de Jong-van den Berg, L.T.

Meijer, W.M.

Tobi, H.

Tuinstra, J.

English

OBJECTIVE: To detect whether there were socio-economic differences in the overall use of prescription and OCT drugs among adolescents. METHODS: This study was a secondary analysis of questionnaire data collected to investigate socio-economic differences in health risk behaviour and decision-making. RESULTS: About 20% of the 741 girls and 10% of the 736 boys reported using at least one prescription drug in the past 14 days, oral contraceptives excluded. For OTC drugs these percentages were 45% and 24%, respectively. No statistically significant socio-economic differences in prescription drug use could be detected. A higher socio-economic status was associated with an increased OTC drug use, especially in boys. The odds of girls who reported medication was about twice that for boys, after adjusting for perceived health and socio-economic status. CONCLUSION: There were socio-economic differences with regard to OTC drug use. No socio-economic differences in prescription medication use could be found. There were gender differences with respect to medication use in adolescence, regardless of perceived health and socio-economic status. Record 5 of 6 - MEDLINE(R) In-Process &amp; Other Citations Nov Wk 

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   University of GroningenSocio-economic differences in prescription and OTC drug use in Dutch adolescentsTobi, H.; Meijer, W.M.; Tuinstra, J.; de Jong-van den Berg, L.T.Published in:Pharmacy World & ScienceIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2003Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):Tobi, H., Meijer, W. M., Tuinstra, J., & de Jong-van den Berg, L. T. (2003). Socio-economic differences inprescription and OTC drug use in Dutch adolescents. Pharmacy World & Science, 25(5), 203 - 206.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 20-06-2022Research articleIntroductionSocial inequalities in health continue to be an impor-tant problem in many European countries. In thepast, the social inequalities in health services accessand health services consumption have been a majorpoint of interest. Partially due to increasing attentionfor the health of ethnic and religious minorities, socio-economic health differences remain of interest1,2. Theincreasing health differences within and between for-mer communist countries also remind one of theimpact of social environment 3. Research from different countries suggests that theassociation between socio-economic status andhealth is modified by age. Health differences associat-ed with socio-economic status exist at birth anddecrease during childhood4–6. According to the inter-national literature, social inequalities in health areeminent in adulthood3,4. Adolescence, in contrast,seems better characterised by the almost absence ofsocio-economic health differences6,7. 203Socio-economic differences in prescription and OTC drug use in Dutchadolescents• Hi lde Tobi ,  Wi l lemi jn M. Mei jer,  Jo landa Tuinstra  and Lolk je  T.W. de Jong-van den BergPharm World Sci 2003; 25(5): 203–206.© 2003 Kluwer Academic Publishers. Printed in the Netherlands.H. Tobi (correspondence), W.M. Meijer, L.T.W. de Jong-vanden Berg: Groningen University Institute of Drug Exploration(GUIDE), Department Social Pharmacy, Pharmaco-epidemiology and Pharmacotherapy, Antonius Deusinglaan1, 9713 AV Groningen, The Netherlands (e-mail: h.tobi@farm.rug.nl).J. Tuinstra: Northern Centre for Healthcare Research,Department of Health Sciences, University of Groningen,Antonius Deusinglaan 1, 9713 AV Groningen, TheNetherlandsKey wordsAdolescent Drug-utilisation Gender OTC drugs Prescription drugsSocio-economic factors The NetherlandsAbstractObjective: To detect whether there were socio-economic dif-ferences in the overall use of prescription and OTC drugsamong adolescents. Methods: This study was a secondary analysis of questionnai-re data collected to investigate socio-economic differences inhealth risk behaviour and decision-making. Results: About 20% of the 741 girls and 10% of the 736 boysreported using at least one prescription drug in the past 14days, oral contraceptives excluded. For OTC drugs these per-centages were 45% and 24%, respectively. No statisticallysignificant socio-economic differences in prescription druguse could be detected. A higher socio-economic status wasassociated with an increased OTC drug use, especially inboys. The odds of girls who reported medication was abouttwice that for boys, after adjusting for perceived health andsocio-economic status.Conclusion: There were socio-economic differences withregard to OTC drug use. No socio-economic differences inprescription medication use could be found. There were gen-der differences with respect to medication use in adolescen-ce, regardless of perceived health and socio-economic status.Accepted February 2003Several Swedish studies investigated the associationbetween prescription drug use and socio-economicstatus8–10, but none of these studies looked into theassociation between socio-economic status and over-all medical drug use in adolescence.In this paper, the association between socio-eco-nomic status and drug use of adolescents in TheNetherlands is investigated. For both prescription andOTC (non-Rx) medication, the associations betweenoverall medical drug consumption and socio-eco-nomic status is investigated, with and without takinginto account gender and perceived health.Materials and methodsData collectionThis study was a secondary analysis of data collectedto investigate social inequalities in health risk behav-iour and decision-making styles11,12. For this project,4th grade scholars from 18 secondary schools in thenorth of the Netherlands filled out a questionnaire atthe end of 1994/early 1995. In the Netherlands, theage of fourth grade scholars ranges from 14 to 21years, resulting from skipping classes in primaryschool and changing from one type of school toanother. The median age of fourth grade scholars is16 years. The response rate was 95%, yielding 1984respondents. 1598 of these respondents were aged15–17 and had answered the following question ondrug use: ‘Did you use any prescription drug (pre-scribed by a medical doctor or dentist) during thepast 14 days, excluding oral contraceptives?’ OTCdrugs were inquired after similarly: ‘Did you use anynon- prescription drug during the past 14 days?’.After exclusion of respondents with incomplete infor-mation (in all cases on socio-economic status) a sam-ple of 1477 adolescents remained (1477/1598 or92% of the respondents aged 15–17). Socio-economic status (SES) was operationalised asthe highest attained educational level of the parentssince education has been reported to be a bettersocio-economic indicator than income or occupationof the head of the household13,14. Six levels of SESwere distinguished, ranking from low (primary educa-tion) to high (university). The respondents rated theirhealth as bad, moderate, good, very good or excellenton the question ‘How do you experience your health?’Because of their rare occurrence, the categories ‘bad’and ‘moderate’ were collapsed in the analyses.Statistical analysisAssociations were investigated using chi-square tests;linear associations were investigated by means of chi-square tests for linear trend. These tests were consid-ered significant at the P < 0.05 level. To obtain adjusted odds ratios, logistic regressionmodels were used. For the logistic regression, socio-204economic status was reclassified into lower, middleand upper class, based on years of secondary andhigher education as given by the six original cate-gories (≤ 4 years, 5–6 years, > 6 years). Variables wereconsidered to contribute significantly to the logisticregression model if P < 0.10 for the Wald statistic. Allstatistical analyses were done using SPSS for Windowsversion 10.ResultsThe data on drug use in this study population are pre-sented in Table 1. The percentage of girls reported tohave used medication was about twice the percent-age of boys (for prescription drugs 20.1% and 10.9%,for OTC drugs 44.8% and 23.6%). Socio-economic status was not significantly associ-ated with prescription drugs (linear trend, P = 0.204).However, socio-economic status was statistically sig-nificant associated with OTC drugs (linear trend, P =0.021). After stratification on gender, the associationbetween socio-economic status and drug useappeared to depend on gender. With increasing SESthe percentage of boys having used OTC drugsincreased from 6.7% to 31.4% (linear trend, P =0.027). No such trend was found in girls (P = 0.179).There appeared to be a strong relation betweenself-rated health and drug-use for both prescriptiondrugs and OTC drugs (both P < 0.005). The poorerthe self-rated health, the higher the percentage ofdrug-use in the last 14 days. No statistically significantassociation could be found between socio-economicstatus and self-rated health (linear trend, P = 0.132). In the logistic regression models, the odds of drug-use was described including all covariables of interest(Table 2). In the logistic model for prescription med-ication, perceived health and gender contributed sig-nificantly, while SES did not (P = 0.45). In the logisticmodel for OTC medication, perceived health andgender were statistically significant (P < 0.001). SESalso contributed significantly to the model (P = 0.07),suggesting a lower socio-economic class was associat-ed with a lower odds of having used an OTC drug.The gender–SES interaction was not included in themodel (P = 0.43). For both prescription and OTCdrugs, a lower self-reported health status was associ-ated with an increased odds for having used a drug,and the odds for girls was about twice that for boys(Table 2).Table 1 Data on the use of drugs and socio-economic status stratified on perceived health and genderBoys (n = 736) Girls (n = 741)Self -reported SES Used Used Total in Used Used Total inhealth prescription OTC stratum prescription OTC stratumdrugs drugs drugs drugsBad/moderateLow 12345High 6Total1000135013225131487773411685425121371053835231614666Good Low 12345High 6Total05712533207142111962429646843222303112320167802164347312015994870876739330Very good Low 12345High 6Total155102528010111816863632678857322820611732291113622151510052476623727231Excellent Low 12345High 6Total0452221514611953642546484225190123243151271474355723342619114Discussion In this study, the drug-use of 15–17-year-old boysand girls in relation to their socio-economic statuswas analysed. An association between drug use andsocio-economic status could be found only for OTCdrugs. After taking gender and self-reported healthinto account, this association did not reach full statis-tical significance at the 0.05 level. Hence, our studyresults were not in full agreement with studies fromother countries that suggest the absence of socio-eco-nomic health differences in adolescence 6,7. Of the total of 1598 15–17-year-olds whoresponded to the questions on drug use, 121 hadmissing information on socio-economic status. Toinvestigate possible bias thus induced, we tested forassociations between socio-economic status known orunknown and any of the other variables (gender, pre-scription drug use OTC drug use, and perceivedhealth). No such association could be detected.Hence we conclude that the influence of bias is prob-ably limited.The questions on prescription and OTC drugs orig-inated from the general health surveys of StatisticsNetherlands (CBS). Statistics Netherlands is aware ofinterpretation problems with respect to the questionon OTC drugs and drew attention to the fact thatsome respondents did not regard aspirin as a drug15.The difficulty with the classification in prescribed andnon-prescribed drugs was that we did not knowexactly how respondents interpreted this classifica-tion. For example, how did they classify a homeo-pathic drug recommended by a general practitionerand bought from a drugstore? What if this homeo-pathic drug was prescribed by the general practition-er and purchased in the community pharmacy? Wethink the impact of this ambiguity is probably small,because our results for prescription and OTC drugswere concordant. However, we do not know whetherthis ambiguity is related to socio-economic factors orgender. No association between prescription drug use andsocio-economic status could be found. Since the liter-ature suggests that the direction of this association inthe general population may differ with druggroups8–10, our results may be due to the fact that thequestion was too crude. On the other hand, ourresults may stem from an actual lack of socio-eco-nomic health differences in Dutch adolescents.Education has a stronger predictive value forhealth than income and occupation4–14. Educationallevel is of good use for studying socio-economichealth differences in the general population but is it inadolescents? During adolescence the influence of par-ents reduces in many areas and the influence of thepeer group increases, or at least remains significant.With this in mind, one could think of current educa-tion of the adolescent as a proxy for future socio-eco-nomic status. Since our data contained informationon school levels, we performed the same analyses asreported in the Results section. School level was asso-ciated with perceived health and OTC drug use, butthere was no linear trend. So one cannot say that ahigher school level is associated with better self-reported health, although some studies report ahealth selection mechanism in educational careers5.After stratification on gender and perceived health,none of the tests for association between school leveland medication were statistically significant.We did find a strong association between drug-useand gender, despite the fact that contraceptive pillswere excluded. Another Dutch study also found thatmore girls than boys use prescription medication15.An obvious though partial explanation for this differ-ence between boys and girls is the associationbetween self-reported health and gender that hasbeen reported16,17. An additional explanation for thedifference in the use of non-prescribed drugs couldbe that girls take OTC-available analgaesics for painrelief during their menstrual period. ConclusionIn conclusion, this study did detect a borderline statis-tically significant socio-economic health differencewith regard to OTC drug-use in adolescence. Moredetailed information on type of prescription drugswould be needed to rule out the possibility of socio-economic differences with respect to prescriptionmedication in adolescence.There were gender differ-ences in adolescence with respect to prescriptiondrugs use and OTC drugs that could not be account-ed for by perceived health and socio-economic status. 205Table 2 Multiple logistic regression results incorperating all covariablesDependent Use of prescription drugs Use of OTC drugsvariableCovariable OR 95% CI P (Wald) OR 95% CI P (Wald)Gender < 0.001 < 0.001Boys 1 1Girls 1.80 1.34–2.43 2.43 1.93–3.04Health < 0.001Excellent 1 1 < 0.001Very good 1.09 0.68–1.74 1.48 1.06–2.06Good 2.02 1.30–3.13 1.86 1.34–2.57Bad/Moderate 3.34 1.87–5.95 2.84 1.75–4.62SES 0.45Upper 1 1 0.07Middle 1.00 0.63–1.59 0.78 0.55–1.11Lower 0.83 0.53–1.32 0.67 0.47–0.95AcknowledgementData made available by the Northern Centre forHealthcare Research. References 1 Abbotts J, Williams R, Ford G. Morbidity and Irish Catholicdescent in Britain relating health disadvantage to socio-eco-nomic position. Soc Sci Med 2001; 52: 999–1005.2 Chandola T. Ethnic and class differences in health to BritishSouth Asians: using the new national statistics socio-econom-ic classification. Soc Sci Med 2001; 52: 1285–96.3 Marmot M, Bobak M. International comparators and povertyand health in Europe. BMJ 2000; 321: 1124–8.4 Mackenbach JP. Socio-economic health differences in theNetherlands: a review of recent empirical findings. Soc SciMed 1992; 34: 213–26.5 Van der Lucht F, Groothoff JW. Social inequalities and healthamong children aged 10-11 in the Netherlands: causes andconsequences. Soc Sci Med 1995; 40:1305–11.6 West P. Health inequalities in the early years: is there equaliza-tion in youth? Soc Sci Med 1997; 44: 833–58.7 Rahkonen O, Arber S, Lahelma E. Health inequalities in earlyadulthood: a comparison of young men and women inBritain and Finland. Soc Sci Med 1995; 41: 163–71.8 Henricson K, Melander E, Mölstad S, Ranstam J, Hanson BS,Rametsteiner G, Stenberg P, Melander A. Intra-urban varia-tion of antibiotic utilisation in children: influence of socio-economic factors. Eur J Clin Pharmacol 1998; 54: 653–7.9 Henricson K, Stenberg P, Rametsteiner G, Ranstam J, HansonBS, Melander A. Socio-economic factors, morbidity and drugutilisation – an ecological study. Pharmacoepidemiol DrugSaf 1998; 7: 261–7.10 Henricson K, Carlsten A, Ranstam J, Rametsteiner G, et al.Utilisation of codeine and propoxyphene: geographic anddemographic variations in prescribing, prescriber and recipi-ent categories. Eur J Clin Pharmacol 1999; 55: 605–11.11 Tuinstra J, Groothoff JW, Van den Heuvel WJA, Post D. Socio-economic differences in health risk behavior in adolescence:do they exist? Soc Sci Med 1998; 47: 67–74.12 Tuinstra J, Van Sonderen FLP, Groothoff JW, Van den HeuvelWJA, Post D. Reliability, validity and structure of the adoles-cent decision making questionnaire among adolescents inThe Netherlands. Pers Indiv Differ 2000; 28: 273–85.13 Van Berkel-van Schaik AB, Tax B. Naar een standaardopera-tionalisatie van sociaal-economische status voor epidemiolo-gisch en sociaal-medisch onderzoek. Rijswijk, TheNetherlands: Ministerie van VWS, 1990. 14 Reynolds JR, Ross CE. Social stratification and health: educa-tion’s benefit beyond economic status and social origins. SocProblems 1998; 45: 221–47.15 Centraal Bureau Statistiek. Statline. Retrieved fromhttp://www.cbs.nl/nl/cijfers/kerncijfers/index.htm#Gezondheidon 7 November 2002.16 Schirm E, Van den Berg P, Gebben H, Sauer P, de Jong-vanden Berg LTW. Drug use of children in the communityassessed through pharmacy dispensing data. Br J ClinPharmacol 2000; 50: 473–8.17 Sweeting H. Reversals of fortune? Sex differences in health inchildhood and adolescence. Soc Sci Med 1995; 40: 77–90.206

Socio-economic differences in prescription and OTC drug use in Dutch adolescents

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Socio-economic differences in prescription and OTC drug use in Dutch adolescents

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