Objective: The goal was to assess the prevalence of prescribed and nonprescribed medicine use, use predictors, and origin of medicines for Finnish female conscripts during their voluntary military service. Methods: An anonymous mail survey was conducted in April 1999 among all Finnish female conscripts on duty. Results: Of the respondents (N = 177; response rate, 68%), 61% had used at least one medicine in the 2 weeks preceding the study, 44% prescribed and 31% nonprescribed medicines. Most of the prescribed medicines were provided by Finnish Defence Forces health care, whereas most of the nonprescribed medicines were of civilian origin. The consumption of prescribed and nonprescribed medicines was differently related to respondents' background variables. Common overall medicine use and use of over-the-counter analgesics and stimulants and their association with potentially negative health behaviors may contribute to inappropriate medicine use. Conclusion: Finnish female conscripts commonly use prescribed and nonprescribed medicines. The importance of sufficient medication information for female conscripts is emphasized.
Introduction
Civillan adolescent and working-aged women use prescribed an nonprescribed medicines more frequently than men.1-8 This gender difference is suggested to be based on physical, psychological, and social factors. These factors include, for example, different occurrence and reporting of symptoms and utilization of health care services between genders, as well as different attitudes of health care providers toward women and men.5,9-14
It is important to know the proportion of a population that is exposed to different medicine groups. For example, medicine use is considered to be an indicator of morbidity, and self-medication may substitute for the use of prescription medicines or other established medical care. It is also important to have information on the predictors of medication use, to improve effective and safe medicine use and to prevent related adverse effects.8,15,16 Not only need factors such as pain but also sociodemographic as well as health behavior and lifestyle factors have been found to influence medicine use.2,5,8,17,18
During conscription, basically healthy young women and men are subjected to increased physical, psychological, and social distress.18-23 In addition to several psychological symptoms and health behaviors such as drinking, use of medicines may be a coping strategy through which individuals adjust themselves to a stressful environment or manage psychological symptoms.24-26
Like prescribed medicines, many nonprescribed medicines can be misused or abused.27,28 Self-medication constitutes the largest part of the overall use of medicines among adolescents and young adults.2,7,29-33 Appropriate self-medication can be seen as an Important resource for health care In both civilian and military settings.17,34 However, long-term or otherwise Inadequate self-medication can increase a risk for adverse effects, such as gastrointestinal adverse effects caused by analgesics and toxlcity.27,35-38
More than 80% of Finnish young men perform compulsory military service of 6 to 12 months. Since 1996, Finnish young women have been able to perform military service on a voluntary basis; each year, 250 to 350 women enter the military. The military training Is equal for the two genders. In addition to the distress caused by the military training itself, the characteristics of female anatomy and physiology, as well as the typically high motivation of female conscripts and their pursuit of good results during the voluntary conscription, may result In Increased need and use of medicines and other health services 36,39,40 por example, musculoskeletal injuries during basic military training are more prevalent among women than among men. To our knowledge, published studies on the medication patterns among female conscripts do not exist.
The aim of this study was to Investigate the overall use of prescribed and nonprescribed medicines and their origin among all Finnish female conscripts on duty In April 1999. The effects of women's sociodemographic and health behavior variables on the use of prescribed and nonprescribed medicines were analyzed. In addition, the indications for female conscripts' Independent self-medication, especially the use of over-the-counter (OTC) analgesics, were assessed.
Methods
Study Design
The study was designed and conducted by the Health Care Division of the Defence Staff. The brigades with voluntary female conscripts were ordered to deliver the questionnaire sheets, with return envelopes, to all female conscripts. The women completed the questionnaire sheets anonymously and sent them directly to the Health Care Division, where the study database was constructed. Reminder letters were not used, to guarantee full anonymity of the responders.
Dependent Variables
The use of medicines for the previous 2 weeks (14 days) was questioned. First, the number (none, one, two, or three or more) of prescribed and nonprescribed medicines (medicines obtained with and without a physician visit, respectively) obtained from the Finnish Defence Forces (FDF) health care and civilian sources and used during this period was investigated separately for these four categories. Independent self-medication (nonprescribed medicines obtained from civilian sources) was investigated by asking for its indications with the following options (yes/no): headache, other aches (muscle, joint, or tooth ache), fever, common cold symptoms or sore throat, cough, skin troubles or yeast, sleeplessness or anxiety, and stomach troubles or constipation. Independent self-medication with caffeine tablets or other stimulants, with vitamins or minerals, or for other purposes and the most typical acquisition route (self-purchase in a community pharmacy or provided by other people, such as parents or peers) were investigated. The use of contraception was assessed with the options of no contraception or no need for it, condom, contraceptive pills, or other.
Independent self-medication with OTC analgesics was assessed by asking about the use of the following active substances (with brand names) in the preceding 14 days: ibuprofen, aspirin, paracetamol, ketoprofen, combined products, and other analgesics. In addition, we asked for the most important indication for the use of these product groups, with five indications, or if not used. The recalled frequency of the use of OTC analgesics both during military service and before it (approximately once per week or more versus less frequently) was assessed.
Independent Variables
The data were derived from a postal questionnaire survey among all 261 Finnish female conscripts in April 1999. The questionnaire consisted of 60 questions on the respondent's sociodemographic background, health status, use and acquisition of medicines, and other health behavior. Sociodemographic background variables were age (17-19 years, 20-22 years, or 23-30 years), civilian area of residence (capital area of Helsinki, city with > 100,000 inhabitants, town with 20,000-100,000 inhabitants, small town, or rural area), education level (three levels), marital status (single, engaged, married, or other), military command, and military entry cohort (July 1998 or January 1999). Health status and health behavior variables were height and weight (body mass index of < 19.00, 19.00-24.99, or >24.99 kg/m^sup 2^), self-perceived current physical and mental health status (poor, moderate, good, or excellent), finding military service mentally stressful (yes or no), social contacts in civilian life (poor, moderate, or good), current smoking status (regularly at least one cigarette daily, less frequently, or no), binge drinking (at least once per 2 months, less frequently, or no), own trials with illegal drugs during lifetime (used, tried, or no), and knowing a person who has tried illegal drugs among civilian peers (yes or no). The use of the military (FDF) and civilian health services for the preceding 12 months was investigated as follows: frequent visits to a physician (yes if at least three), a nurse (yes if at least three), or a dentist (yes if at least three) and receiving physiotherapy (yes or no).
Statistical Methods
The prevalence of the use of medicines is presented as a percentage with 95% confidence interval (CI). In the bivariate analyses, the associations between the dependent and independent variables were evaluated by calculating odds ratios with 95% CIs. To control for the effect of potential confounders, a logistic regression model was constructed and odds ratios with 95% CIs were calculated. The model included all of the background variables that showed statistical significance of p < 0.10 in the bivariate analyses of the use of prescribed or nonprescribed medicines. Data analyses were performed with Epilnfo (version 6.04b) software (Centers for Disease Control and Prevention, Atlanta, Georgia) and SPSS (10.0.7) software (SPSS, Chicago, Illinois).
Results
Our sample consisted of 177 responses from a total of 261 female conscripts on duty in April 1999 (response rate, 67.8%). The sample characteristics are described in Table I.
Of the female conscripts, 61% (95% CI, 53-68%) reported the use of medicines in the 2-week period before the study (Table II). The use of prescribed medicines was claimed by 44% (95% CI, 36-51%), whereas the use of nonprescribed medicines was claimed by 31% (95% CI, 24-39%) of the respondents. Among the users of prescribed medicines, the number of nonprescribed medicines used gently increased linearly (from 0.30 to 0.67; slope, 0.19; R^sup 2^ = 0.96) with the number of prescribed medicines used when the users of three or more medicines were classified as users of three medicines. The average number of nonprescription medicines used for the nonusers of prescribed medicines was 0.46
Among all medicine users, 70% (95% CI, 61-79%) had used medicines provided by the FDF health care. Of the users of prescribed medicines, 82% (95% CI, 71-90%) had received these medicines from FDF health care, whereas 67% (95% CI, 53-79%) of the users of nonprescribed medicines had obtained nonprescribed medicines from civilian sources. The most typical way to obtain nonprescribed medicines from civilian sources was self-purchase in a community pharmacy (68%; 95% CI, 61-75%), whereas these medicines were provided by other people for 32% (95% CI, 25-40%).
In the bivariate analyses, the use of prescribed medicines was associated (p < 0.10) with experiments with illegal drugs during the respondent's lifetime, poor or moderate self-perceived physical condition, frequent visits to a physician in the past 12 months, and age category of 20 to 22 years (Table III). The use of nonprescribed medicines was related to education level, binge drinking, and being provided with nonprescribed medicines by other people. In the multivariate analysis, trials with illegal drugs and frequent physician visits remained statistically significant predictors for the use of prescribed medicines and binge drinking and education level for the use of nonprescribed medicines (Table III).
The most frequently reported symptomatic indications for independent self-medication among all of the women were headache (49%; 95% CI, 41-56%), symptoms of common cold (34%; 95% CI. 27-41%), and other aches (27%; 95% CI, 21-34%) (Fig. 1). Altogether, 67% (95% CI, 60-74%) of the respondents had used self-medication for these purposes. Self-medication with caffeine tablets or other stimulants was reported by 10% (95% CI, 6-16%), and self-medication for sleeplessness or anxiety was reported by 0.6% (95% CI, 0-3%). Vitamins were taken by 36% (95% CI, 29-44%). The sum prevalence of independent selfmedication on the basis of recognized diagnoses was 79% (95% CI, 72-84%).
Of the OTC analgesics obtained from civilian sources, ibuprofen products were taken by 46% (95% CI, 39-54%) of the women. Aspirin, paracetamol, ketoprofen, or combined analgesics were used by 9 to 11% each. On the basis of the recognized brand names, 56% (95% CI, 48-63%) of the women had taken OTC analgesics. In the previous 2 weeks, 21% (95% CI, 15-28%) of all respondents had used these analgesics at least once per week and 7% (95% CI, 4-12%) daily or almost daily. Under civilian circumstances before military service, 7% (95% CI, 4-12%) recalled weekly and none daily or almost-daily use of these medications. Among the users of OTC ibuprofen, aspirin, and ketoprofen products, headache was the most important indication (53%; 95% CI, 42-64%; 80%; 95% CI, 56-94%; and 44%; 95% CI, 23-66%, respectively). The most frequently reported indication for paracetamol and other nonprescribed analgesics was common cold symptoms (47%; 95% CI, 23-72%; and 64%; 95% CI, 31-89%, respectively). Furthermore, all of the 16 users of OTC combined products claimed common cold symptoms as the most important indication.
Discussion
Prevalence of Medicine Use
The present study showed that ~60% of the female conscripts had used at least one medicine in the 2 weeks preceding the questionnaire in spring 1999. Comparisons between the prevalence of the use of medicines in this study and previous studies among civilian populations are challenging because of differences in the recall periods, target populations, and other aspects of study design.
The prevalence of the overall use of medicines in this study was ~20 percentage points lower than that suggested among the few female respondents in our earlier study in February 1999.41 In spring 1999, a Finnish population survey3 indicated that 75% of the women 15 to 24 years of age used medicines weekly, including one-third (31%) of the respondents who had used contraceptive pills. According to an earlier study,5 65% of young women of the age of 18 years reported the use of medicines monthly. In another Finnish population survey in 1995 to 1996,30 28% of the women in the age group of 15 to 24 years had used some prescribed medicine; 17% had used nonprescribed medicines and 11% vitamins at the time of the interview, In other European and U.S. studies with recall periods of 1 to 2 weeks, the prevalence of the use of medicines among adolescent and young women varied between 30 and 85%.2,7,29,32 Despite the challenges with comparisons between the studies, the prevalence of the overall use of medicines among the female conscripts in our study achieved the same or lower level, compared with values reported in earlier studies among civilian young women of this age group. The difference in the overall prevalence of medicine use among the female conscripts in February and April 1999 might also reflect differences in morbidity rates in the winter and spring seasons or occasional differences in morbidity rates in the garrisons.
According to a Finnish population survey,30 the use of prescribed and nonprescribed medicines among women and men 15 to 24 years of age is of the same magnitude. In our study, the ratio of the use of prescribed and nonprescribed medicines was 1.4. which probably reflects more-intensive need and use20-22 of the free-of-charge FDF health care services during military service. A corresponding ratio among the female conscripts was found in our earlier study in February 1999.41 The more-frequent use of nonprescribed medicines among the nonusers of prescribed medicines, compared with the users of prescribed medicines, may indicate a moderate substitution of self-medication for prescribed medication. However, the number of nonprescribed medicines used among the users of prescribed medicines increased only moderately with the number of prescribed medicines.
A total of 59% of the female conscripts reported the use of contraceptive pills. This prevalence was in accordance with that (55%) reported among civilian women 20 to 24 years of age,42 but it was higher than that (31%) reported among 15- to 24-year-old women in Finnish or U.S. populations.3 6 As expected, the use of contraceptive pills was associated with prescribed medication use. It should be noted that, in a bivariate analysis, the relationship was not statistically significant (odds ratio, 1.8; 95% CI, 0.9-3.5), which may indicate that all of the women did not categorize these pills as medicines. This observation should be interpreted cautiously, however, because the use of contraceptive pills was questioned not for the previous 2 weeks but as part of the use of contraception in general.
Self-medication
In agreement with the literature on self-medication among adolescents and young adults,1,3,5,7 most of the female conscripts' independent self-medication was for headaches (49% of the users of self-medication), other aches (27%), and symptoms of the common cold (34%). Two-thirds (67%) of the women had used self-medication for these indications. In comparison with earlier studies, the rates of independent self-medication for aches in our study were relatively high. According to two Finnish studies,3,5 ~40% of young women of this age used medicines for headache in the past week or month. However, 79% of 17- to 24-year-old U.S. women were found to have taken any nonprescribed analgesic in the past month.33 In our study, the prevalence of weekly or daily use of OTC analgesics was higher during military service (21%) than recalled for the preceding civilian circumstances (7%; p < 0.001). The long recall period probably caused memory failure and underreporting of civilian use.5,43 However, the reported civilian rate was similar among the women in the July 1998 and January 1999 entry cohorts.
Caffeine tablets are the only stimulants available on the OTC market in Finland. According to this study, one-tenth (10%) of the women had used caffeine tablets or other stimulants in the previous 2 weeks. The prevalence was at the same level as among the male conscripts in February 1999 (12%) but lower than that among the women (27%) in that sample.41 The use of caffeine tablets or other stimulants may indicate, for example, shortage of sleep or pursuit of better performance in military service. Inappropriate use of these medicines and the symptoms underlying such use may cause medical risks to individual conscripts and also to a safe military training environment.44,45 In contrast to the use of caffeine tablets or other stimulants, self-medication for sleeplessness and anxiety was rare among the women. This suggests that independent self-medication of psychological symptoms, for example with OTC analgesics, as suggested for a Finnish rural population,24 was not common among the female conscripts.
Advertising strongly influences the choice of an OTC analgesic.46,47 In this study, the most frequently used group of OTC analgesics was ibuprofen products, as expected on the basis of their leading market position in Finland.4 OTC combined and paracetamol products were most often used for common cold symptoms, whereas aspirin, ibuprofen, and ketoprofen products were used for headache and other aches. Of the users of ketoprofen products, as many as one-third (35%) used these products for muscle and joint aches. Vitamins or minerals were used by 36% of the women, Indicating a similar level (32%), compared with a responding civilian population during 1 week.3,7
Our study indicated that the way to ask about the use of medicines strongly affects the detected prevalence. On the basis of direct questions concerning the use of nonprescribed medicines, 31% of the women claimed the use of nonprescribed medicines obtained from a civilian source. In contrast, the overall prevalences of independent self-medication for at least one of the given indications or brand names of OTC analgesics were as high as 79% and 56%, respectively. To study more exactly the prevalence of medicine use and the structure of the medications, for example, personal interviews with visual brand illustrations should be used.
Predictors of Medicine Use
In accordance with earlier studies,5,8,17,18 the profiles of the respondents' sociodemographic background were different between the users of prescribed and nonprescribed medicines, and most of the relationships between sociodemographic background variables and medicine use were weak. On the basis of the bivariate analysis, women from the middle category of age (20-22 years) used prescribed medicines most frequently, which might Indicate their more-common need for prescribed medicines or a greater tendency to obtain them than in other age groups. The association between the use of nonprescribed medicines and higher education remained statistically significant after adjustment for the other statistically significant independent variables In bivariate analyses. The literature provides varying evidence on the relationship between the use of nonprescribed medicines and education level and socioeconomic status.5,8,18,32,48
Of the health behavior variables, experiments with illegal drugs during the respondent's lifetime, frequent visits to a physician in the past 12 months, and to a less extent poor or moderate physical condition were suggested to be related to the use of prescribed medicines. These associations are thought to indicate medical problems such as poorer health status or mixed used of medicines and alcohol/illegal drugs among the users of these medicines.29,49 To estimate the rationality of the prescribed medicine use, however, need variables and additional information on the content of the medication should be investigated. As expected, the use of nonprescribed medicines was most common among the women who reported binge drinking once per 2 months or more often. This observation is in accordance with an earlier finding5 on the relationship between overall medicine use and the use of alcohol among 12- to 18-year-old Finnish girls and young women. The concomitant use of alcohol may increase the risk of, for example, medicine-associated gastrointestinal adverse effects.50 The earlier observation5 of the association between smoking and medicine use was not confirmed in our study.
Origin of Medicines
The present study confirmed our earlier finding41 that most prescribed medicines for conscripts were provided by the FDF health care system, whereas most self-medication was from civilian sources. As expected on the basis of women's active health care utilization in civilian circumstances,10 the female conscripts revealed they obtained self-medication very independently; for almost 70% of the women, the most typical civilian way to obtain nonprescribed medicines was through self-purchase in a pharmacy. For other women, these medicines were provided by other people, in most cases (27% of all respondents) by their parents.
Comments
The main limitation of the present study was that it relied on self-reported information, which probably resulted in underreporting of medicine use. As shown in our study, more-detailed questions with indications might yield a higher frequency of medication use than single questions. Therefore, our results probably show an underestimate of the real medicine use. To obtain more detailed information on the duration, content, and intervals of administration of medication, and on the use of alternative medicines and other products not recognized or reported as medicines, personal interviews should be used.31,51-53 Although the response rate of 68% was acceptable, being based on a single anonymous mail questionnaire, the lack of response of one-third of all women biased the results, at least to some extent. The cross- sectional study design did not allow any interpretations of the causality between the background and outcome variables.
Conclusions
Female conscripts performing voluntary military service frequently used medicines, particularly prescribed ones. Most of the prescribed medicines were provided by the FDF health care system. The use of prescribed medicines was related to health behavior variables that might reflect medical problems, i.e., own experience with illegal drugs, frequent visits to a physician in the past 12 months, and poor or moderate self-perceived health status. The use of nonprescribed medicines was related to binge drinking and higher education. However, part of the present relationships between the use of medicines and respondents' sociodemographic background and health behavior may suggest appropriate use of medicines in general. For example, no associations between psychological symptoms and the use of medicines were found. In addition, independent self-medication for sleeplessness or anxiety was rare. However, the female conscripts used plenty of self-medication such as OTC analgesics and stimulants of civilian origin, and the use of prescribed medicines was more common among those who experimented with illegal drugs. The results of this study emphasize the importance of discussions on medicine use between military and civilian health care providers and female conscripts.
[Reference]
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[Author Affiliation]
Guarantor: Lt SrGr Vesa Jormanainen, MC
Contributors: Kari Linden, PhD MSc (Pharm) MSc(Econ)*[dagger]; Lt SrGr Vesa Jormanainen, MC[double dagger]; Kirsi Pietil�, PhD MSc (Pharm)�; MajGen (Res) Timo Sahi, MC[double dagger]
[Author Affiliation]
* Finnish Defence Forces, POB 50,00301 Helsinki, Finland.
[dagger] Division of Pharmacology and Toxicology, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
[double dagger] Health Care Division, Defence Staff, Finnish Defence Forces, Helsinki, Finland.
� Social Pharmacy Unit, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
This manuscript was received for review in January 2005 and was accepted for publication in October 2005.
Reprint & Copyright � by Association of Military Surgeons of U.S., 2006.
Medicine Use by Finnish Female Conscripts during Voluntary Military Service
Objective: The goal was to assess the prevalence of prescribed and nonprescribed medicine use, use predictors, and origin of medicines for Finnish female conscripts during their voluntary military service. Methods: An anonymous mail survey was conducted in April 1999 among all Finnish female conscripts on duty. Results: Of the respondents (N = 177; response rate, 68%), 61% had used at least one medicine in the 2 weeks preceding the study, 44% prescribed and 31% nonprescribed medicines. Most of the prescribed medicines were provided by Finnish Defence Forces health care, whereas most of the nonprescribed medicines were of civilian origin. The consumption of prescribed and nonprescribed medicines was differently related to respondents' background variables. Common overall medicine use and use of over-the-counter analgesics and stimulants and their association with potentially negative health behaviors may contribute to inappropriate medicine use. Conclusion: Finnish female conscripts commonly use prescribed and nonprescribed medicines. The importance of sufficient medication information for female conscripts is emphasized.
Introduction
Civillan adolescent and working-aged women use prescribed an nonprescribed medicines more frequently than men.1-8 This gender difference is suggested to be based on physical, psychological, and social factors. These factors include, for example, different occurrence and reporting of symptoms and utilization of health care services between genders, as well as different attitudes of health care providers toward women and men.5,9-14
It is important to know the proportion of a population that is exposed to different medicine groups. For example, medicine use is considered to be an indicator of morbidity, and self-medication may substitute for the use of prescription medicines or other established medical care. It is also important to have information on the predictors of medication use, to improve effective and safe medicine use and to prevent related adverse effects.8,15,16 Not only need factors such as pain but also sociodemographic as well as health behavior and lifestyle factors have been found to influence medicine use.2,5,8,17,18
During conscription, basically healthy young women and men are subjected to increased physical, psychological, and social distress.18-23 In addition to several psychological symptoms and health behaviors such as drinking, use of medicines may be a coping strategy through which individuals adjust themselves to a stressful environment or manage psychological symptoms.24-26
Like prescribed medicines, many nonprescribed medicines can be misused or abused.27,28 Self-medication constitutes the largest part of the overall use of medicines among adolescents and young adults.2,7,29-33 Appropriate self-medication can be seen as an Important resource for health care In both civilian and military settings.17,34 However, long-term or otherwise Inadequate self-medication can increase a risk for adverse effects, such as gastrointestinal adverse effects caused by analgesics and toxlcity.27,35-38
More than 80% of Finnish young men perform compulsory military service of 6 to 12 months. Since 1996, Finnish young women have been able to perform military service on a voluntary basis; each year, 250 to 350 women enter the military. The military training Is equal for the two genders. In addition to the distress caused by the military training itself, the characteristics of female anatomy and physiology, as well as the typically high motivation of female conscripts and their pursuit of good results during the voluntary conscription, may result In Increased need and use of medicines and other health services 36,39,40 por example, musculoskeletal injuries during basic military training are more prevalent among women than among men. To our knowledge, published studies on the medication patterns among female conscripts do not exist.
The aim of this study was to Investigate the overall use of prescribed and nonprescribed medicines and their origin among all Finnish female conscripts on duty In April 1999. The effects of women's sociodemographic and health behavior variables on the use of prescribed and nonprescribed medicines were analyzed. In addition, the indications for female conscripts' Independent self-medication, especially the use of over-the-counter (OTC) analgesics, were assessed.
Methods
Study Design
The study was designed and conducted by the Health Care Division of the Defence Staff. The brigades with voluntary female conscripts were ordered to deliver the questionnaire sheets, with return envelopes, to all female conscripts. The women completed the questionnaire sheets anonymously and sent them directly to the Health Care Division, where the study database was constructed. Reminder letters were not used, to guarantee full anonymity of the responders.
Dependent Variables
The use of medicines for the previous 2 weeks (14 days) was questioned. First, the number (none, one, two, or three or more) of prescribed and nonprescribed medicines (medicines obtained with and without a physician visit, respectively) obtained from the Finnish Defence Forces (FDF) health care and civilian sources and used during this period was investigated separately for these four categories. Independent self-medication (nonprescribed medicines obtained from civilian sources) was investigated by asking for its indications with the following options (yes/no): headache, other aches (muscle, joint, or tooth ache), fever, common cold symptoms or sore throat, cough, skin troubles or yeast, sleeplessness or anxiety, and stomach troubles or constipation. Independent self-medication with caffeine tablets or other stimulants, with vitamins or minerals, or for other purposes and the most typical acquisition route (self-purchase in a community pharmacy or provided by other people, such as parents or peers) were investigated. The use of contraception was assessed with the options of no contraception or no need for it, condom, contraceptive pills, or other.
Independent self-medication with OTC analgesics was assessed by asking about the use of the following active substances (with brand names) in the preceding 14 days: ibuprofen, aspirin, paracetamol, ketoprofen, combined products, and other analgesics. In addition, we asked for the most important indication for the use of these product groups, with five indications, or if not used. The recalled frequency of the use of OTC analgesics both during military service and before it (approximately once per week or more versus less frequently) was assessed.
Independent Variables
The data were derived from a postal questionnaire survey among all 261 Finnish female conscripts in April 1999. The questionnaire consisted of 60 questions on the respondent's sociodemographic background, health status, use and acquisition of medicines, and other health behavior. Sociodemographic background variables were age (17-19 years, 20-22 years, or 23-30 years), civilian area of residence (capital area of Helsinki, city with > 100,000 inhabitants, town with 20,000-100,000 inhabitants, small town, or rural area), education level (three levels), marital status (single, engaged, married, or other), military command, and military entry cohort (July 1998 or January 1999). Health status and health behavior variables were height and weight (body mass index of < 19.00, 19.00-24.99, or >24.99 kg/m^sup 2^), self-perceived current physical and mental health status (poor, moderate, good, or excellent), finding military service mentally stressful (yes or no), social contacts in civilian life (poor, moderate, or good), current smoking status (regularly at least one cigarette daily, less frequently, or no), binge drinking (at least once per 2 months, less frequently, or no), own trials with illegal drugs during lifetime (used, tried, or no), and knowing a person who has tried illegal drugs among civilian peers (yes or no). The use of the military (FDF) and civilian health services for the preceding 12 months was investigated as follows: frequent visits to a physician (yes if at least three), a nurse (yes if at least three), or a dentist (yes if at least three) and receiving physiotherapy (yes or no).
Statistical Methods
The prevalence of the use of medicines is presented as a percentage with 95% confidence interval (CI). In the bivariate analyses, the associations between the dependent and independent variables were evaluated by calculating odds ratios with 95% CIs. To control for the effect of potential confounders, a logistic regression model was constructed and odds ratios with 95% CIs were calculated. The model included all of the background variables that showed statistical significance of p < 0.10 in the bivariate analyses of the use of prescribed or nonprescribed medicines. Data analyses were performed with Epilnfo (version 6.04b) software (Centers for Disease Control and Prevention, Atlanta, Georgia) and SPSS (10.0.7) software (SPSS, Chicago, Illinois).
Results
Our sample consisted of 177 responses from a total of 261 female conscripts on duty in April 1999 (response rate, 67.8%). The sample characteristics are described in Table I.
Of the female conscripts, 61% (95% CI, 53-68%) reported the use of medicines in the 2-week period before the study (Table II). The use of prescribed medicines was claimed by 44% (95% CI, 36-51%), whereas the use of nonprescribed medicines was claimed by 31% (95% CI, 24-39%) of the respondents. Among the users of prescribed medicines, the number of nonprescribed medicines used gently increased linearly (from 0.30 to 0.67; slope, 0.19; R^sup 2^ = 0.96) with the number of prescribed medicines used when the users of three or more medicines were classified as users of three medicines. The average number of nonprescription medicines used for the nonusers of prescribed medicines was 0.46
Among all medicine users, 70% (95% CI, 61-79%) had used medicines provided by the FDF health care. Of the users of prescribed medicines, 82% (95% CI, 71-90%) had received these medicines from FDF health care, whereas 67% (95% CI, 53-79%) of the users of nonprescribed medicines had obtained nonprescribed medicines from civilian sources. The most typical way to obtain nonprescribed medicines from civilian sources was self-purchase in a community pharmacy (68%; 95% CI, 61-75%), whereas these medicines were provided by other people for 32% (95% CI, 25-40%).
In the bivariate analyses, the use of prescribed medicines was associated (p < 0.10) with experiments with illegal drugs during the respondent's lifetime, poor or moderate self-perceived physical condition, frequent visits to a physician in the past 12 months, and age category of 20 to 22 years (Table III). The use of nonprescribed medicines was related to education level, binge drinking, and being provided with nonprescribed medicines by other people. In the multivariate analysis, trials with illegal drugs and frequent physician visits remained statistically significant predictors for the use of prescribed medicines and binge drinking and education level for the use of nonprescribed medicines (Table III).
The most frequently reported symptomatic indications for independent self-medication among all of the women were headache (49%; 95% CI, 41-56%), symptoms of common cold (34%; 95% CI. 27-41%), and other aches (27%; 95% CI, 21-34%) (Fig. 1). Altogether, 67% (95% CI, 60-74%) of the respondents had used self-medication for these purposes. Self-medication with caffeine tablets or other stimulants was reported by 10% (95% CI, 6-16%), and self-medication for sleeplessness or anxiety was reported by 0.6% (95% CI, 0-3%). Vitamins were taken by 36% (95% CI, 29-44%). The sum prevalence of independent selfmedication on the basis of recognized diagnoses was 79% (95% CI, 72-84%).
Of the OTC analgesics obtained from civilian sources, ibuprofen products were taken by 46% (95% CI, 39-54%) of the women. Aspirin, paracetamol, ketoprofen, or combined analgesics were used by 9 to 11% each. On the basis of the recognized brand names, 56% (95% CI, 48-63%) of the women had taken OTC analgesics. In the previous 2 weeks, 21% (95% CI, 15-28%) of all respondents had used these analgesics at least once per week and 7% (95% CI, 4-12%) daily or almost daily. Under civilian circumstances before military service, 7% (95% CI, 4-12%) recalled weekly and none daily or almost-daily use of these medications. Among the users of OTC ibuprofen, aspirin, and ketoprofen products, headache was the most important indication (53%; 95% CI, 42-64%; 80%; 95% CI, 56-94%; and 44%; 95% CI, 23-66%, respectively). The most frequently reported indication for paracetamol and other nonprescribed analgesics was common cold symptoms (47%; 95% CI, 23-72%; and 64%; 95% CI, 31-89%, respectively). Furthermore, all of the 16 users of OTC combined products claimed common cold symptoms as the most important indication.
Discussion
Prevalence of Medicine Use
The present study showed that ~60% of the female conscripts had used at least one medicine in the 2 weeks preceding the questionnaire in spring 1999. Comparisons between the prevalence of the use of medicines in this study and previous studies among civilian populations are challenging because of differences in the recall periods, target populations, and other aspects of study design.
The prevalence of the overall use of medicines in this study was ~20 percentage points lower than that suggested among the few female respondents in our earlier study in February 1999.41 In spring 1999, a Finnish population survey3 indicated that 75% of the women 15 to 24 years of age used medicines weekly, including one-third (31%) of the respondents who had used contraceptive pills. According to an earlier study,5 65% of young women of the age of 18 years reported the use of medicines monthly. In another Finnish population survey in 1995 to 1996,30 28% of the women in the age group of 15 to 24 years had used some prescribed medicine; 17% had used nonprescribed medicines and 11% vitamins at the time of the interview, In other European and U.S. studies with recall periods of 1 to 2 weeks, the prevalence of the use of medicines among adolescent and young women varied between 30 and 85%.2,7,29,32 Despite the challenges with comparisons between the studies, the prevalence of the overall use of medicines among the female conscripts in our study achieved the same or lower level, compared with values reported in earlier studies among civilian young women of this age group. The difference in the overall prevalence of medicine use among the female conscripts in February and April 1999 might also reflect differences in morbidity rates in the winter and spring seasons or occasional differences in morbidity rates in the garrisons.
According to a Finnish population survey,30 the use of prescribed and nonprescribed medicines among women and men 15 to 24 years of age is of the same magnitude. In our study, the ratio of the use of prescribed and nonprescribed medicines was 1.4. which probably reflects more-intensive need and use20-22 of the free-of-charge FDF health care services during military service. A corresponding ratio among the female conscripts was found in our earlier study in February 1999.41 The more-frequent use of nonprescribed medicines among the nonusers of prescribed medicines, compared with the users of prescribed medicines, may indicate a moderate substitution of self-medication for prescribed medication. However, the number of nonprescribed medicines used among the users of prescribed medicines increased only moderately with the number of prescribed medicines.
A total of 59% of the female conscripts reported the use of contraceptive pills. This prevalence was in accordance with that (55%) reported among civilian women 20 to 24 years of age,42 but it was higher than that (31%) reported among 15- to 24-year-old women in Finnish or U.S. populations.3 6 As expected, the use of contraceptive pills was associated with prescribed medication use. It should be noted that, in a bivariate analysis, the relationship was not statistically significant (odds ratio, 1.8; 95% CI, 0.9-3.5), which may indicate that all of the women did not categorize these pills as medicines. This observation should be interpreted cautiously, however, because the use of contraceptive pills was questioned not for the previous 2 weeks but as part of the use of contraception in general.
Self-medication
In agreement with the literature on self-medication among adolescents and young adults,1,3,5,7 most of the female conscripts' independent self-medication was for headaches (49% of the users of self-medication), other aches (27%), and symptoms of the common cold (34%). Two-thirds (67%) of the women had used self-medication for these indications. In comparison with earlier studies, the rates of independent self-medication for aches in our study were relatively high. According to two Finnish studies,3,5 ~40% of young women of this age used medicines for headache in the past week or month. However, 79% of 17- to 24-year-old U.S. women were found to have taken any nonprescribed analgesic in the past month.33 In our study, the prevalence of weekly or daily use of OTC analgesics was higher during military service (21%) than recalled for the preceding civilian circumstances (7%; p < 0.001). The long recall period probably caused memory failure and underreporting of civilian use.5,43 However, the reported civilian rate was similar among the women in the July 1998 and January 1999 entry cohorts.
Caffeine tablets are the only stimulants available on the OTC market in Finland. According to this study, one-tenth (10%) of the women had used caffeine tablets or other stimulants in the previous 2 weeks. The prevalence was at the same level as among the male conscripts in February 1999 (12%) but lower than that among the women (27%) in that sample.41 The use of caffeine tablets or other stimulants may indicate, for example, shortage of sleep or pursuit of better performance in military service. Inappropriate use of these medicines and the symptoms underlying such use may cause medical risks to individual conscripts and also to a safe military training environment.44,45 In contrast to the use of caffeine tablets or other stimulants, self-medication for sleeplessness and anxiety was rare among the women. This suggests that independent self-medication of psychological symptoms, for example with OTC analgesics, as suggested for a Finnish rural population,24 was not common among the female conscripts.
Advertising strongly influences the choice of an OTC analgesic.46,47 In this study, the most frequently used group of OTC analgesics was ibuprofen products, as expected on the basis of their leading market position in Finland.4 OTC combined and paracetamol products were most often used for common cold symptoms, whereas aspirin, ibuprofen, and ketoprofen products were used for headache and other aches. Of the users of ketoprofen products, as many as one-third (35%) used these products for muscle and joint aches. Vitamins or minerals were used by 36% of the women, Indicating a similar level (32%), compared with a responding civilian population during 1 week.3,7
Our study indicated that the way to ask about the use of medicines strongly affects the detected prevalence. On the basis of direct questions concerning the use of nonprescribed medicines, 31% of the women claimed the use of nonprescribed medicines obtained from a civilian source. In contrast, the overall prevalences of independent self-medication for at least one of the given indications or brand names of OTC analgesics were as high as 79% and 56%, respectively. To study more exactly the prevalence of medicine use and the structure of the medications, for example, personal interviews with visual brand illustrations should be used.
Predictors of Medicine Use
In accordance with earlier studies,5,8,17,18 the profiles of the respondents' sociodemographic background were different between the users of prescribed and nonprescribed medicines, and most of the relationships between sociodemographic background variables and medicine use were weak. On the basis of the bivariate analysis, women from the middle category of age (20-22 years) used prescribed medicines most frequently, which might Indicate their more-common need for prescribed medicines or a greater tendency to obtain them than in other age groups. The association between the use of nonprescribed medicines and higher education remained statistically significant after adjustment for the other statistically significant independent variables In bivariate analyses. The literature provides varying evidence on the relationship between the use of nonprescribed medicines and education level and socioeconomic status.5,8,18,32,48
Of the health behavior variables, experiments with illegal drugs during the respondent's lifetime, frequent visits to a physician in the past 12 months, and to a less extent poor or moderate physical condition were suggested to be related to the use of prescribed medicines. These associations are thought to indicate medical problems such as poorer health status or mixed used of medicines and alcohol/illegal drugs among the users of these medicines.29,49 To estimate the rationality of the prescribed medicine use, however, need variables and additional information on the content of the medication should be investigated. As expected, the use of nonprescribed medicines was most common among the women who reported binge drinking once per 2 months or more often. This observation is in accordance with an earlier finding5 on the relationship between overall medicine use and the use of alcohol among 12- to 18-year-old Finnish girls and young women. The concomitant use of alcohol may increase the risk of, for example, medicine-associated gastrointestinal adverse effects.50 The earlier observation5 of the association between smoking and medicine use was not confirmed in our study.
Origin of Medicines
The present study confirmed our earlier finding41 that most prescribed medicines for conscripts were provided by the FDF health care system, whereas most self-medication was from civilian sources. As expected on the basis of women's active health care utilization in civilian circumstances,10 the female conscripts revealed they obtained self-medication very independently; for almost 70% of the women, the most typical civilian way to obtain nonprescribed medicines was through self-purchase in a pharmacy. For other women, these medicines were provided by other people, in most cases (27% of all respondents) by their parents.
Comments
The main limitation of the present study was that it relied on self-reported information, which probably resulted in underreporting of medicine use. As shown in our study, more-detailed questions with indications might yield a higher frequency of medication use than single questions. Therefore, our results probably show an underestimate of the real medicine use. To obtain more detailed information on the duration, content, and intervals of administration of medication, and on the use of alternative medicines and other products not recognized or reported as medicines, personal interviews should be used.31,51-53 Although the response rate of 68% was acceptable, being based on a single anonymous mail questionnaire, the lack of response of one-third of all women biased the results, at least to some extent. The cross- sectional study design did not allow any interpretations of the causality between the background and outcome variables.
Conclusions
Female conscripts performing voluntary military service frequently used medicines, particularly prescribed ones. Most of the prescribed medicines were provided by the FDF health care system. The use of prescribed medicines was related to health behavior variables that might reflect medical problems, i.e., own experience with illegal drugs, frequent visits to a physician in the past 12 months, and poor or moderate self-perceived health status. The use of nonprescribed medicines was related to binge drinking and higher education. However, part of the present relationships between the use of medicines and respondents' sociodemographic background and health behavior may suggest appropriate use of medicines in general. For example, no associations between psychological symptoms and the use of medicines were found. In addition, independent self-medication for sleeplessness or anxiety was rare. However, the female conscripts used plenty of self-medication such as OTC analgesics and stimulants of civilian origin, and the use of prescribed medicines was more common among those who experimented with illegal drugs. The results of this study emphasize the importance of discussions on medicine use between military and civilian health care providers and female conscripts.
[Reference]
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[Author Affiliation]
Guarantor: Lt SrGr Vesa Jormanainen, MC
Contributors: Kari Linden, PhD MSc (Pharm) MSc(Econ)*[dagger]; Lt SrGr Vesa Jormanainen, MC[double dagger]; Kirsi Pietil�, PhD MSc (Pharm)�; MajGen (Res) Timo Sahi, MC[double dagger]
[Author Affiliation]
* Finnish Defence Forces, POB 50,00301 Helsinki, Finland.
[dagger] Division of Pharmacology and Toxicology, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
[double dagger] Health Care Division, Defence Staff, Finnish Defence Forces, Helsinki, Finland.
� Social Pharmacy Unit, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
This manuscript was received for review in January 2005 and was accepted for publication in October 2005.
Reprint & Copyright � by Association of Military Surgeons of U.S., 2006.
