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Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers’ attitudes toward their children’s health management

Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers’... Background: Since 2009, when the revised Pharmaceutical Affairs Act was enacted in Japan, self-medication practices have increased. Because the concept of self-medication was recently introduced in Japan, few studies exist on this topic. Therefore, it is necessary to explore how self-medication is practiced. This study examined Japanese consumers’ self-medication practices and attitudes toward over-the-counter (OTC) medicines based on their sex, age, and socioeconomic status (SES). Methods: The participants were 403 adults (M = 41.1 years, SD = 16.22). A quota sampling method was age employed based on age group, and participants completed an online questionnaire. Results: Participants in the 20–29 age group reported medical costs as an obstacle in seeing a doctor; in contrast, transportation was a mitigating factor for elderly people. Regarding SES, people at lower SES levels chose to rest instead of seeing a doctor or purchasing over-the-counter (OTC) medicines when sick. They also placed more value on national brand OTC medicines than private brands (likely due to advertisements). This finding suggests individuals with a low SES do not select OTC medicines based on their effects or ingredients. Regarding attitudes toward OTC medicines, Japanese participants seemed to be unaware of the potential for abuse and side effects associated with OTC medicines. Finally, in relation to caregivers’ self-medication practices for their children, the majority of participants reported taking their children to the hospital since children tend to receive free medical care. Furthermore, caregivers with a high educational background are more confident in being able to help manage their children’s health. Conclusions: Our results suggest that health and medical discrepancies among Japanese consumers pose new social problems. In Japan, universal health care is available, but the cost of receiving medical care is not completely free of charge. Thus, we hope that the government will attempt to meet the various needs of patients and support their well-being. Consumers also have to be more independent and aware of their health management, as self-medication practices will continue to play a more significant role in healthcare. More research is needed to find ways to teach Japanese consumers/patients of both the benefits and risks of over-the-counter (OTC) medicines. Keywords: Attitude toward OTC medicines, Health disparity, Medical disparity, Self-medication, Choice of OTC medicines * Correspondence: Ikuko_aoyama@baylor.edu Department of Design Science, Graduate School of Engineering, Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba-shi, Chiba 263-8522, Japan © 2012 Aoyama et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 2 of 9 http://www.apfmj.com/content/11/1/7 Background countries for over a decade. In the U.S., 70% of illnesses Self-medication, which is a common self-care practice, among preschoolers were treated with non-prescription is widespread around the world [1]. Self-medication medicines [7]. However, the use of non-prescription products account for approximately 20% of the total medicines for children was often inappropriate. A U.S. international pharmaceutical market [2]. Among various study found that 71% of caregivers have inappropriately self-medication options, the use of over-the-counter used non-prescription medicines for their children, and (OTC) medicines is the most prevalent. In the U.K., an 10.9% reported that they only “sometimes” read labels estimated £1,268.5 million was spent on OTC medicines and drug information [8]. Similarly, parents in the U.K. in 1994, which equates to one-third of the total cost of were generally unaware of potential side effects of OTC prescribed drugs [3]. In Germany, self-medication sales medicines because they believe that “over-the-counter were over £5.4 billion in 2006 [4]. The benefits of OTC medicines are not strong and were unlikely to harm medicines include convenience to consumers/patients, their child,” or they believe that “prescription medicines better self-management of minor problems, and a reduc- are strong and otherwise carry risks” [9 p. 27]. On the tion in governmental medical costs. Thus, throughout other hand, Du and Knopf [4] conducted a profile ana- the world, a wider range of medicines is becoming avail- lysis of caregivers who use OTC medicines and found able directly to the public [2], and the current practice “the higher the socioeconomic status of the children’s of self-medication offers consumers/patients more flex- family, or the higher the educational level of the chil- ible choices in health management. dren’s mother, the more OTC medicines the children Self-care choices vary according to sex, age, and socio- were likely to receive” (p. 606). Because OTC medicines economic status (SES). For example, in Ireland, females for children are relatively new in Japan, few studies have report buying OTC medicines more often than do males, been conducted. Therefore, it is necessary for public and younger adults report buying OTC medicines more health policy makers to explore how self-medication is often than older adults do [5]. With regard to SES, costs practiced for children in order to better construct paren- can function as a barrier that reduces access to prescrip- tal education regarding OTC administration. Caregivers’ tion medicines [6], but the significance of this variable demographic information, along with their attitudes, depends on the healthcare system within a particular must be addressed. country. In the U.S., where a universal health care sys- In Japan, the revised Pharmaceutical Affairs Act was tem is unavailable, a study found that a significantly only recently enacted in 2009; this introduced the con- large number of mothers without health insurance were cept of self-medication. In 2008, a group of Japanese likely to give OTC medicines to their young children [7]. researchers asked approximately 1,000 adults if they In contrast, in Denmark, a country with an established knew the term “self-medication” and 60.5% did not universal health care system, medical costs do not ap- recognize this term [10]. However, research on self- pear to function as a barrier that reduces access to pre- medication issues is important given the fact that declin- scription medicines [6]. In Japan, the effects of a long- ing birthrates and a growing proportion of elderly people term recession have negatively influenced the overall will have a significant impact on the Japanese pension economic situation of many individuals. Thus, a med- and social welfare system in the near future. ical/health discrepancy between people low and high in Therefore, the goals of the present study were to SES is apparent. Do people at lower SES levels hesitate examine the following: (1) how Japanese consumers/ to see a doctor because of medical costs? This question patients practice self-medication to manage their health has yet to be well researched. When people at lower SES problems, (2) how Japanese consumers/patients select levels are encouraged to practice self-medication, are particular OTC medicines, (3) how consumers/patients’ they able to choose medicines based on valid evidence of attitudes toward OTC medicines, and (4) caregiver- initiated medication behaviors for children. This study the medicine’s safety? Advertisements for OTC medi- cines are legal in many countries, including Japan, and also investigated the role of sex, age, and socioeconomic such marketing might affect perceptions among consu- status (SES) on the preceding research questions. mers/patients as to the benefits of different products [2]. Traditionally, patients are rather passive and dependent, Method and they tend to follow the instructions of experts [1]. Participants However, taking individual responsibility for safe self- Participants were 403 adults living in the Kanto area of medication practices is increasingly necessary as several Japan, which consists of seven prefectures including OTC medicines become available on the market. Tokyo (M = 41.12, SD = 16.19, range 20–79, male = age When discussing self-medication issues, the topic of 47.4%, female = 52.6%). The research company, Media self-medication for children is noteworthy. Research on Interactive Inc., recruited participants in 2011. Among this topic has been accumulating within Western the 403 participants, 331 had children. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 3 of 9 http://www.apfmj.com/content/11/1/7 A quota sampling method was employed to compare Self-medication behaviors the following three age groups: a young group (20–29), Self-medication behaviors were measured by the ques- middle age group (30–49) and a senior group (65 years tion: “When you have a high fever (39°C/102.2°F or old and above). There were an approximately equal higher), what do you do?” Response choices were (1) I number of male and female participants within each will see a doctor and treat with prescribed drugs, (2) I stratum (Table 1). These three age groups were selected will treat with OTC medicines, (3) I will rest for a while, for the following reasons. First, we wanted to examine (4) I will treat with an alternative method such as acu- how parents of young children (elementary school and puncture and reflexology, or (5) Other. Next, partici- younger) practiced self-medication for both their chil- pants were asked the reason for their choice (e.g., “Why dren and themselves. Thus, we placed a focus on asses- do you see a doctor?” or “Why don’t you see a doctor?”). sing participants in their 30s and 40s. Second, we For their children, the question was, “When your child wanted to examine age differences in self-medication has a high fever (39°C/102.2°F or higher), what do you practices. These age groups (20s, 30 − 40s, and 65 and do?” older) are especially important groups to address given the intergenerational economic inequality in Japan. The choice of OTC medicines According to a report from the Cabinet Office, Govern- The choice of OTC medicines was measured by the ment of Japan (2012), the differences in net benefit (the question: “Which OTC medicines do you want to buy ratio of net benefit from the social security system rela- when you treat your illness?” Response choices were: (A) tive to lifetime income) between younger and older a national brand OTC medicine often seen in a TV ad- adults is 12% [11]. The government is acutely aware of vertisement or (B) a private brand OTC medicine that the fact that the younger generation suffers a larger net has the same effects and ingredients but is 50% cheaper burden and believes that intergenerational inequality than the national brand. National brand OTC medicines should not be ignored. refer to medicines produced by a major pharmaceutical company (i.e., Tylenol and Advil in the U.S.). On the other hand, private brand OTC medicines refer to medi- Procedures cines that are similar to a national brand OTC medicine All of the survey questions were uploaded online. The but are sold at specific retailers (i.e., Walmart). Examples participants who agreed to complete the survey accessed of OTC medicines in Japan are aspirin and cough and it through a provided URL. After filling out the online cold medicines; antibiotics are not included. survey, Media Interactive Inc. gave the participants In terms of reasons for selecting a national brand points that could be accumulated in exchange for a gift OTC medicine, response choices were (1) I feel safe be- card. cause I often see the item on a TV advertisement, (2) I feel safe because a well-known pharmaceutical company produces it, (3) I feel safe because I have always taken Questionnaire and measures the same medicine, (4) Cheap medicines make me feel Participants answered 43 questions, including informa- anxious, (5) Unknown pharmaceutical companies make tion about demographics. The survey inquired about me feel anxious, (6) More expensive medicines seem to self-medication behaviors (for the individual and for work better, (7) I like the package design, or (8) Other. children if the participant was a parent) and the reasons Response choices for selecting a private brand OTC for their choice, the choice of OTC medicines, and atti- medicine were (1) It is cheaper, (2) Ingredients and ef- tudes toward OTC medicines (for the individual and for fectiveness will be the same as the national brand OTC children if the participant was a parent). medicine, (3) There will not be a big difference among OTC medicines, (4) It seems better than the national brand sold by a major pharmaceutical company, (5) I Table 1 Participants’ sex and age like the package design, or (6) Other. n% Total (N) 403 100.0 Attitudes toward OTC medicines Male: 20s 61 15.1 Several questionnaires developed by Bradley et al., [3] Male: 30–40s 90 22.3 Trajanovska, Manias, Cranswick, and Johnston [12], and Male: 65–79 40 9.9 Wazaify et al. [5] were adapted and translated for this Female: 20s 82 20.3 study to measure patients’ attitude toward medicines. Female: 30–40s 90 22.3 The questionnaire consisted of 23 questions measuring Female: 65–79 40 9.9 positive and negative attitudes toward OTC medicines, Note: There were no participants in the 50–64-year-old category. perceived value and side effects of OTC medicines, and Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 4 of 9 http://www.apfmj.com/content/11/1/7 criteria for purchasing OTC medicines. All questionnaire behaviors and the choice of OTC medicines according items and responses are listed in Table 2. to sex, age, and SES. Phi coefficients (Φ)werecalculated as measures of effect size. Phi values of 0.1, 0.3, and 0.5 Caregiver-initiated medication behavior for children may be interpreted as indicating a small, medium, and Six questions from Maiman, Becker, Cummings, Drachman, large effect between groups, respectively [14]. Standar- and O’Connor [13] were used and translated to assess dized residuals within each cell greater or lesser than caregiver-initiated medication behavior for children. 1.96 were considered to be statistically significant at the The questionnaire evaluated caregivers’ beliefs about .05 level. Subsequently, ANOVAs were conducted to their efficacy in managing the health of their children examine which demographic variables were related to and their attitudes toward OTC medicines. All ques- attitudes toward OTC medicines. There were no missing tionnaire items and responses are listed in Table 3. data, and SPSS 18.0 was used for all data analyses. Socioeconomic status (SES) Results SES was measured by annual income in Japanese yen. Descriptive statistics Possible responses were (1) less than 300 K, (2) 301– Participants’ demographic information is summarized in 400 K, (3) 401–500 K, (4) 501–600 K, (5) 601–800 K, (6) Tables 1 and 4. 801–1000 K, (7) 1001–1500 K, or (8) 1501 K and above. Regarding descriptive statistics for self-medication practice, 65.8% of the participants chose, “(When I have Data analysis high fever) I will see a doctor and treat with prescribed Various chi-square (χ ) analyses were conducted to exam- drugs.” When asked to explain their behavior, one-third ine the presence of any differences in self-medication of this group reported, “We are not health care Table 2 Patients’ attitude toward OTC medicines: questions and responses (%) Strongly Agree Disagree Strongly agree disagree The chemist is a good source of advice/information about minor medical problems. 14.9 67.2 15.6 2.2 A person should take medicines/treatment only when it is necessary. 60.3 36.5 2.2 1.0 You get good value from a doctor’s prescription. 23.1 66.0 10.7 0.2 Even if I have a health problem, I prefer to avoid taking any medicines. 17.4 35.7 39.5 7.4 We should be careful with non-prescribed OTC medicines. 18.4 52.6 27.8 1.2 People are less likely to bother their doctor with minor problems nowadays. 18.4 49.9 27.0 4.7 Only medicines/treatment from a doctor will really help. 3.7 18.4 57.3 20.6 Medicines/treatments you can buy are just as effective as those you get from a doctor. 3.0 18.4 57.3 20.6 Overall, seeing a doctor costs me less than buying OTC medicines. 7.7 43.2 39.5 9.7 Generally, I find the medicines you can buy are less effective. 7.4 38.7 48.6 5.2 More prescribed drugs should be deregulated to OTC status. 7.4 49.9 38.5 4.2 Prescription medicines are completely safe to use. 7.9 46.7 40.7 4.7 Non-prescription medicines can have dangerous side effects. 3.5 30.0 62.5 4.0 Non-prescription medicines can sometimes mask serious health problems. 8.2 50.9 39.0 2.0 Some non-prescription medicines interfere with the natural healing process of the body. 4.0 38.5 55.1 2.5 With continual use, some non-prescription medicines lose their effectiveness. 11.4 53.1 33.7 1.7 Some non-prescription medicines may cause dependency or addiction if taken for a long 8.2 47.1 40.9 3.7 period of time. Reading the label on the package is one of the ways I decide which medicines to take. 29.3 58.6 10.7 1.5 Advertisements help me to learn what types or brand of medicines you can buy. 3.7 39.7 47.6 8.9 I sometimes cannot afford to buy all the medicines I would like to buy myself 10.9 32.5 44.7 11.9 (without a prescription). I sometimes cannot afford to buy all the items on a prescription issued by a doctor. 4.0 16.9 58.6 20.6 If I am unsure about a problem, I always look for advice from a doctor or nurse. 25.6 48.1 23.6 2.7 I read the instructions carefully before taking a medicine or treatment for the first time. 27.3 46.2 23.8 2.7 Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 5 of 9 http://www.apfmj.com/content/11/1/7 Table 3 Caregiver-initiated medication behavior for children: questions and responses (%) Very Somewhat Somewhat not Not true at true true true all Family is very often troubled by sickness. 7.1 23.4 56.0 13.5 I usually trust my own opinions about my child’s health more than a doctor’s opinion. 3.5 11.3 63.1 22.0 You have to use your own judgment in deciding how much of a doctor’s advice to 11.3 61.7 24.1 2.8 follow. I have been satisfied with prescription medicines I’ve given a child. 5.7 72.3 20.6 1.4 When I give a child an OTC medicine, I am as careful as I am when giving prescribed 22.0 56.7 18.4 2.8 medicines. I sometimes give a child OTCs in addition to those prescribed by a doctor for a problem. 2.1 22.0 34.0 41.8 professionals; thus, we should not make our own judg- make me feel anxious.” In contrast, when respondents ments.” The participants who chose, “I will treat the who chose private brands were asked to explain their problem with OTC medicines” comprised 18% of the behaviors, about 50% reported “Ingredients and effect- total group. When asked to explain their behavior, 20.3% iveness will be the same as national brand OTC medi- of this group reported, “I want to treat the problem by cines,” and the other 50% reported “It is cheaper.” The myself,” and 19.6% reported, “First, I want to see if OTC comparison could not be made for children because only medicines work for me.” For a summary of responses, a few caregivers reported that they would use OTC med- see Tables 5, 6, 7. icines to treat their children’s high fever. However, when a child has a high fever, more than 90% of the caregivers would take their child to the doc- Sex differences tor. The most common response was “We are not health A 2 (sex) × 5 (self-medication behavior choices) chi- care professionals; thus, we should not make our own square analysis did not reveal statistically significant dif- judgments (63%).” The second most common response ferences, χ (3) = 2.18, p = 0.53, n.s. As for the choice of was “Medical costs are free for children” (12.6%). OTC medicines, no sex difference was found. The With the regard to the question, “Which OTC medi- results suggest that participants’ self-medication beha- cines do you want to buy when you treat your illness,” viors and their choice of OTC medicines are not affected 51.4% chose (A) a national brand OTC medicine, and by their sex. This is partially consistent with findings 48.6% chose (B) a private brand OTC medicine. Logistic reported by Hanibuchi [15], where no sex differences regression was performed in the selection of either a na- emerged in whether or not participants saw a doctor. tional brand or a private brand; however, none of the in- dependent variables (age group, sex, and SES) showed significant group differences. Among respondents who Age differences chose a national brand, 13.5% reported “I feel safe be- A 3 (age group) × 5 (self-medication behavior choices) cause I often see the item on TV advertisements,” 27.0% chi-square analysis did not reveal statistically significant reported “I feel safe because a well-known pharmaceut- differences, χ (6) = 11.06, p = 0.08, n.s. A 3 (age group) × ical company produces it,” 45.9% reported “I feel safe be- 2 (the choice of OTC medicines) chi-square analysis cause I have always taken the same medicine,” and also did not reveal statistically significant differences, χ 13.5% reported “Unknown pharmaceutical companies (2) = 0.88, p = 0.64, n.s. The results suggest that age group does not affect participants’ self-medication beha- viors and choice of OTC medicines. Table 4 Participants’ income level n% Table 5 Summary of patients’ responses regarding Total (N) 403 100.0 self-medication behaviors Less than 300 K 72 17.9 n% 301–400 K 73 18.1 Total (N) 403 100.0 401–500 K 67 16.6 1 I will see a doctor and treat with prescribed drugs. 265 65.8 501–600 K 50 12.4 2 I will treat with OTC medicines. 72 17.9 601–800 K 65 16.1 3 I will rest and see for a while. 63 15.6 801–1000 K 45 11.2 4 I will treat with alternative methods such as 3 0.7 1001–1500 K 25 6.2 acupuncture and reflexology. 1501 K and more 6 1.5 5 Other 0 0.0 Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 6 of 9 http://www.apfmj.com/content/11/1/7 Table 6 Summary of patients’ responses regarding why than 300 K” group fell within the “will rest and see for a they see a doctor while” category as compared to the rest of the SES n% groups. As for the choice of OTC medicines, a 6 (SES Total (N) 265 100.0 groups) × 2 (the choice of OTC medicines) chi-square 1 We use health care professionals; thus, we should 168 63.4 not make our own judgments. analysis (χ (6) = 8.70, p = 0.19, n.s), a 6 (SES groups) × 5 (reason to pick private brand OTC medicines) chi- 2 I trust a doctor. 43 16.2 square analysis (χ (12) = 6.51, p = 0.88, n.s.), and a 6 3 Seeing a doctor is free of charge for me. 3 1.1 (SES groups) × 5 (reason to pick national brand OTC 4 Prescribed drugs are cheaper than OTC medicines. 15 5.7 medicines) chi-square analysis (χ (18) = 21.94, p = 0.23, 5 I feel comfortable seeing the same doctor. 31 11.7 n.s) did not reveal statistically significant differences. 6 Other 5 1.9 However, analyses of standardized residuals revealed that participants in the group whose annual income was less Subsequently, a 3 (age group) × 5 (reasons for not see- than 300 K were significantly more likely to fall into ing a doctor) chi-square analysis revealed statistically the “I feel safe because I often see the item on TV” significant age differences, χ (20) = 49.80, p< 0.01, and “Unknown pharmaceutical companies make me Φ = .60. The phi coefficient indicated a moderate effect feel anxious” categories than the rest of the SES groups. size. In examining the standardized residuals for each cell In sum, people at lower SES levels are more likely to within the chi-square analysis, a significantly larger number be influenced by advertisements when selecting OTC of younger participants chose “(I am not going to see a medicines. This is partially consistent with a U.S. study, doctor because) it costs money” as compared to the other which found that caregivers with a lower annual two age groups. In addition, a significantly large number of income (<US $20,000) are more likely to rely on pack- senior participants chose “(I am not going to see a doctor aging than caregivers who have a higher annual income because) there are no hospitals nearby” as compared to (>US $ 60,000) [9]. the other two age groups. In sum, younger adults are less likely to see a doctor because of financial constraints, and Attitude toward OTC medicines transportation issues can mitigate older adults’ ability/ An analysis of participants’ awareness of side effects pro- choice in seeing a doctor. vided interesting results. Thirty percent of the partici- pants agreed, and 3.5% strongly agreed, with the SES differences statement “Non-prescription medicines can have danger- A 6 (SES group) × 5 (self-medication behavior choices) ous side effects.” These are much lower percentages chi-square analysis did not reveal statistically significant compared with the findings of a European study in differences overall, χ (21) = 21.89, p = 0.40, n.s. which 59.7% of Irish respondents agreed and 5.9% However, in examining the standardized residuals for strongly agreed with that same statement [5]. Similarly, each cell within the chi-square analysis, results indicated only 38.5% of Japanese participants agreed with the that a significantly larger number of people in the “less statement “Some non-prescription medicines interfere with the natural healing process of the body,” as com- pared to 50.5% of participants in Ireland. Regarding the Table 7 Summary of patients’ responses regarding why statement “Some non-prescription medicines may cause they do not see a doctor dependency or addiction if taken for a long period of n% time,” 47.1% of Japanese participants agreed compared Total (N) 138 100.0 to 65.2% of Irish participants. These results indicate that 1 I have no time to see a doctor. 9 6.5 people in Ireland might be more aware of the potential 2 It costs money. 19 13.8 abuse of some OTC medicines [5] as compared to Japa- 3 First, I want to see if OTC medicines work for me. 27 19.6 nese participants. 4 If I rest, it will be okay. 24 17.4 5 I want to treat the problem by myself. 28 20.3 Caregiver-initiated medication behavior for children The majority of caregivers (78%) were satisfied with the 6 I don’t like doctors. 1 0.7 medicine they give to their children. Whereas 78.7% of 7 I don’t like hospitals. 5 3.6 the caregivers answered, “When I give child an OTC 8 There are no hospitals nearby. 1 0.7 medicine, I am as careful as I am when giving prescribed 9 There is no transportation to get to a hospital. 2 1.4 medicines,” 23.1% reported “I sometimes give a child 10 It bothers me to go to see a doctor. 18 13.0 OTCs in addition to those prescribed by a doctor for a 11 Other 4 2.9 problem”; thus, the results are somewhat contradictory. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 7 of 9 http://www.apfmj.com/content/11/1/7 Caregiver-initiated medication behaviors for children relative to the cost of providing OTC medicines from were also analyzed based on caregivers’ age, SES, and the beginning. Advocacy for active self-medication has educational level. Only education was a significant factor just begun during the past few years in Japan; thus, in a chi-square analysis: χ (15) = 27.43, p < 0.05. In exam- usage patterns for OTC medicines in terms of a cost- ining the standardized residuals for each cell within the benefit analysis have yet to be assessed. Future research chi-square analysis, caregivers who held a master’s de- should pursue this topic. We hope that the government gree or above were more likely to answer “very true” for will attempt to meet the various needs of patients to “I usually trust my own opinions about my child’s health support their well-being. more than a doctor’s opinion.” In other words, caregivers When assessing reasons why participants chose either with a higher educational background were more national or private brand OTC medicines, results indi- confident in managing their children’s health. cated that people in the lower SES groups placed more value on national brands than private brands. This was Discussion because they often saw national brands advertised on The goals of the present study were to examine the fol- TV. These results suggest that OTC medicine advertise- lowing: (1) how Japanese consumers/patients practice ments have a powerful affect on perceptions among low self-medication to manage their health problems and the SES consumers/patients. However, the influence of TV reasons behind these practices, (2) how Japanese consu- advertisements on public perceptions of OTC medicines mers/patients select particular OTC medicines, (3) how has not been well researched. Advertisements on TV caregivers practice self-medication for their children, convey both intentional and unintentional messages to and (4) caregivers’ attitudes toward self-medication for their audience, and consumers/patients should not rely their children. This study also investigated differences in solely on information garnered from such advertise- self-medication management and attitudes across sex, ments when choosing a product. Even though private age, and socioeconomic status (SES). brand OTC medicines are cheaper and have the same No significant sex differences were observed, but inter- effects and ingredients as national brands, people among esting age differences emerged; younger adults were less low SES groups prefer national brands; this might be be- likely to see a doctor because of medical costs, and eld- cause unknown pharmaceutical companies evoke some erly adults were less likely to see a doctor because they anxiety. In other words, low SES consumers might not lacked transportation. The younger-adult results partially choose OTC medicines based on relevant criteria, such support previous research that found that about 50% of as evidence of their effects or their ingredients. Even younger adults (20s − 30s) were very anxious about their though major pharmaceutical companies produce some future medical expenses [16]. OTC medicines, consumers/patients still need to be With regard to SES, participants within lower income aware of their potential adverse effects and use them as levels were less likely to see a doctor or buy OTC medi- directed. Consumers/patients should consult a pharma- cines for their health problems. This result is also con- cist to obtain more information, especially since phar- sistent with previous research showing that the number macists are easier to access than are doctors. A study in of individuals who do not see a doctor when they are Ireland found that a recommendation by a pharmacist sick because of costs more than doubles for individuals most frequently influenced consumer/patients’ choice of in lower SES groups as compared to those in higher SES OTC medicines [5]. As self-medication practices become groups [17]. However, Nielsen et al. [6] argue, “it is im- more common, it is important to be a wise consumer to portant that possible intervention by reimbursement sys- improve one’s health and reduce medical costs. There- tems is not socially imbalanced” [p. 199]. In Japan, fore, pharmacists might play a more active role to help universal health care is available, but the cost of medical educate consumers/patients, especially since a large number of people do not pay attention to written infor- attention is not completely free (as is the case in the U.K.). For people who receive governmental financial mation provided with medicines [18]. In fact, our support in Japan, medical services dispensed at a hos- results showed that 67.2% of participants agree with the statement “The chemist is a good source of advice/ pital are often free. However, there is no equivalent fi- nancial support system helping those individuals information about minor medical problems,” with acquire OTC medicines for free or at a reduced cost. 14.9% strongly agreeing. Some consumers/patients may not be ready to accept the more active role of pharma- Often, minor health problems can be treated with OTC medicines, but if these opportunities are inaccessible, cists in their personal healthcare; however, pharmacists’ medical attention might be postponed and problems increasing involvement could lead to changes in public attitudes [3]. can get worse. Consequently, patients might end up seeing a doctor and receiving long-term medical treat- Our study also observed that Japanese participants ment, which would be more costly for the government were less aware of the potential for abuse and side Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 8 of 9 http://www.apfmj.com/content/11/1/7 effects associated with OTC medicines when compared independent in managing their health, and self- to participants in a previous study conducted in Ireland medication practice will likely play a key role. [5]. Since the Pharmaceutical Affairs Act was recently Our results also suggest that more research is needed revised and enacted in Japan, it is possible that Japanese in order to find a way to teach both the benefits and consumers/patients are not highly aware of the risks risks of OTC medicines to Japanese consumers/patients. associated with OTC medicines compared to Europeans. Along with public education, pharmaceutical companies In fact, Kawase et al. [19] found that Japanese consu- can also improve the methods they use to deliver med- mers/patients paid less attention to risk information la- ical information. Raynor et al. [18] argue that risk infor- beled on OTC medicine packages than did Americans. mation delivered numerically, rather than verbal Finally, caregivers with higher educational back- descriptions, provides a more accurate estimation of the grounds are more confident in managing the health of probability and likelihood of understanding a side effect their children. As Du and Knopf [4] argue, “well- or health risk. MacLennan & Sturdee [23] also suggest educated mothers often believe they have enough med- that all medicines should have a simple, visible labeling ical knowledge” [p. 607]. This trend is also consistent in system on the outside of the package. Therefore, Japan. However, we did not observe significant differ- pharmaceutical companies might want to connect better ences in parents’ efficacy in dealing with their children’s with consumers/patients’ information processing sys- health based on SES. Given that medical costs for chil- tems by utilizing perspectives from cognitive psychology. dren are free in Japan, access to health care professionals Finally, one limitation of this study is that it was cross- is easy; thus, caregivers can take their children to the sectional in nature, which makes it difficult to infer hospital if necessary. In fact, the majority of our partici- causal relationships. Therefore, the generalizability of pants reported they would take their sick children to the our findings is limited, and future research is required. hospital instead of giving them OTC medicines. In Nevertheless, the present study brings a unique perspec- addition, the second most common reason for taking tive to the literature by addressing differences in self- their children to the hospital was “Free medical cost for medication practices and attitudes according to sex, age, children.” This suggests that the social welfare system and SES among Japanese consumers/patients and for supporting children helps reduce caregivers’ anxiety. caregivers. Competing interests Conclusions The authors declare that they have no competing interests. Our results suggest that individuals within different age groups and SES levels have different medical needs. This Authors’ contributions is noteworthy because dramatic changes in the Japanese IA carried out data collection, participated in the design of the study, and social structure have occurred over the past few decades. performed the statistical analysis. SK and HH participated in the study design and helped draft the manuscript. All authors read and approved the final The number of senior citizens is rapidly increasing while manuscript. the birth rate remains low. In 2008, the birth rate was 1.37, a number that has not changed significantly over Acknowledgement the past 10 years [20]. Meanwhile, people tend to live This study was supported by the Japan Society for the Promotion of Science longer, and senior citizens now comprise 22.7% of the (JSPS)’s KAKENHI, Grants-in-aid for Scientific Research (B) (Project # 22300072). total Japanese population according to recent govern- Received: 23 January 2012 Accepted: 3 September 2012 mental statistics [21]. It is expected that senior citizens Published: 11 September 2012 will comprise 33.7% of the total Japanese population by 2035, and this figure will increase to 40.5% by 2055 [22]. References As a result, the financial burden placed upon younger 1. Chewning B, Sleath B: Medication decision-making and management: A client-centered model. Soc Sci Med 1996, 42:389–398. adults will increase in order to support senior citizens in 2. Bond C, Hannaford P: Issues Related to Monitoring the Safety of Over- Japan. Consequently, younger adults might forfeit the The-Counter (OTC) Medicines. Dr Safe 2003, 26:1065–1074. opportunity to receive appropriate medical treatment 3. Bradley PC, Riaz ASR, Tobias EJ, Kentre Dassu YD: Patient attitudes to over- the-counter drugs and possible professional responses to self- from a doctor. The existing governmental healthcare medication. Fam Prac 1998, 15:44–50. system not match the current and future social struc- 4. Du Y, Knopf H: Self-medication among children and adolescents in ture. It is highly probable that more medical problems Germany: results of the National Health Survey for Children and Adolescents (KiGGS). Brit J Clin Pharm 2009, 68:599–608. and need for treatment will emerge within the changing 5. Wazaify M, Shields E, Hughes MC, McElnay CJ: Societal perspectives on society; thus, we, as consumers/patients, have to change over-the-counter (OTC) medicines. Fam Prac 2005, 22:170–176. our mindset. The governmental social welfare system 6. Nielsen WM, Hansen HE, Rasmussen KN: Patterns of psychotropic medicine use and related diseases across educational groups: national has functioned well, but it might not be as effective as it cross-sectional survey. Eur J Clin Pharm 2004, 60:199–204. is currently in the future. To accommodate the changing 7. Kogan DM, Pappas G, Yu MS, Kotelchuck M: Over-the counter medication social structure, people will need to become more use among US preschool-age children. JAMA 1994, 272:1025–1030. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 9 of 9 http://www.apfmj.com/content/11/1/7 8. Eiland L, Salazar M, English T: Caregivers’ perspectives when evaluating nonprescription medication utilization in children. Clin Ped 2008, 47:578–587. 9. Birchley N, Conroy S: Parental management of over-the-counter medicines. Paed Nur 2002, 14:24. 10. Narui K, Suetsugu D, Watanabe K: Survey of consumer views on non- prescription drugs and self-medication before enactment of revised pharmaceutical affairs law in 2009 [In Japanese]. JJPHCS 2010, 36:240–251. 11. Suzuki W, Masujima M, Shiraishi K, Morishige A: Intergenerational inequality caused by social security system. http://www.esri.go.jp/jp/archive/e_dis/ e_dis290/e_dis281.pdf. 12. Trajanovska M, Manias E, Cranswick N, Johnston L: Parental management of childhood complaints: Over-the-counter medicine use and advice- seeking behaviours. J Clin Nur 2010, 19:2065–2075. 13. Maiman AL, Becker HM, Cummings KM, Drachman HR, O’Connor AP: Effects of sociodemographic and attitudinal factors on mother-initiated medication behavior for children. PHR 1982, 94:140–149. 14. Green BS, Salkind WJ: Using SPSS for Windows and Macintosh: Analyzing and Understanding Data. 4th edition. London: Pearson; 2004. 15. Hanibuchi K: Inequalities in health and health care access: Analysis of access to medical care using JGSS-2008 [In Japanese]. JGSS Research Series 2010, 10:99–110. 16. Health and Global Policy Institute: Public Opinion Survey on Healthcare Policy. 2010. http://www.hgpi.org/handout/2010-02-08_06_973999.pdf. 17. Health and Global Policy Institute: Public Opinion Survey on Healthcare Policy. 2007. http://www.hgpi.org/handout/2010-02-03_51_616703.pd. 18. Raynor D, Blenkinsopp A, Knapp P, Grime J, Nicolson D, Pollock K, Spoor P: A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Tech Assess (Winchester, England) 2007, 11:1–160. 19. Kawase A, Sembiring ET, Choi J, Koyama S, Hibino H: The evaluation of consumers’ attention to risk and benefit information on OTC medicine packages [In Japanese]. Hyogo, Japan: Paper presented at Japan Association for Consumer Studies Conference; 2010. 20. Ministry of Health, Labour and Welfare: Statistics on annual population [In Japanese]. 2009. http://www.mhlw.go.jp/toukei/saikin/hw/jinkou/suikei09/dl/ suikei.pdf. 21. Ministry of Internal Affairs and Communication: Population census of Japan [In Japanese]. 2010. http://www.stat.go.jp/data/jinsui/2009np/pdf/gaiyou.pdf. 22. Kaneko R, Ishikawa A, Ishii F, Sasai T, Iwasawa M, Mita F, Moriizumi R: Population projections for Japan: 2006–2055: Outline of results, methods, and assumptions. JJP 2008, 6:76–11. http://www.ipss.go.jp/webj-ad/WebJournal.files/population/2008_4/ 05population.pdf. 23. MacLennan HA, Sturdee WD: Time for evidence-based labeling of over- the-counter medicines. Climacteric 2007, 10:179–180. doi:10.1186/1447-056X-11-7 Cite this article as: Aoyama et al.: Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers’ attitudes toward their children’s health management. Asia Pacific Family Medicine 2012 11:7. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers’ attitudes toward their children’s health management

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Copyright © 2012 by Aoyama et al.; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Since 2009, when the revised Pharmaceutical Affairs Act was enacted in Japan, self-medication practices have increased. Because the concept of self-medication was recently introduced in Japan, few studies exist on this topic. Therefore, it is necessary to explore how self-medication is practiced. This study examined Japanese consumers’ self-medication practices and attitudes toward over-the-counter (OTC) medicines based on their sex, age, and socioeconomic status (SES). Methods: The participants were 403 adults (M = 41.1 years, SD = 16.22). A quota sampling method was age employed based on age group, and participants completed an online questionnaire. Results: Participants in the 20–29 age group reported medical costs as an obstacle in seeing a doctor; in contrast, transportation was a mitigating factor for elderly people. Regarding SES, people at lower SES levels chose to rest instead of seeing a doctor or purchasing over-the-counter (OTC) medicines when sick. They also placed more value on national brand OTC medicines than private brands (likely due to advertisements). This finding suggests individuals with a low SES do not select OTC medicines based on their effects or ingredients. Regarding attitudes toward OTC medicines, Japanese participants seemed to be unaware of the potential for abuse and side effects associated with OTC medicines. Finally, in relation to caregivers’ self-medication practices for their children, the majority of participants reported taking their children to the hospital since children tend to receive free medical care. Furthermore, caregivers with a high educational background are more confident in being able to help manage their children’s health. Conclusions: Our results suggest that health and medical discrepancies among Japanese consumers pose new social problems. In Japan, universal health care is available, but the cost of receiving medical care is not completely free of charge. Thus, we hope that the government will attempt to meet the various needs of patients and support their well-being. Consumers also have to be more independent and aware of their health management, as self-medication practices will continue to play a more significant role in healthcare. More research is needed to find ways to teach Japanese consumers/patients of both the benefits and risks of over-the-counter (OTC) medicines. Keywords: Attitude toward OTC medicines, Health disparity, Medical disparity, Self-medication, Choice of OTC medicines * Correspondence: Ikuko_aoyama@baylor.edu Department of Design Science, Graduate School of Engineering, Chiba University, 1-33 Yayoi-cho, Inage-ku, Chiba-shi, Chiba 263-8522, Japan © 2012 Aoyama et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 2 of 9 http://www.apfmj.com/content/11/1/7 Background countries for over a decade. In the U.S., 70% of illnesses Self-medication, which is a common self-care practice, among preschoolers were treated with non-prescription is widespread around the world [1]. Self-medication medicines [7]. However, the use of non-prescription products account for approximately 20% of the total medicines for children was often inappropriate. A U.S. international pharmaceutical market [2]. Among various study found that 71% of caregivers have inappropriately self-medication options, the use of over-the-counter used non-prescription medicines for their children, and (OTC) medicines is the most prevalent. In the U.K., an 10.9% reported that they only “sometimes” read labels estimated £1,268.5 million was spent on OTC medicines and drug information [8]. Similarly, parents in the U.K. in 1994, which equates to one-third of the total cost of were generally unaware of potential side effects of OTC prescribed drugs [3]. In Germany, self-medication sales medicines because they believe that “over-the-counter were over £5.4 billion in 2006 [4]. The benefits of OTC medicines are not strong and were unlikely to harm medicines include convenience to consumers/patients, their child,” or they believe that “prescription medicines better self-management of minor problems, and a reduc- are strong and otherwise carry risks” [9 p. 27]. On the tion in governmental medical costs. Thus, throughout other hand, Du and Knopf [4] conducted a profile ana- the world, a wider range of medicines is becoming avail- lysis of caregivers who use OTC medicines and found able directly to the public [2], and the current practice “the higher the socioeconomic status of the children’s of self-medication offers consumers/patients more flex- family, or the higher the educational level of the chil- ible choices in health management. dren’s mother, the more OTC medicines the children Self-care choices vary according to sex, age, and socio- were likely to receive” (p. 606). Because OTC medicines economic status (SES). For example, in Ireland, females for children are relatively new in Japan, few studies have report buying OTC medicines more often than do males, been conducted. Therefore, it is necessary for public and younger adults report buying OTC medicines more health policy makers to explore how self-medication is often than older adults do [5]. With regard to SES, costs practiced for children in order to better construct paren- can function as a barrier that reduces access to prescrip- tal education regarding OTC administration. Caregivers’ tion medicines [6], but the significance of this variable demographic information, along with their attitudes, depends on the healthcare system within a particular must be addressed. country. In the U.S., where a universal health care sys- In Japan, the revised Pharmaceutical Affairs Act was tem is unavailable, a study found that a significantly only recently enacted in 2009; this introduced the con- large number of mothers without health insurance were cept of self-medication. In 2008, a group of Japanese likely to give OTC medicines to their young children [7]. researchers asked approximately 1,000 adults if they In contrast, in Denmark, a country with an established knew the term “self-medication” and 60.5% did not universal health care system, medical costs do not ap- recognize this term [10]. However, research on self- pear to function as a barrier that reduces access to pre- medication issues is important given the fact that declin- scription medicines [6]. In Japan, the effects of a long- ing birthrates and a growing proportion of elderly people term recession have negatively influenced the overall will have a significant impact on the Japanese pension economic situation of many individuals. Thus, a med- and social welfare system in the near future. ical/health discrepancy between people low and high in Therefore, the goals of the present study were to SES is apparent. Do people at lower SES levels hesitate examine the following: (1) how Japanese consumers/ to see a doctor because of medical costs? This question patients practice self-medication to manage their health has yet to be well researched. When people at lower SES problems, (2) how Japanese consumers/patients select levels are encouraged to practice self-medication, are particular OTC medicines, (3) how consumers/patients’ they able to choose medicines based on valid evidence of attitudes toward OTC medicines, and (4) caregiver- initiated medication behaviors for children. This study the medicine’s safety? Advertisements for OTC medi- cines are legal in many countries, including Japan, and also investigated the role of sex, age, and socioeconomic such marketing might affect perceptions among consu- status (SES) on the preceding research questions. mers/patients as to the benefits of different products [2]. Traditionally, patients are rather passive and dependent, Method and they tend to follow the instructions of experts [1]. Participants However, taking individual responsibility for safe self- Participants were 403 adults living in the Kanto area of medication practices is increasingly necessary as several Japan, which consists of seven prefectures including OTC medicines become available on the market. Tokyo (M = 41.12, SD = 16.19, range 20–79, male = age When discussing self-medication issues, the topic of 47.4%, female = 52.6%). The research company, Media self-medication for children is noteworthy. Research on Interactive Inc., recruited participants in 2011. Among this topic has been accumulating within Western the 403 participants, 331 had children. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 3 of 9 http://www.apfmj.com/content/11/1/7 A quota sampling method was employed to compare Self-medication behaviors the following three age groups: a young group (20–29), Self-medication behaviors were measured by the ques- middle age group (30–49) and a senior group (65 years tion: “When you have a high fever (39°C/102.2°F or old and above). There were an approximately equal higher), what do you do?” Response choices were (1) I number of male and female participants within each will see a doctor and treat with prescribed drugs, (2) I stratum (Table 1). These three age groups were selected will treat with OTC medicines, (3) I will rest for a while, for the following reasons. First, we wanted to examine (4) I will treat with an alternative method such as acu- how parents of young children (elementary school and puncture and reflexology, or (5) Other. Next, partici- younger) practiced self-medication for both their chil- pants were asked the reason for their choice (e.g., “Why dren and themselves. Thus, we placed a focus on asses- do you see a doctor?” or “Why don’t you see a doctor?”). sing participants in their 30s and 40s. Second, we For their children, the question was, “When your child wanted to examine age differences in self-medication has a high fever (39°C/102.2°F or higher), what do you practices. These age groups (20s, 30 − 40s, and 65 and do?” older) are especially important groups to address given the intergenerational economic inequality in Japan. The choice of OTC medicines According to a report from the Cabinet Office, Govern- The choice of OTC medicines was measured by the ment of Japan (2012), the differences in net benefit (the question: “Which OTC medicines do you want to buy ratio of net benefit from the social security system rela- when you treat your illness?” Response choices were: (A) tive to lifetime income) between younger and older a national brand OTC medicine often seen in a TV ad- adults is 12% [11]. The government is acutely aware of vertisement or (B) a private brand OTC medicine that the fact that the younger generation suffers a larger net has the same effects and ingredients but is 50% cheaper burden and believes that intergenerational inequality than the national brand. National brand OTC medicines should not be ignored. refer to medicines produced by a major pharmaceutical company (i.e., Tylenol and Advil in the U.S.). On the other hand, private brand OTC medicines refer to medi- Procedures cines that are similar to a national brand OTC medicine All of the survey questions were uploaded online. The but are sold at specific retailers (i.e., Walmart). Examples participants who agreed to complete the survey accessed of OTC medicines in Japan are aspirin and cough and it through a provided URL. After filling out the online cold medicines; antibiotics are not included. survey, Media Interactive Inc. gave the participants In terms of reasons for selecting a national brand points that could be accumulated in exchange for a gift OTC medicine, response choices were (1) I feel safe be- card. cause I often see the item on a TV advertisement, (2) I feel safe because a well-known pharmaceutical company produces it, (3) I feel safe because I have always taken Questionnaire and measures the same medicine, (4) Cheap medicines make me feel Participants answered 43 questions, including informa- anxious, (5) Unknown pharmaceutical companies make tion about demographics. The survey inquired about me feel anxious, (6) More expensive medicines seem to self-medication behaviors (for the individual and for work better, (7) I like the package design, or (8) Other. children if the participant was a parent) and the reasons Response choices for selecting a private brand OTC for their choice, the choice of OTC medicines, and atti- medicine were (1) It is cheaper, (2) Ingredients and ef- tudes toward OTC medicines (for the individual and for fectiveness will be the same as the national brand OTC children if the participant was a parent). medicine, (3) There will not be a big difference among OTC medicines, (4) It seems better than the national brand sold by a major pharmaceutical company, (5) I Table 1 Participants’ sex and age like the package design, or (6) Other. n% Total (N) 403 100.0 Attitudes toward OTC medicines Male: 20s 61 15.1 Several questionnaires developed by Bradley et al., [3] Male: 30–40s 90 22.3 Trajanovska, Manias, Cranswick, and Johnston [12], and Male: 65–79 40 9.9 Wazaify et al. [5] were adapted and translated for this Female: 20s 82 20.3 study to measure patients’ attitude toward medicines. Female: 30–40s 90 22.3 The questionnaire consisted of 23 questions measuring Female: 65–79 40 9.9 positive and negative attitudes toward OTC medicines, Note: There were no participants in the 50–64-year-old category. perceived value and side effects of OTC medicines, and Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 4 of 9 http://www.apfmj.com/content/11/1/7 criteria for purchasing OTC medicines. All questionnaire behaviors and the choice of OTC medicines according items and responses are listed in Table 2. to sex, age, and SES. Phi coefficients (Φ)werecalculated as measures of effect size. Phi values of 0.1, 0.3, and 0.5 Caregiver-initiated medication behavior for children may be interpreted as indicating a small, medium, and Six questions from Maiman, Becker, Cummings, Drachman, large effect between groups, respectively [14]. Standar- and O’Connor [13] were used and translated to assess dized residuals within each cell greater or lesser than caregiver-initiated medication behavior for children. 1.96 were considered to be statistically significant at the The questionnaire evaluated caregivers’ beliefs about .05 level. Subsequently, ANOVAs were conducted to their efficacy in managing the health of their children examine which demographic variables were related to and their attitudes toward OTC medicines. All ques- attitudes toward OTC medicines. There were no missing tionnaire items and responses are listed in Table 3. data, and SPSS 18.0 was used for all data analyses. Socioeconomic status (SES) Results SES was measured by annual income in Japanese yen. Descriptive statistics Possible responses were (1) less than 300 K, (2) 301– Participants’ demographic information is summarized in 400 K, (3) 401–500 K, (4) 501–600 K, (5) 601–800 K, (6) Tables 1 and 4. 801–1000 K, (7) 1001–1500 K, or (8) 1501 K and above. Regarding descriptive statistics for self-medication practice, 65.8% of the participants chose, “(When I have Data analysis high fever) I will see a doctor and treat with prescribed Various chi-square (χ ) analyses were conducted to exam- drugs.” When asked to explain their behavior, one-third ine the presence of any differences in self-medication of this group reported, “We are not health care Table 2 Patients’ attitude toward OTC medicines: questions and responses (%) Strongly Agree Disagree Strongly agree disagree The chemist is a good source of advice/information about minor medical problems. 14.9 67.2 15.6 2.2 A person should take medicines/treatment only when it is necessary. 60.3 36.5 2.2 1.0 You get good value from a doctor’s prescription. 23.1 66.0 10.7 0.2 Even if I have a health problem, I prefer to avoid taking any medicines. 17.4 35.7 39.5 7.4 We should be careful with non-prescribed OTC medicines. 18.4 52.6 27.8 1.2 People are less likely to bother their doctor with minor problems nowadays. 18.4 49.9 27.0 4.7 Only medicines/treatment from a doctor will really help. 3.7 18.4 57.3 20.6 Medicines/treatments you can buy are just as effective as those you get from a doctor. 3.0 18.4 57.3 20.6 Overall, seeing a doctor costs me less than buying OTC medicines. 7.7 43.2 39.5 9.7 Generally, I find the medicines you can buy are less effective. 7.4 38.7 48.6 5.2 More prescribed drugs should be deregulated to OTC status. 7.4 49.9 38.5 4.2 Prescription medicines are completely safe to use. 7.9 46.7 40.7 4.7 Non-prescription medicines can have dangerous side effects. 3.5 30.0 62.5 4.0 Non-prescription medicines can sometimes mask serious health problems. 8.2 50.9 39.0 2.0 Some non-prescription medicines interfere with the natural healing process of the body. 4.0 38.5 55.1 2.5 With continual use, some non-prescription medicines lose their effectiveness. 11.4 53.1 33.7 1.7 Some non-prescription medicines may cause dependency or addiction if taken for a long 8.2 47.1 40.9 3.7 period of time. Reading the label on the package is one of the ways I decide which medicines to take. 29.3 58.6 10.7 1.5 Advertisements help me to learn what types or brand of medicines you can buy. 3.7 39.7 47.6 8.9 I sometimes cannot afford to buy all the medicines I would like to buy myself 10.9 32.5 44.7 11.9 (without a prescription). I sometimes cannot afford to buy all the items on a prescription issued by a doctor. 4.0 16.9 58.6 20.6 If I am unsure about a problem, I always look for advice from a doctor or nurse. 25.6 48.1 23.6 2.7 I read the instructions carefully before taking a medicine or treatment for the first time. 27.3 46.2 23.8 2.7 Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 5 of 9 http://www.apfmj.com/content/11/1/7 Table 3 Caregiver-initiated medication behavior for children: questions and responses (%) Very Somewhat Somewhat not Not true at true true true all Family is very often troubled by sickness. 7.1 23.4 56.0 13.5 I usually trust my own opinions about my child’s health more than a doctor’s opinion. 3.5 11.3 63.1 22.0 You have to use your own judgment in deciding how much of a doctor’s advice to 11.3 61.7 24.1 2.8 follow. I have been satisfied with prescription medicines I’ve given a child. 5.7 72.3 20.6 1.4 When I give a child an OTC medicine, I am as careful as I am when giving prescribed 22.0 56.7 18.4 2.8 medicines. I sometimes give a child OTCs in addition to those prescribed by a doctor for a problem. 2.1 22.0 34.0 41.8 professionals; thus, we should not make our own judg- make me feel anxious.” In contrast, when respondents ments.” The participants who chose, “I will treat the who chose private brands were asked to explain their problem with OTC medicines” comprised 18% of the behaviors, about 50% reported “Ingredients and effect- total group. When asked to explain their behavior, 20.3% iveness will be the same as national brand OTC medi- of this group reported, “I want to treat the problem by cines,” and the other 50% reported “It is cheaper.” The myself,” and 19.6% reported, “First, I want to see if OTC comparison could not be made for children because only medicines work for me.” For a summary of responses, a few caregivers reported that they would use OTC med- see Tables 5, 6, 7. icines to treat their children’s high fever. However, when a child has a high fever, more than 90% of the caregivers would take their child to the doc- Sex differences tor. The most common response was “We are not health A 2 (sex) × 5 (self-medication behavior choices) chi- care professionals; thus, we should not make our own square analysis did not reveal statistically significant dif- judgments (63%).” The second most common response ferences, χ (3) = 2.18, p = 0.53, n.s. As for the choice of was “Medical costs are free for children” (12.6%). OTC medicines, no sex difference was found. The With the regard to the question, “Which OTC medi- results suggest that participants’ self-medication beha- cines do you want to buy when you treat your illness,” viors and their choice of OTC medicines are not affected 51.4% chose (A) a national brand OTC medicine, and by their sex. This is partially consistent with findings 48.6% chose (B) a private brand OTC medicine. Logistic reported by Hanibuchi [15], where no sex differences regression was performed in the selection of either a na- emerged in whether or not participants saw a doctor. tional brand or a private brand; however, none of the in- dependent variables (age group, sex, and SES) showed significant group differences. Among respondents who Age differences chose a national brand, 13.5% reported “I feel safe be- A 3 (age group) × 5 (self-medication behavior choices) cause I often see the item on TV advertisements,” 27.0% chi-square analysis did not reveal statistically significant reported “I feel safe because a well-known pharmaceut- differences, χ (6) = 11.06, p = 0.08, n.s. A 3 (age group) × ical company produces it,” 45.9% reported “I feel safe be- 2 (the choice of OTC medicines) chi-square analysis cause I have always taken the same medicine,” and also did not reveal statistically significant differences, χ 13.5% reported “Unknown pharmaceutical companies (2) = 0.88, p = 0.64, n.s. The results suggest that age group does not affect participants’ self-medication beha- viors and choice of OTC medicines. Table 4 Participants’ income level n% Table 5 Summary of patients’ responses regarding Total (N) 403 100.0 self-medication behaviors Less than 300 K 72 17.9 n% 301–400 K 73 18.1 Total (N) 403 100.0 401–500 K 67 16.6 1 I will see a doctor and treat with prescribed drugs. 265 65.8 501–600 K 50 12.4 2 I will treat with OTC medicines. 72 17.9 601–800 K 65 16.1 3 I will rest and see for a while. 63 15.6 801–1000 K 45 11.2 4 I will treat with alternative methods such as 3 0.7 1001–1500 K 25 6.2 acupuncture and reflexology. 1501 K and more 6 1.5 5 Other 0 0.0 Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 6 of 9 http://www.apfmj.com/content/11/1/7 Table 6 Summary of patients’ responses regarding why than 300 K” group fell within the “will rest and see for a they see a doctor while” category as compared to the rest of the SES n% groups. As for the choice of OTC medicines, a 6 (SES Total (N) 265 100.0 groups) × 2 (the choice of OTC medicines) chi-square 1 We use health care professionals; thus, we should 168 63.4 not make our own judgments. analysis (χ (6) = 8.70, p = 0.19, n.s), a 6 (SES groups) × 5 (reason to pick private brand OTC medicines) chi- 2 I trust a doctor. 43 16.2 square analysis (χ (12) = 6.51, p = 0.88, n.s.), and a 6 3 Seeing a doctor is free of charge for me. 3 1.1 (SES groups) × 5 (reason to pick national brand OTC 4 Prescribed drugs are cheaper than OTC medicines. 15 5.7 medicines) chi-square analysis (χ (18) = 21.94, p = 0.23, 5 I feel comfortable seeing the same doctor. 31 11.7 n.s) did not reveal statistically significant differences. 6 Other 5 1.9 However, analyses of standardized residuals revealed that participants in the group whose annual income was less Subsequently, a 3 (age group) × 5 (reasons for not see- than 300 K were significantly more likely to fall into ing a doctor) chi-square analysis revealed statistically the “I feel safe because I often see the item on TV” significant age differences, χ (20) = 49.80, p< 0.01, and “Unknown pharmaceutical companies make me Φ = .60. The phi coefficient indicated a moderate effect feel anxious” categories than the rest of the SES groups. size. In examining the standardized residuals for each cell In sum, people at lower SES levels are more likely to within the chi-square analysis, a significantly larger number be influenced by advertisements when selecting OTC of younger participants chose “(I am not going to see a medicines. This is partially consistent with a U.S. study, doctor because) it costs money” as compared to the other which found that caregivers with a lower annual two age groups. In addition, a significantly large number of income (<US $20,000) are more likely to rely on pack- senior participants chose “(I am not going to see a doctor aging than caregivers who have a higher annual income because) there are no hospitals nearby” as compared to (>US $ 60,000) [9]. the other two age groups. In sum, younger adults are less likely to see a doctor because of financial constraints, and Attitude toward OTC medicines transportation issues can mitigate older adults’ ability/ An analysis of participants’ awareness of side effects pro- choice in seeing a doctor. vided interesting results. Thirty percent of the partici- pants agreed, and 3.5% strongly agreed, with the SES differences statement “Non-prescription medicines can have danger- A 6 (SES group) × 5 (self-medication behavior choices) ous side effects.” These are much lower percentages chi-square analysis did not reveal statistically significant compared with the findings of a European study in differences overall, χ (21) = 21.89, p = 0.40, n.s. which 59.7% of Irish respondents agreed and 5.9% However, in examining the standardized residuals for strongly agreed with that same statement [5]. Similarly, each cell within the chi-square analysis, results indicated only 38.5% of Japanese participants agreed with the that a significantly larger number of people in the “less statement “Some non-prescription medicines interfere with the natural healing process of the body,” as com- pared to 50.5% of participants in Ireland. Regarding the Table 7 Summary of patients’ responses regarding why statement “Some non-prescription medicines may cause they do not see a doctor dependency or addiction if taken for a long period of n% time,” 47.1% of Japanese participants agreed compared Total (N) 138 100.0 to 65.2% of Irish participants. These results indicate that 1 I have no time to see a doctor. 9 6.5 people in Ireland might be more aware of the potential 2 It costs money. 19 13.8 abuse of some OTC medicines [5] as compared to Japa- 3 First, I want to see if OTC medicines work for me. 27 19.6 nese participants. 4 If I rest, it will be okay. 24 17.4 5 I want to treat the problem by myself. 28 20.3 Caregiver-initiated medication behavior for children The majority of caregivers (78%) were satisfied with the 6 I don’t like doctors. 1 0.7 medicine they give to their children. Whereas 78.7% of 7 I don’t like hospitals. 5 3.6 the caregivers answered, “When I give child an OTC 8 There are no hospitals nearby. 1 0.7 medicine, I am as careful as I am when giving prescribed 9 There is no transportation to get to a hospital. 2 1.4 medicines,” 23.1% reported “I sometimes give a child 10 It bothers me to go to see a doctor. 18 13.0 OTCs in addition to those prescribed by a doctor for a 11 Other 4 2.9 problem”; thus, the results are somewhat contradictory. Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 7 of 9 http://www.apfmj.com/content/11/1/7 Caregiver-initiated medication behaviors for children relative to the cost of providing OTC medicines from were also analyzed based on caregivers’ age, SES, and the beginning. Advocacy for active self-medication has educational level. Only education was a significant factor just begun during the past few years in Japan; thus, in a chi-square analysis: χ (15) = 27.43, p < 0.05. In exam- usage patterns for OTC medicines in terms of a cost- ining the standardized residuals for each cell within the benefit analysis have yet to be assessed. Future research chi-square analysis, caregivers who held a master’s de- should pursue this topic. We hope that the government gree or above were more likely to answer “very true” for will attempt to meet the various needs of patients to “I usually trust my own opinions about my child’s health support their well-being. more than a doctor’s opinion.” In other words, caregivers When assessing reasons why participants chose either with a higher educational background were more national or private brand OTC medicines, results indi- confident in managing their children’s health. cated that people in the lower SES groups placed more value on national brands than private brands. This was Discussion because they often saw national brands advertised on The goals of the present study were to examine the fol- TV. These results suggest that OTC medicine advertise- lowing: (1) how Japanese consumers/patients practice ments have a powerful affect on perceptions among low self-medication to manage their health problems and the SES consumers/patients. However, the influence of TV reasons behind these practices, (2) how Japanese consu- advertisements on public perceptions of OTC medicines mers/patients select particular OTC medicines, (3) how has not been well researched. Advertisements on TV caregivers practice self-medication for their children, convey both intentional and unintentional messages to and (4) caregivers’ attitudes toward self-medication for their audience, and consumers/patients should not rely their children. This study also investigated differences in solely on information garnered from such advertise- self-medication management and attitudes across sex, ments when choosing a product. Even though private age, and socioeconomic status (SES). brand OTC medicines are cheaper and have the same No significant sex differences were observed, but inter- effects and ingredients as national brands, people among esting age differences emerged; younger adults were less low SES groups prefer national brands; this might be be- likely to see a doctor because of medical costs, and eld- cause unknown pharmaceutical companies evoke some erly adults were less likely to see a doctor because they anxiety. In other words, low SES consumers might not lacked transportation. The younger-adult results partially choose OTC medicines based on relevant criteria, such support previous research that found that about 50% of as evidence of their effects or their ingredients. Even younger adults (20s − 30s) were very anxious about their though major pharmaceutical companies produce some future medical expenses [16]. OTC medicines, consumers/patients still need to be With regard to SES, participants within lower income aware of their potential adverse effects and use them as levels were less likely to see a doctor or buy OTC medi- directed. Consumers/patients should consult a pharma- cines for their health problems. This result is also con- cist to obtain more information, especially since phar- sistent with previous research showing that the number macists are easier to access than are doctors. A study in of individuals who do not see a doctor when they are Ireland found that a recommendation by a pharmacist sick because of costs more than doubles for individuals most frequently influenced consumer/patients’ choice of in lower SES groups as compared to those in higher SES OTC medicines [5]. As self-medication practices become groups [17]. However, Nielsen et al. [6] argue, “it is im- more common, it is important to be a wise consumer to portant that possible intervention by reimbursement sys- improve one’s health and reduce medical costs. There- tems is not socially imbalanced” [p. 199]. In Japan, fore, pharmacists might play a more active role to help universal health care is available, but the cost of medical educate consumers/patients, especially since a large number of people do not pay attention to written infor- attention is not completely free (as is the case in the U.K.). For people who receive governmental financial mation provided with medicines [18]. In fact, our support in Japan, medical services dispensed at a hos- results showed that 67.2% of participants agree with the statement “The chemist is a good source of advice/ pital are often free. However, there is no equivalent fi- nancial support system helping those individuals information about minor medical problems,” with acquire OTC medicines for free or at a reduced cost. 14.9% strongly agreeing. Some consumers/patients may not be ready to accept the more active role of pharma- Often, minor health problems can be treated with OTC medicines, but if these opportunities are inaccessible, cists in their personal healthcare; however, pharmacists’ medical attention might be postponed and problems increasing involvement could lead to changes in public attitudes [3]. can get worse. Consequently, patients might end up seeing a doctor and receiving long-term medical treat- Our study also observed that Japanese participants ment, which would be more costly for the government were less aware of the potential for abuse and side Aoyama et al. Asia Pacific Family Medicine 2012, 11:7 Page 8 of 9 http://www.apfmj.com/content/11/1/7 effects associated with OTC medicines when compared independent in managing their health, and self- to participants in a previous study conducted in Ireland medication practice will likely play a key role. [5]. Since the Pharmaceutical Affairs Act was recently Our results also suggest that more research is needed revised and enacted in Japan, it is possible that Japanese in order to find a way to teach both the benefits and consumers/patients are not highly aware of the risks risks of OTC medicines to Japanese consumers/patients. associated with OTC medicines compared to Europeans. Along with public education, pharmaceutical companies In fact, Kawase et al. [19] found that Japanese consu- can also improve the methods they use to deliver med- mers/patients paid less attention to risk information la- ical information. Raynor et al. [18] argue that risk infor- beled on OTC medicine packages than did Americans. mation delivered numerically, rather than verbal Finally, caregivers with higher educational back- descriptions, provides a more accurate estimation of the grounds are more confident in managing the health of probability and likelihood of understanding a side effect their children. As Du and Knopf [4] argue, “well- or health risk. MacLennan & Sturdee [23] also suggest educated mothers often believe they have enough med- that all medicines should have a simple, visible labeling ical knowledge” [p. 607]. This trend is also consistent in system on the outside of the package. Therefore, Japan. However, we did not observe significant differ- pharmaceutical companies might want to connect better ences in parents’ efficacy in dealing with their children’s with consumers/patients’ information processing sys- health based on SES. Given that medical costs for chil- tems by utilizing perspectives from cognitive psychology. dren are free in Japan, access to health care professionals Finally, one limitation of this study is that it was cross- is easy; thus, caregivers can take their children to the sectional in nature, which makes it difficult to infer hospital if necessary. In fact, the majority of our partici- causal relationships. Therefore, the generalizability of pants reported they would take their sick children to the our findings is limited, and future research is required. hospital instead of giving them OTC medicines. In Nevertheless, the present study brings a unique perspec- addition, the second most common reason for taking tive to the literature by addressing differences in self- their children to the hospital was “Free medical cost for medication practices and attitudes according to sex, age, children.” This suggests that the social welfare system and SES among Japanese consumers/patients and for supporting children helps reduce caregivers’ anxiety. caregivers. Competing interests Conclusions The authors declare that they have no competing interests. Our results suggest that individuals within different age groups and SES levels have different medical needs. This Authors’ contributions is noteworthy because dramatic changes in the Japanese IA carried out data collection, participated in the design of the study, and social structure have occurred over the past few decades. performed the statistical analysis. SK and HH participated in the study design and helped draft the manuscript. All authors read and approved the final The number of senior citizens is rapidly increasing while manuscript. the birth rate remains low. In 2008, the birth rate was 1.37, a number that has not changed significantly over Acknowledgement the past 10 years [20]. Meanwhile, people tend to live This study was supported by the Japan Society for the Promotion of Science longer, and senior citizens now comprise 22.7% of the (JSPS)’s KAKENHI, Grants-in-aid for Scientific Research (B) (Project # 22300072). total Japanese population according to recent govern- Received: 23 January 2012 Accepted: 3 September 2012 mental statistics [21]. It is expected that senior citizens Published: 11 September 2012 will comprise 33.7% of the total Japanese population by 2035, and this figure will increase to 40.5% by 2055 [22]. References As a result, the financial burden placed upon younger 1. Chewning B, Sleath B: Medication decision-making and management: A client-centered model. 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Climacteric 2007, 10:179–180. doi:10.1186/1447-056X-11-7 Cite this article as: Aoyama et al.: Self-medication behaviors among Japanese consumers: sex, age, and SES differences and caregivers’ attitudes toward their children’s health management. Asia Pacific Family Medicine 2012 11:7. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Asia Pacific Family MedicineSpringer Journals

Published: Sep 11, 2012

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