1998. Aprova a Política Nacional de Medicamentos. Brasília: Diário Oficial da União; 1998. Seção 1, p. 18-22..

A Spanish study found a prevalence of 57.7% for the use of medication and of 14.5% for self-medicating in men (≥ 16 years), considering the use of any medication (with/without prescription) and a recording period of 2 weeks. Age, consumption of alcohol, hours of sleep, and the absence of a visit to the doctor's, among other factors, were associated with self-medication¹³13. Carrasco-Garrido P, Hernández-Barrera V, López de Andrés A, Jiménez-Trujillo I, Jiménez-García R. Sex-differences on self-medication in Spain. Pharmacoepidemiol Drug Saf 2010; 19(12): 1293-9.. In the population from Campinas, São Paulo, in 2001/2002, for a recall period of 3 days, self-medication was highest among women of all ages, except for the 20 to 39 age group, where the prevalence among men in this age subgroup was of 43.3%¹⁴14. Perrone AMF, Molina MC, Bertonha MEAM, Nativio J, Barros MBA. Uso de medicamentos. In: Barros MBA, César CLG, Carandina L, Goldbaum M. As dimensões da saúde: inquérito populacional em Campinas. São Paulo: Aderaldo & Rothschild Editores; 2008. p. 218-229..

The need to investigate these health conditions and the conduct related to the health of men justifies the assessment of the use of medication in this population. In addition, the identification of the pharmaceuticals consumed without a prescription is important in guiding actions that promote health and prevent the worsening of conditions, in favor of an approach that includes the rational use of medication among men. The objective of this study was to estimate the prevalence, find the factors associated with the use of medication according to prescription, identify the main pharmaceuticals consumed without indication, and the reason for this use, among adult men living in the urban area of Campinas, São Paulo, Brazil.

METHODS

This is a population-based cross-sectional study, which included 1,063 noninstitutionalized men (≥ 20 years), living in the urban area of the city of Campinas, São Paulo, between 2008 and 2009. Data from the Health Survey in the city of Campinas ("Inquérito de Saúde no município de Campinas" - ISACamp) were utilized, a questionnaire conducted by the Collaborating Center in Health Situation Analysis (Centro Colaborador em Análise de Situação de Saúde - CCAS) from the Department of Public Health from the College of Medical Science at Universidade Estadual de Campinas (UNICAMP).

The survey sample was obtained through probabilistic sampling by clusters and in two stages: census tracts and household. In the first stage, 50 census tracts were selected with probability proportional to size (number of households). In the second stage, households were selected through systematic sampling applied to the frame of existing households in each of the selected tracts. The number of people in the sample was obtained considering the situation corresponding to the maximum variability for the frequency of events studied (p = 0.50), confidence level of 95% in the determination of the confidence intervals (score z = 1.96), sample error between 4 and 5%, and design effect equal to 2, totaling 1,000 individuals in each age group: adolescents (10 - 19 years), adults (20 - 59 years), and elderly men (≥ 60 years). A response rate of 80% was expected; so, the sample was corrected to 1,250 and, in order to reach it in each age group, after updating the selected tracts and compiling the list of addresses, households for adolescents, adults, and elderly men were selected respectively: 2,150, 700, and 3,900. All of the inhabitants of the age group were interviewed in the households, as reported at: http://www.fcm.unicamp.br/fcm/sites/default/files/plano_de_amostragem.pdf. The information was obtained through a structured questionnaire that had been previously tested during a pilot study, conducted in household interviews by trained and supervised interviewers.

In this study, the data utilized from the questionnaire referred to the adult (≥ 20 years) male (n = 1,063) population, and the dependent variable was created according to the following questions:

Next, based on the answers obtained, the participants were allocated into three groups: those who did not use medication (reference category), those who reported having used medication prescribed by a doctor or dentist, and those who consumed exclusively nonprescribed medication (self-medication). The records relative to those who reported the simultaneous use of prescription and nonprescription were excluded from the analyses. The use of medication without a prescription of a trained professional (doctor or dentist) refers to the pharmaceuticals utilized through the indication of a pharmacist/pharmacy attendant, layperson (relative, friend, or neighbor), consumed on their own, or leftover from a treatment prior to the survey. Within this concept, responsible self-medication is discussed, which is the treatment of diseases, signs, and symptoms utilizing "over-the-counter" medication (OTCs), which should have proved efficacy and safety when utilized rationally¹²12. Brasil. Ministério da Saúde. Portaria nº 3.916, de 30 de outubro de 1998. Aprova a Política Nacional de Medicamentos. Brasília: Diário Oficial da União; 1998. Seção 1, p. 18-22..

For the identification of the medication, the package and/or the prescription was solicited in order to minimize possible errors when recording the data. The medication was classified utilizing the five levels of the Anatomical Therapeutic Chemical Code (ATC). This classification was often used for comparing national and international data and takes into consideration the anatomical group or the system in which it acts, its chemical, therapeutic, and pharmacological characteristics¹⁵15. World Health Organization. ATC/ DDD Index 2009. Disponível em http://www.whocc.no/atc_ddd_index/ (Acessado em 03 de março de 2010).
http://www.whocc.no/atc_ddd_index/... . The Dictionary of Pharmaceutical Specialties (Dicionário de Especialidades Farmacêuticas - DEF 2008/2009) was utilized to identify the composition of the pharmaceuticals¹⁶16. DEF Dicionário de Especialidades Farmacêuticas 2008/09. 37ª ed. São Paulo; Epub; 2008.. For the medication whose name the interviewee was unable to report, a code on nonidentification was given; for those that were not listed in the ATC, codes were created to identify them; and for those that did not present a specific code in the ATC, a code was utilized that allowed the identification of the group, class, and therapeutic action. In the codification of the reported morbidity, the International Classification of Diseases version 10 (ICD10)¹⁷17. World Health Organization. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde. 10ª revisão. Geneva: WHO; 2007., was utilized.

In the analysis of the factors associated with the use of medication according to a prescription, the following independent variables were selected:

In the data analysis, initially the association was found between the many variables and the consumption of medication according to a prescription, through the RaoScott test with a significance level of 5%. Next, a multiple analysis was conducted through a multinomial logistic regression, adequate to the variable polytomous response with mutually exclusive categories that have no implicit order between them¹⁸18. Agresti A. Categorical data analysis. New York: John Wiley & Sons; 1990., to obtain an estimate of the odds ratio (OR) and their respective confidence intervals of 95% (95%CI). The initial logistic model included all the variables that presented an association at a level of p < 0.20 in the bivariate analysis and those that presented a p value lower than 0.05 remained in the final model.

In this analysis, the groups were simultaneously compared with the reference category, that is, the group that did not consume medication in the 3 days prior to the survey. Moreover, all pharmaceuticals consumed through self-medication were identified, regarding the reason for use, and the percentage of frequency were presented. The analyses were conducted utilizing the program Stata 11.0, whose analysis procedures for population surveys incorporate features of complex sampling. The project was approved by the Ethics Committee of Universidade Estadual de Campinas (Addendum to Opinion nº 079/2007). All of the respondent/legal guardians signed the Term of Free and Informed Consent, and there is no conflict of interests.

RESULTS

The study included 1,063 individuals of the male sex, ≥ 20 years, with responses (yes or no) for the use of medication in the 3 days prior to the survey. The average age of the population studied was 41.6 years (95%CI 40.3 - 42.9). Regarding the consumption of medication, 45.3% (95%CI 41.3 - 49.4) reported having consumed at least 1 medication in the 3 days prior to the interview: 521 (32.9%) had consumed exclusively prescription medication; 80 (11.2%) reported only nonprescribed medication; and 26 (1.3%) reported having consumed simultaneously prescribed and nonprescribed medication. Regarding the average number of medication used according to a prescription, a significant statistical difference was observed for the ≥ 80 years age group (p < 0.05).

The prevalence of medication use following a prescription, according to the sociodemographic characteristics of men, is presented in Table 1. Age group, marital status, education level, and paid work presented significant association to the use of medication in the bivariate analysis (p < 0.05). Among the men who perform paid work, 13.3% reported the use of nonprescribed medication during the survey.

Regarding the prevalence of the use of medication and behavior related to health, having health insurance and using health services, the BMI index, tobacco use, practicing physical activities during leisure time, seeking out medical professionals or health services in the last two weeks, and hospitalization in the last year were all significantly associated with the use of medication following a prescription. Among smokers, the prevalence of self-medication was of 12.4% (95%CI 7.5 - 20.0) (Table 2).

In Table 3, the prevalence of use of medication according to a prescription is presented for the health status indicators. The prevalence of self-medication was of 17.6% among men who reported morbidity in the two weeks prior to the survey and around 22% in those who reported frequent headaches/migraines.

The results of the multinomial analysis of the factors associated with the use of medication according to a prescription are presented in Table 4. A higher use of prescription medication was found for age (40 - 59 years and ≥ 60 years), not doing paid work, BMI (25 to 30 kg/m²⁾, seeking medical professionals or services within the last 15 days, dental care in the last year, reported morbidity, and the presence of chronic diseases. Among the men who reported doing physical activity in their leisure time, a lower use of prescription medication was observed. Regarding self-medication, a higher OR was found for reported morbidity in the two weeks prior to the survey, and for frequent headaches/migraines, (OR=3.18; 95%CI 1.82-5.58). Moreover, an independent and negative association was found for hospitalization within the last year for this subgroup.

Table 5 presents the percentage frequency found for the sample design of the questionnaire, of the medication consumed without a prescription, and the reasons reported for the use as well. For sodium dipyrone, paracetamol, and acetylsalicylic acid (ASA), the frequency is given by its occurrence in monodrugs or in combination drugs. Thus, it could be noted that analgesics and anti-inflammatories were predominant among the most consumed medication without a prescription.

DISCUSSION

This study assessed the prevalence of use of medication and associated factors, according to prescription. Regarding the identified profile for prescribed use, the effect of age observed in the higher use of medication is described in various studies⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46.^,99. Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saúde Pública 2004; 38(2): 228-38.^,1919. Costa KS, Barros MBA, Francisco PMSB, César CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados:um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2011; 27(4): 649-58.. Comparisons among the subgroups investigated revealed an older age among men who reported the exclusive use of prescription medication in comparison to the others. Regarding average use, the profiles were similar, except for the age group ≥ 80 years, in which a lower use of nonprescribed medication was observed. This subgroup, in general, is more vulnerable, presents a lower level of health status, higher frequency of hospitalization, higher prevalence of chronic diseases and other health problems, and seeks health services more often. Perrone et al.¹⁴14. Perrone AMF, Molina MC, Bertonha MEAM, Nativio J, Barros MBA. Uso de medicamentos. In: Barros MBA, César CLG, Carandina L, Goldbaum M. As dimensões da saúde: inquérito populacional em Campinas. São Paulo: Aderaldo & Rothschild Editores; 2008. p. 218-229. point to the probable reasoning in the practice of self-medication in the more vulnerable age groups - children and elderly people -, who present health problems more frequently and are routinely monitored by a health professional.

Higher prevalence was observed for use of prescription medication in those who did not perform paid work. A population-based study conducted in Spain, with a recall period of 2 weeks and records from 1,799 men between the ages of 25 and 64 years, found a more elevated use among retired men²⁰20. 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): 121-30.. A health survey conducted in Fortaleza, Ceará, with a recall of 15 days, pointed to higher prevalence of medication use and self-medication among those who were unemployed⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46..

More prescription medication use was noted among overweight men. An important health determinant, excess weight is associated with adverse metabolism alterations-increase in arterial pressure, cholesterol, and resistance to insulin²¹21. World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO: 2002. Disponível em http://www.who.int/whr/2002/en/whr02_en.pdf (Acessado em 12 de junho de 2012).
http://www.who.int/whr/2002/en/whr02_en.... .

Seeking health services and having dental care were positively associated to the use of prescription medication in the multiple regression analysis, as observed in other studies¹⁹19. Costa KS, Barros MBA, Francisco PMSB, César CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados:um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2011; 27(4): 649-58.^,2222. Oliveira MA, Francisco PMSB, Costa KS, Barros MBA. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saúde Pública 2012; 28(2): 335-45.. In this study, from the men who reported having sought some health service, 97% received treatment, which reflects the access to services in the city. It should be noted that the access depends on the perception of health needs and its conversion into demands³3. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Ciênc Saúde Coletiva 2002; 7(4): 687-707..

An independent association was found between reported morbidity and the use of prescription medication. The illnesses, acute and chronic, are predictors of the use of medication⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46.^,99. Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saúde Pública 2004; 38(2): 228-38.^,1919. Costa KS, Barros MBA, Francisco PMSB, César CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados:um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2011; 27(4): 649-58.. This finding is, in part, explained through the higher use of services within this subgroup (data are not presented).

Self-medication was positively associated with reported morbidity and headaches/migraines and inversely associated with hospitalization in the last year. A common practice within the population⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46.^,2323. Vitor RS, Lopes CP, Menezes HS, Kerkhoff CE. Padrão de consumo de medicamentos sem prescrição médica na cidade de Porto Alegre, RS. Ciênc Saúde Coletiva, 2008; 13(Suppl 0): 737-43.^,2424. Naves JOS, Castro LLC, Carvalho CMS, Merchán-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Ciênc Saúde Coletiva 2010; 15(Suppl 1): 1751-62., self-medication is influenced by the familiarity with the medication, positive prior experiences, difficulty in accessing services, and the symbolic role that medication plays on the population⁸8. Arrais PSD, Brito LL, Barreto ML, Coelho HLL. Prevalência e fatores determinantes do consumo de medicamentos no Município de Fortaleza, Ceará, Brasil. Cad Saúde Pública 2005; 21(6): 1737-46.^,2424. Naves JOS, Castro LLC, Carvalho CMS, Merchán-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Ciênc Saúde Coletiva 2010; 15(Suppl 1): 1751-62.^,2525. Wannmacher L. Medicamentos de uso corrente no manejo de dor e febre. In: Brasil. Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Uso racional de medicamentos: temas selecionados. Brasília: Ministério da Saúde; 2012. p. 73-82.. It should be noted that headaches are a very frequent complaint among the adults and can be related to other health problems²⁶26. Wannmacher L. Paracetamol versus dipirona: como mensurar o risco? In: Organização Pan-Americana da Saúde, Organização Mundial da Saúde. Uso racional de medicamentos: temas selecionados. Brasília: OPAS; 2005.. In Porto Alegre, Rio Grande do Sul, in the assessment for the reason for using nonprescribed medication, the most reported were headaches and the flu²⁴24. Naves JOS, Castro LLC, Carvalho CMS, Merchán-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Ciênc Saúde Coletiva 2010; 15(Suppl 1): 1751-62.. As for independent and inverse association with hospitalization, a hypothesis would be that individuals with a history of severe problems would be more attentive and careful with the use of medication without guidance or would already be using an elevated number of prescription drugs. In this study, an association was observed between the presence of chronic diseases and self-medication, as found in Spain by CarrascoGarrido et al.¹³13. Carrasco-Garrido P, Hernández-Barrera V, López de Andrés A, Jiménez-Trujillo I, Jiménez-García R. Sex-differences on self-medication in Spain. Pharmacoepidemiol Drug Saf 2010; 19(12): 1293-9. for a recall period of 2 weeks.

In the assessment of pharmaceutical specialties used without a prescription, the main were: sodium dipyrone, paracetamol, ASA (in monodrugs or combination drugs), and diclofenac. Sodium dipyrone presented the highest frequency of use for cephalea/migraines and the flu. This higher proportion, which has been highlighted since the 1980s in Brazil¹⁰10. Arrais PSD. Medicamentos, consumo e reações adversas: um estudo de base populacional. Fortaleza: Edições UFC; 2009., does not occur in European countries or in the United States owing to allergic reaction and idiosyncrasies²⁶26. Wannmacher L. Paracetamol versus dipirona: como mensurar o risco? In: Organização Pan-Americana da Saúde, Organização Mundial da Saúde. Uso racional de medicamentos: temas selecionados. Brasília: OPAS; 2005.. Owing to its similar antithermal and analgesic efficacies compared with other pharmaceuticals, its use should be based on evidence²⁷27. Ong CK, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med. Res 2007; 5(1): 19-34.. A multicenter case - control study, which assessed the incidence and the risk factors for agranulocytosis and aplastic anemia (AA), did not find any association with dipyrone in the causative factor of AA²⁸28. Maluf E, Hamerschlak N, Cavalcanti AB, Júnior AA, Eluf-Neto J, Falcão RP, et al. Incidence and risk factors of aplastic anemia in Latin American countries: the LATIN case-control study. Haematologica 2009; 94(4): 1220-6..

Paracetamol and ASA, used separately or in combination, also presented an elevated proportion of use for cephalea, fever, and common cold management. Both hold analgesic and anti-thermal properties, but the anti-inflammatory and antiplatelet are not shared by paracetamol and dipyrone. In this study, the prevalence of the use of ASA without a prescription, reported for disorders of the circulatory system, was only 0.2%. According to Ong et al.²⁷27. Ong CK, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med. Res 2007; 5(1): 19-34., paracetamol is the first choice agent for the treatment of light to moderate pain, acute and chronic, associated with peripheral inflammatory reaction or otherwise, showing itself to be efficient and the safest profile, in comparison to the other nonopioid analgesics, making it the most prescribed drug for acute pain in the United States²⁹29. Sachs CJ. Oral analgesics for acute nonspecific pain. Am Fam Physician 2005; 71(5): 913-8.. ASA presents analgesic efficacy equal to paracetamol, but its use requires caution owing to the adverse side effects of salicylates in susceptible people²⁶26. Wannmacher L. Paracetamol versus dipirona: como mensurar o risco? In: Organização Pan-Americana da Saúde, Organização Mundial da Saúde. Uso racional de medicamentos: temas selecionados. Brasília: OPAS; 2005.. In addition, even at a single oral dose for pain treatment, gastric irritation can occur.³⁰30. Gotzsche PC. NSAIDs. In: BMJ Clinical Evidence, 2010. Disponível em http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217803/pdf/2010-1108.pdf (Acessado em 12 de junho de 2012).
http://www.ncbi.nlm.nih.gov/pmc/articles... .

Diclofenac was the most used nonprescribed anti-inflammatory, especially for cephalea and back pain. Ibuprofen presents less gastrointestinal risk, while diclofenac and naproxen hold intermediate risk²⁷27. Ong CK, Lirk P, Tan CH, Seymour RA. An evidence-based update on nonsteroidal anti-inflammatory drugs. Clin Med. Res 2007; 5(1): 19-34..

Among the disadvantages of self-medication, several issues can be highlighted such as delay in diagnosis and adequate therapy, drug interactions, adverse reactions, and intoxication²²22. Oliveira MA, Francisco PMSB, Costa KS, Barros MBA. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saúde Pública 2012; 28(2): 335-45.^,2424. Naves JOS, Castro LLC, Carvalho CMS, Merchán-Hamann E. Automedicação: uma abordagem qualitativa de suas motivações. Ciênc Saúde Coletiva 2010; 15(Suppl 1): 1751-62.. Men often adopt a behavior that denies fragility³¹31. Courtenay WH. Construction of masculinity and their influence on men's well-being: a theory of gender and health. Soc Sci Med 2000; 50(10): 1385-401.^,3232. Mendonça VS, Andrade AN. A Política Nacional de Saúde do Homem: necessidade ou ilusão? Psicol Polít 2010; 10(20): 215-26. Disponível em:, and incurring in not seeking help, even in situations related to health³³33. Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, et al. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saúde Pública 2010; 26(5) :961-70.. The risk of practicing self-medication is related to the level of education, the information the users have about medicines, and their access to a health system. National Policy for Integral Attention to Men's Health (Política Nacional de Atenção Integral à Saúde do Homem) has aligned with the National Primary Care Policy (Política Nacional de Atenção Básica) and the principles of the Public Health System (Sistema Único de Saúde - SUS), strengthening the actions and services in care networks, highlighting the necessity to amplify the access to primary care⁷7. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem: princípios e diretrizes. Brasília: Ministério da Saúde; 2008..

For Viacava et al.³⁴34. Viacava F, Almeira C, Caetano R, Fausto M, Macinko J, Martins M, et al. Uma metodologia de avaliação do desempenho do sistema de saúde brasileiro. Ciênc Saúde Coletiva 2004; 9(3): 711-24., access is defined as people's capacity to obtain necessary services, while adequacy is conceptualized as the degree with which care and interventions are based on existing technical knowledge. Thus, access to medical and pharmaceutical care does not necessarily imply in better health conditions, as bad prescription habits, dispensing errors, inadequate self-medication, failure of use of medication according to the indicated dosage and administration, among other factors, can lead to inefficient and unsafe treatments³⁵35. Valadão AF, Moreira ALP, Andrade LC, Pires CA, Firmino KF, Brum CA. Prescrição médica: um foco nos erros de prescrição. Rev Bras Farm 2009; 90(4): 340-3.^,3636. Brasil. Ministério da Saúde. Portaria nº 1.214, de 13 de junho de 2012. Institui o Programa Nacional de Qualificação da Assistência Farmacêutica no âmbito do Sistema Único de Saúde. Brasília: Diário Oficial da União; 2012.. Particularly, regarding pharmaceutical assistance, insufficient financial resources and the need for better training of the professionals who work in the processes and their managers can be highlighted¹¹11. Oliveira LCF, Assis MMA, Bardoni AR. Assistência Farmacêutica no Sistema Único de Saúde: da Política Nacional de Medicamentos à Atenção Básica à Saúde. Ciênc Saúde Coletiva 2010; 15(Suppl 3): 3561-7.^,3636. Brasil. Ministério da Saúde. Portaria nº 1.214, de 13 de junho de 2012. Institui o Programa Nacional de Qualificação da Assistência Farmacêutica no âmbito do Sistema Único de Saúde. Brasília: Diário Oficial da União; 2012.. Medicalization as the one and main representation of health needs should be deconstructed among its users³³33. Schraiber LB, Figueiredo WS, Gomes R, Couto MT, Pinheiro TF, Machin R, et al. Necessidades de saúde e masculinidades: atenção primária no cuidado aos homens. Cad Saúde Pública 2010; 26(5) :961-70.. Nevertheless, it should be highlighted that the possibility of receiving adequate treatment, when necessary, is fundamental to the reduction of morbidity and mortality³⁵35. Valadão AF, Moreira ALP, Andrade LC, Pires CA, Firmino KF, Brum CA. Prescrição médica: um foco nos erros de prescrição. Rev Bras Farm 2009; 90(4): 340-3.^,3636. Brasil. Ministério da Saúde. Portaria nº 1.214, de 13 de junho de 2012. Institui o Programa Nacional de Qualificação da Assistência Farmacêutica no âmbito do Sistema Único de Saúde. Brasília: Diário Oficial da União; 2012..

Among the limitations of this study, it should be considered that the recall period of 3 days can influence in the prevalence of the use of medication⁹9. Bertoldi AD, Barros AJD, Hallal PC, Lima RC. Utilização de medicamentos em adultos: prevalência e determinantes individuais. Rev Saúde Pública 2004; 38(2): 228-38.^,1919. Costa KS, Barros MBA, Francisco PMSB, César CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados:um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2011; 27(4): 649-58.^,2222. Oliveira MA, Francisco PMSB, Costa KS, Barros MBA. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saúde Pública 2012; 28(2): 335-45.. The use of medication can be underestimated due to the short period being considered, however, this period amplifies the possibility of obtaining information regarding the use of any drug (occasional or chronic/prescribed or nonprescribed). The unusual recall period makes the comparability to other findings difficult. The information regarding the use and the prescription were reported by the interviewees, and the memory bias can alter its precision¹⁹19. Costa KS, Barros MBA, Francisco PMSB, César CLG, Goldbaum M, Carandina L. Utilização de medicamentos e fatores associados:um estudo de base populacional no Município de Campinas, São Paulo, Brasil. Cad Saúde Pública 2011; 27(4): 649-58.; however, the period used can improve the information regarding the nonprescribed pharmaceuticals²²22. Oliveira MA, Francisco PMSB, Costa KS, Barros MBA. Automedicação em idosos residentes em Campinas, São Paulo, Brasil: prevalência e fatores associados. Cad Saúde Pública 2012; 28(2): 335-45.. It can be emphasized that although the size of the sample has been calculated for the adult and elderly cluster, and this study has included only men, a design effect was obtained (deff ) - a parameter that indicates the estimative precision obtained through complex sampling in comparison to simple random sampling - around 1.8 for the association tests.

It should be pointed out that the sociodemographic and cultural characteristics related to the medication, the recall period, and the definitions of the event studied, among other aspects, should be considered in comparative analyses. In this study, before the definition adopted for self-medication, the necessity for prescription for medication was not assessed. The dispensing of medication, free from prescription or otherwise, should be understood as a process of medical care. When dispensing is followed by adequate guidance, the risks related to inadequate use decrease. In this study, the proportion of medication indicated by pharmacists was inferior to 4%. Still, it should be considered that differences observed for use according to prescription can be partially attributed to the specificities of the population studied, the health status, the use of services, and the model of medical care.

This study utilized data from an ample health survey, which prevents detailing of questions that can be further investigated in a more specific study on the topic. However, the population-based health survey allowed for information to be obtained, which was unavailable in other databases, such as the secondary source of information for health³⁸38. Barros MBA. Inquéritos domiciliares de saúde: potencialidades e desafios. Rev Bras Epidemiol 2008; 11(Suppl 1): 6-19., and is fundamental for the planning and assessment of health policies.

CONCLUSION

In the assessment of the use of prescription medication, a chance of use can be pointed out, starting at 40 years, which is statistically similar to the elderly persons, overweight men, and those who have sought health professionals or services in the last two weeks. For those who reported self-medication, a higher chance of use was found to be among those who complained of frequent headaches/migraines.

Self-medication can be seen as a form of relieving the public health system, which is desirable; however, it is necessary that it be a responsible self-medication so that individuals can treat symptoms and ailments safely.

The use of medication according to prescription, observed for men living in Campinas, São Paulo, offers benefits for the direction of the actions and the development of critical awareness in the adult male population and in health professionals, contributing to the promotion of the rational use of medication and the improvement of health conditions among men.

ACKNOWLEDGEMENTS

Thank you to the Conselho Nacional de Desenvolvimento Científico e Tecnológico Desenvolvimento (CNPq), process nº 409747/20068, for the financing of the study and the productivity fellowship for M. B. A. Barros. To the Ministry of Health (Ministério da Saúde) and the Health Department of the City of Campinas (Secretaria Municipal de Saúde de Campinas) for the financial support for the study (In partnership with UNICAMP/Funcamp/SMS nº 4300). To the São Paulo Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo - FAPESP) for the PhD fellowship for T. F. Bastos and postdoctoral for P. M. S. B. Francisco.

References

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