Self-medication, self-prescription and medicating “by proxy” in paediatrics

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"en" => "Study design." ] ] ] "textoCompleto" => "IntroductionFrom certain perspectives, self-medication could be considered a positive self-care measure, as it can expedite the care for mild illnesses.<a class="elsevierStyleCrossRefs" href="#bib0170">1–4</a> However, when done irresponsibly, that is, when it turns into self-prescription,<a class="elsevierStyleCrossRefs" href="#bib0190">5,6</a> there can be potential adverse effects whose consequences may be hard to predict. The World Medical Association<a class="elsevierStyleCrossRef" href="#bib0200">7</a> established a simple distinction between self-medication (use of medicines that do not require a physician's prescription) and self-prescription (self-determined use of medicines that require a physician's prescription due to their indications or risks); however, the boundaries between the two concepts may not be well understood by the general population.<a class="elsevierStyleCrossRef" href="#bib0205">8</a>In children, there are unique factors at play in both self-prescription and self-medication that carry a higher risk compared to their practice in adults. On one hand, we do not know the actual effects on children of many drugs used in adults that have not been authorised for paediatric use.<a class="elsevierStyleCrossRefs" href="#bib0210">9,10</a> At present, there are several conditions limiting the use of medicines in children: not recommended, authorised with restrictions, not specified, use for unauthorised indications, or off-label use.<a class="elsevierStyleCrossRefs" href="#bib0220">11–15</a> On the other hand, and perhaps this may be the most particular aspect, it could be said that in children, both self-prescription and self-medication are carried out “by proxy,” that is, the decision is made by a third party, usually the mother, in the absence of any type of professional prescription. In children, this is not a self-directed, free and voluntary decision on the part of the patient based on the patient's knowledge or perceived symptoms, as it is in adults,<a class="elsevierStyleCrossRef" href="#bib0245">16</a> but is based on the subjective interpretation of the symptoms by the mother or a third party in charge of the minor. Thus, we think that exploring this phenomenon is of vital importance in order to learn the factors and perceptions associated with this issue, which may not correspond to reality.Materials and methodsWe conducted a prospective observational study on the population of paediatric patients in the catchment area of the Hospital Universitario San Cecilio de Granada that sought care in the outpatient emergency department. We recruited patients seeking care in dates selected at random after informing the parents or legal guardians about the study and obtaining their consent for participation. We provided the parents with a questionnaire that was designed, validated, corrected and approved by the competent Ethics Committee (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>We recruited patients on days selected at random with a seasonal chronogram during the 2010–2011period. For the purposes of analysis, we classified patients into two groups: the exposure group, consisting of the children that had been exclusively self-medicated by the mother prior to visiting the emergency department, and the control group, consisting of children that did not fulfil this criterion. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> represents the study design.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>We entered the data on an electronic database, validated and analysed them with the Epi Info software version 3.4.3 for Windows. We guaranteed the confidentiality of the data in writing. We conducted a descriptive analysis of quantitative variables by calculating proportions and comparing them with the chi square test. We analysed qualitative variables by calculating odds ratios (ORs) with a confidence interval (CI) of 95%.ResultsWe recruited 1.714 children, of who 345 (20.1%) were exclusively self-medicated by the mother. Of the 1.369 remaining children, 494 had received no medication, 273 were taking medication prescribed for a different illness, 564 were receiving prescribed medication for the current illness, and 38 were self-medicated by someone other than the mother. Of these 1.369 patients, 217 had also been self-medicated. Out of all the patients under study, 70.3% were receiving some sort of medication at the time of the visit: the overall percentage of self-medicated patients was 32.8% (345+217 of the 1714 patients). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the association between self-medication and different social and familial factors in our study.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The individual that decided on the use of medication was most frequently the mother (90.1%) with a significant difference (P<.01) compared to all other situations: grandmother or hired caregiver (4.2%), father (2.6%), patient/itself (1.8%) or pharmacist (1.3%).We did not find a significant association between maternal age and the frequency of self-medication of children, taking mothers aged less than 20 years as reference: mothers aged 21–30 years (OR, 1.36; 95% CI, 0.49–4.08), mothers aged 31–40 years (OR, 1.39; 95% CI, 0.50–4.18), mothers aged 40 years (OR, 2.01; 95% CI, 0.66–6.49).Maternal educational attainment (We designed a three-level scale for the study that summarised the scale used in the National Health Survey [Encuesta Nacional de Salud, ENS])<a class="elsevierStyleCrossRef" href="#bib0305">28</a> was categorised as basic (primary-compulsory secondary education [ESO]), with 54.7% of mothers; intermediate, with 20.9% of mothers, and higher, with 24.4% of mothers. We found statistically significant differences between groups (P<.05 to P<.01) that were also significantly associated with the frequency of self-medication, which increased with higher educational attainment. For the intermediate educational attainment group, the OR was 1.41 (95% CI, 1.05–1.91) and for the higher educational attainment group, it was 1.62 (95% CI, 1.22–2.14).We did not find a significant association between the socioeconomic level of the family (assessed with a method similar to the one used for educational attainment) and the frequency of self-medication: low (OR, 1 [reference]), middle (OR, 1.18; 95% CI, 0.89–1.56) and high (OR, 1.23; 95% CI, 0.92–1.65).As for the number of children in the family, there was a predominance of families with one or two children (38.1 and 41.3%), with statistically significant differences (P<.01) between each of these and families with three or more children (20.6%). The frequency of self-medication was significantly associated with the number of children: it was more frequent in families with more children, with an OR of 3.14 for families with more than three children (95% CI, 2.21–4.44).The frequency of self-medication was also significantly associated with the sibling order of the patient: it was greater the higher the sibling order. This criterion was distributed in the sample with a predominance of first-born children (56.2%) with a significant difference compared to the other groups (P<.01). Self-medication in second-born children corresponded to an OR of 1.83 (95% CI, 1.38–2.44), and for third and subsequent children, to an OR of 2.32 (95% CI, 1.69–3.20).The frequency of self-medication was directly correlated to the age of patients, although this association was only significant starting at age 6 years. In our study, 1.8% of patients self-medicated without parental involvement; most of them were adolescents, mainly females, and nearly always due to treat menstruation symptoms.The analysis of the duration of symptoms prior to seeking care found that it was of less than 6h in 45.3%, 6–12h in 25.6%, and that the frequencies declined for other durations. We found statistically significant differences (P<.01) between all duration groups, and also a significant association between duration of symptoms and self-medication frequency. Self-medication was more frequent with increasing duration of symptoms prior to seeking care: the OR for a duration of 6–12h was 4.60 (95% CI, 3.20–6.62), and for durations of more than 24h, it was 12.16 (95% CI, 7.83–18.86).The type of medication used was consistent with the reason for seeking care. Antipyretic drugs (56.8%), cough medicine and mucolytic agents (40.3%) predominated over all other types (P<.01), which included oral rehydration solutions (6.1%), bronchodilators (5.5%), topical agents (4.6%) and others (22.8%). Eighteen percent of patients were taking antibiotics. Of all self-medicated patients, 62.6% were taking a single drug, 27.8% two drugs, and 9.6% three or more drugs.As for the source of the medicines used, the majority were left over from the treatment of previous illnesses (84.9%), with medicines obtained specifically to treat the current episode amounting to only 11.9% and medicines of a different source to 3.2%. The choice of medication was based on a previous prescription for another child (49%), a previous prescription for the same child (44%) and a recommendation from outside the healthcare field (7%).DiscussionThe issue of self-medication is an infrequent subject matter in the paediatric medical literature, while it is addressed more commonly in the adult and family medicine literature.<a class="elsevierStyleCrossRefs" href="#bib0250">17–19</a> Many studies have been designed to assess the use of medication,<a class="elsevierStyleCrossRefs" href="#bib0220">11–15,20–25</a> but few have provided evidence on aspects as specific as the association between the mother's and the family's role and self-medication.The percentage of patients that were receiving medication (70.3%) and of patients that were self-medicated (32.8%) in our study were consistent with those published by other authors.<a class="elsevierStyleCrossRef" href="#bib0265">20</a> There is wide variability owing to cultural influences and factors related to health care and social welfare. A rate of self-medication of 34% has been reported in Spain,<a class="elsevierStyleCrossRef" href="#bib0265">20</a> which rose to 63% when narrowed down to the use of antipyretics in particular.<a class="elsevierStyleCrossRef" href="#bib0280">23</a> The percentage reported in Italy is 28%,<a class="elsevierStyleCrossRef" href="#bib0295">26</a> and in rural areas in Mexico, 58%.<a class="elsevierStyleCrossRef" href="#bib0285">24</a>In our sample, the individual that decided on self-medication was the mother in 90% of the patients, similar to the 85.1% reported by other authors.<a class="elsevierStyleCrossRef" href="#bib0285">24</a> Consultation with a pharmacist is rare, with a reported frequency in Spain of approximately 1%,<a class="elsevierStyleCrossRef" href="#bib0265">20</a> which was consistent with our findings. Higher frequencies have also been described, although they have been questioned by the very authors that reported them.<a class="elsevierStyleCrossRef" href="#bib0300">27</a>The association found between the number of children and the frequency of self-medication could be attributed to the experience acquired by the mother with previous children: as they grow in years, they feel “qualified” to treat symptoms already observed in previous children. This hypothesis seemed even more plausible when we found that the frequency of self-medication increased with the patient's sibling order.Our data show that maternal educational attainment is associated with the frequency of self-medication, which was greater in mothers with intermediate and higher education compared to mothers with basic education. When we analysed data obtained from the ENS, we found that adult women use emergency services less frequently when they have a higher education (OR, 0.89; 95% CI, 0.81–0.97).<a class="elsevierStyleCrossRef" href="#bib0305">28</a>Some authors<a class="elsevierStyleCrossRefs" href="#bib0265">20,28</a> have reported that children aged less than 4 or 5 years are the most medicated patients; this does not necessarily contradict our results, which show that medication “by proxy” is less frequent in children aged less than 2 years, a finding that could be explained by the greater vulnerability perceived by mothers in younger children, which would motivate mothers to medicate them by prescription as opposed to self-medication.We did not find data in the literature regarding the association between duration of symptoms and the frequency of self-medication. The analysis of our data suggests that medication “by proxy” may delay seeking medical care, which could result in the need for emergency services in cases in which the problem is not resolved with self-medication.The higher frequency of visits within 6h from the onset of symptoms found in our data (45.3%) was corroborated by the figure we obtained by analysing the data from the ENS<a class="elsevierStyleCrossRef" href="#bib0305">28</a> for patients aged 0–14 years: patients sought care most frequently within 6h starting at age 5 years.We also did not find any references in the literature on the frequency of the use of combined drugs in medication “by proxy.” A study of 336 children that visited the emergency department already medicated with one, two or three or more drugs found that fewer patients had received two or more drugs compared to only one.<a class="elsevierStyleCrossRef" href="#bib0265">20</a> These results are similar to those of our study when considering self-medicated patients alone.The “home medicine cabinet”, understood as the collection of medications kept at home, most of which are left over from previous treatments,<a class="elsevierStyleCrossRef" href="#bib0310">29</a> is a tradition in our health culture, and although its prevalence is variable,<a class="elsevierStyleCrossRefs" href="#bib0260">40,19,29</a> we found it to be the main source of the medicines being used. The source of these medicines is frequently a prescription made for a past treatment, and less frequently its isolated purchase, as most can be obtained over the counter.Antibiotics deserve special attention, as they are prescription medicines of which at least one container is found in 37% of Spanish households. In 85% of these households, the antibiotics had been prescribed by a physician, even though only 30% had a member that was being treated with antibiotics at the time they were surveyed.<a class="elsevierStyleCrossRefs" href="#bib0310">29,30</a> In our study, antibiotics accounted for 18% of self-prescribed medicines. Previous studies have found that 24% of mothers self-prescribe antibiotics for their children and that 21% save leftover antibiotics for future use,<a class="elsevierStyleCrossRefs" href="#bib0320">31,32</a> which may result in the use of antibiotics that are expired or at ineffective doses.Using the data provided by the ENS,<a class="elsevierStyleCrossRef" href="#bib0305">28</a> we analysed which pharmaceuticals had been consumed in the past two weeks by patients aged 0–14 years, and found that 11% had taken antibiotics, of which 98% had been obtained by prescription. It is very likely that courses of treatment in which the actual dosage and duration were lower than those prescribed also contributed to medicine stockpiles.There is evidence of an association between maternal self-medication and more frequent self-medication of children.<a class="elsevierStyleCrossRef" href="#bib0330">33</a> Our findings seem to confirm that the education mothers gain in the identification of symptoms through their experience with previous children allows them to acquire certain “competences” to indicate the administration of a medicine that they usually consider most appropriate on account of past prescriptions made by physicians for illnesses mothers consider to be similar. This hypothesis also fits with the source of the medicines used for self-medication, as 84.9% are left overs from previous treatments.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres833072" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec828994" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres833071" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec828995" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-03-16" "fechaAceptado" => "2016-06-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec828994" "palabras" => array:4 [ 0 => "Self-medicating in children" 1 => "Primary health care" 2 => "Self-care" 3 => "Medicating ‘by proxy’" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec828995" "palabras" => array:4 [ 0 => "Automedicación en niños" 1 => "Atención Primaria" 2 => "Autocuidados" 3 => "Medicación por poderes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionSelf-prescribing or medicating ‘by proxy’ is not an autonomous, free and voluntary decision in the case of children. On the contrary, in this case it is based on the subjective interpretation of symptoms made by the mother or by a third person who is legally responsible for the minor. Analysing this situation is of great importance in order to know the determining factors, perceptions, and realities related to this problem. MethodsOur proposal is to perform a prospective observational study for analysing maternal and familiar determinant factors related to self-prescribing and self-medicating ‘by proxy’ in paediatrics. A validated survey was developed to be applied to mothers of children aged 0–14 who are users of the Paediatric Emergency Department in a hospital. ResultsA total of 1.714 mothers were recruited in a random period of time. This sample included 345 mothers who exclusively self-medicated their children (case group), and 1.369 mothers (control group) who did not meet this requirement. The overall percentage of medicating ‘by proxy’ was 32.8%. There is a significant association between self-medicating and educational level of the mother, the number of children, and the birth order among siblings. Neither maternal age nor social-occupational level are related to this problem. Most frequently used drugs include antipyretics and ‘anticatharrals’, usually administered as a monotherapy. ConclusionsOur results seem to indicate that the educational level and the parental experience acquired with previous children could generate the required confidence in parents to choose the medication by themselves. Almost 85% of these drugs come from the ‘home first-aid kit’." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa autoprescripción o medicación «por poderes» en el niño no es una decisión autónoma, libre y voluntaria del paciente, sino que se fundamenta en la interpretación subjetiva que hace de los síntomas la madre o una tercera persona responsable del menor. Analizar esta situación nos parece de vital importancia, a fin de conocer condicionantes, percepciones y realidades relacionadas con esta problemática. MétodosNos planteamos analizar mediante un estudio observacional prospectivo condicionantes maternos y familiares relacionados con la autoprescripción y medicación «por poderes» en pediatría. Desarrollamos una encuesta validada para madres de usuarios de 0–14 años de un Servicio de Urgencias pediátricas hospitalario. ResultadosEn un periodo de tiempo aleatorio se selecciona a 1.714 madres, de las cuales 345 habían automedicado exclusivamente a sus hijos (grupo problema), las otras 1.369 (grupo control) no cumplían con el requisito anterior. La prevalencia total de medicación «por poderes» fue del 32.8%. Hay unaasociación significativa entre la automedicación y el nivel de estudios maternos, el número de hijos, el orden que ocupa entre los hermanos. Ni la edad materna, ni el nivel sociolaboral de la familia se relacionan con el problema. Los fármacos utilizados con más frecuencia incluyen antitérmicos y «anticatarrales», habitualmente como monoterapia. ConclusionesNuestros resultados parecen indicar que el nivel educativo, y la experiencia adquirida por las madres con hijos previos, les genera la confianza suficiente para elegir los fármacos, que casi en el 85% de los casos proceden del «botiquín doméstico»." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Valenzuela Ortiz M, Sánchez Ruiz-Cabello FJ, Uberos J, Checa Ros AF, Valenzuela Ortiz C, Augustín Morales MC, et al. Automedicación, autoprescripción y medicación «por poderes» en pediatría. An Pediatr (Barc). 2017;86:264–269." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1164 "Ancho" => 1652 "Tamanyo" => 174301 ] ] "descripcion" => array:1 [ "en" => "Study design." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "fx1.jpeg" "imagenAlto" => 3130 "imagenAncho" => 2336 "imagenTamanyo" => 510875 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Validated questionnaire form." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "CI, confidence interval; ESO, Spanish compulsory secondary education; OR, odds ratio." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factor \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR (95% CI) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Number of children (reference group: 1 child)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 children \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.47 (1.82–3.37) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 or more children \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.14 (2.21–4.44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Sibling order (reference group: first child)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Second child \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.83 (1.38–2.44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Third or more \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.32 (1.69–3.20) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Patient age (years) (reference group: 3–6 years)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0–2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.90 (0.66–1.23)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.47 (1.10–1.97) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">11–14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.12 (1.28–3.49) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.51 (1.51–8.16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Duration of symptoms prior to emergency department visit (hours) (reference group: <6h)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6–12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.60 (3.20–6.62) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">12–24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.32 (4.31–9.27) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">24–48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.16 (7.83–18.86) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.77 (14.30–46.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Maternal educational attainment<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a>(reference group: primary/ESO)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intermediate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.41 (1.05–1.91) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Higher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.62 (1.22–2.14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Maternal age (years) (reference group: <20 years)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">21–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.36 (0.49–4.08)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">31–40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.39 (0.50–4.18)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.01 (0.66–6.49)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Family socioeconomic status<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a>(reference group: low)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Middle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.18 (0.8–1.56)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.23 (0.92–1.65)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1403221.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Association not statistically significant." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Data assessed based on the scale used in the National Health Survey (Encuesta Nacional de Salud [ENS]), which we subsequently summarised into three categories for the sake of simplicity." ] ] ] "descripcion" => array:1 [ "en" => "Association between the frequency of self-medication and various factors." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0170" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "ISBN 9243541358" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atención Primaria de Salud (Alma-Ata-URSS-1978). Serie Salud para todos, n.° 1" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "OMS" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1978" "editorial" => "OMS" "editorialLocalizacion" => "Ginebra" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0175" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Appropriate use of nonprescription analgesics in pediatric patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.K. Dlugosz" 1 => "R.W. Charter" 2 => "J.P. 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Original Article

Self-medication, self-prescription and medicating “by proxy” in paediatrics

Automedicación, autoprescripción y medicación «por poderes» en pediatría

María Valenzuela Ortiza, Francisco Javier Sánchez Ruiz-Cabellob, José Uberosc,

Corresponding author

juberos@ugr.es

Corresponding author.

, Ana Fátima Checa Rosc, Cristina Valenzuela Ortizd, María Carmen Augustín Moralese, Antonio Muñoz Hoyosf

a Grupo de Investigación (PAI) CTS 190, Granada, Spain

b Centro de Salud Zaidín Sur, Granada, Spain

c Servicio de Pediatría, Hospital Universitario San Cecilio, Granada, Spain

d Servicio de Anestesia, Complejo Hospitalario Ciudad de Jaén, Grupo de Investigación (PAI) CTS 190, Granada, Spain

e Centro de Salud de Guadix, Grupo de Investigación (PAI) CTS 190, Granada, Spain

f UGC de Pediatría, Hospital Universitario San Cecilio, Facultad de Medicina, Grupo de Investigación (PAI) CTS 190, Granada, Spain

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        "titulo" => "Automedicaci&#243;n&#44; autoprescripci&#243;n y medicaci&#243;n &#171;por poderes&#187; en pediatr&#237;a"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">From certain perspectives&#44; self-medication could be considered a positive self-care measure&#44; as it can expedite the care for mild illnesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">1&#8211;4</span></a> However&#44; when done irresponsibly&#44; that is&#44; when it turns into self-prescription&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">5&#44;6</span></a> there can be potential adverse effects whose consequences may be hard to predict&#46; The World Medical Association<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">7</span></a> established a simple distinction between self-medication &#40;use of medicines that do not require a physician&#39;s prescription&#41; and self-prescription &#40;self-determined use of medicines that require a physician&#39;s prescription due to their indications or risks&#41;&#59; however&#44; the boundaries between the two concepts may not be well understood by the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In children&#44; there are unique factors at play in both self-prescription and self-medication that carry a higher risk compared to their practice in adults&#46; On one hand&#44; we do not know the actual effects on children of many drugs used in adults that have not been authorised for paediatric use&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">9&#44;10</span></a> At present&#44; there are several conditions limiting the use of medicines in children&#58; not recommended&#44; authorised with restrictions&#44; not specified&#44; use for unauthorised indications&#44; or off-label use&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#8211;15</span></a> On the other hand&#44; and perhaps this may be the most particular aspect&#44; it could be said that in children&#44; both self-prescription and self-medication are carried out &#8220;by proxy&#44;&#8221; that is&#44; the decision is made by a third party&#44; usually the mother&#44; in the absence of any type of professional prescription&#46; In children&#44; this is not a self-directed&#44; free and voluntary decision on the part of the patient based on the patient&#39;s knowledge or perceived symptoms&#44; as it is in adults&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">16</span></a> but is based on the subjective interpretation of the symptoms by the mother or a third party in charge of the minor&#46; Thus&#44; we think that exploring this phenomenon is of vital importance in order to learn the factors and perceptions associated with this issue&#44; which may not correspond to reality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We conducted a prospective observational study on the population of paediatric patients in the catchment area of the Hospital Universitario San Cecilio de Granada that sought care in the outpatient emergency department&#46; We recruited patients seeking care in dates selected at random after informing the parents or legal guardians about the study and obtaining their consent for participation&#46; We provided the parents with a questionnaire that was designed&#44; validated&#44; corrected and approved by the competent Ethics Committee &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">We recruited patients on days selected at random with a seasonal chronogram during the 2010&#8211;2011period&#46; For the purposes of analysis&#44; we classified patients into two groups&#58; the exposure group&#44; consisting of the children that had been exclusively self-medicated by the mother prior to visiting the emergency department&#44; and the control group&#44; consisting of children that did not fulfil this criterion&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> represents the study design&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">We entered the data on an electronic database&#44; validated and analysed them with the Epi Info software version 3&#46;4&#46;3 for Windows&#46; We guaranteed the confidentiality of the data in writing&#46; We conducted a descriptive analysis of quantitative variables by calculating proportions and comparing them with the chi square test&#46; We analysed qualitative variables by calculating odds ratios &#40;ORs&#41; with a confidence interval &#40;CI&#41; of 95&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">We recruited 1&#46;714 children&#44; of who 345 &#40;20&#46;1&#37;&#41; were exclusively self-medicated by the mother&#46; Of the 1&#46;369 remaining children&#44; 494 had received no medication&#44; 273 were taking medication prescribed for a different illness&#44; 564 were receiving prescribed medication for the current illness&#44; and 38 were self-medicated by someone other than the mother&#46; Of these 1&#46;369 patients&#44; 217 had also been self-medicated&#46; Out of all the patients under study&#44; 70&#46;3&#37; were receiving some sort of medication at the time of the visit&#58; the overall percentage of self-medicated patients was 32&#46;8&#37; &#40;345<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>217 of the 1714 patients&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the association between self-medication and different social and familial factors in our study&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The individual that decided on the use of medication was most frequently the mother &#40;90&#46;1&#37;&#41; with a significant difference &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; compared to all other situations&#58; grandmother or hired caregiver &#40;4&#46;2&#37;&#41;&#44; father &#40;2&#46;6&#37;&#41;&#44; patient&#47;itself &#40;1&#46;8&#37;&#41; or pharmacist &#40;1&#46;3&#37;&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We did not find a significant association between maternal age and the frequency of self-medication of children&#44; taking mothers aged less than 20 years as reference&#58; mothers aged 21&#8211;30 years &#40;OR&#44; 1&#46;36&#59; 95&#37; CI&#44; 0&#46;49&#8211;4&#46;08&#41;&#44; mothers aged 31&#8211;40 years &#40;OR&#44; 1&#46;39&#59; 95&#37; CI&#44; 0&#46;50&#8211;4&#46;18&#41;&#44; mothers aged 40 years &#40;OR&#44; 2&#46;01&#59; 95&#37; CI&#44; 0&#46;66&#8211;6&#46;49&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Maternal educational attainment &#40;We designed a three-level scale for the study that summarised the scale used in the National Health Survey &#91;Encuesta Nacional de Salud&#44; ENS&#93;&#41;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> was categorised as basic &#40;primary-compulsory secondary education &#91;ESO&#93;&#41;&#44; with 54&#46;7&#37; of mothers&#59; intermediate&#44; with 20&#46;9&#37; of mothers&#44; and higher&#44; with 24&#46;4&#37; of mothers&#46; We found statistically significant differences between groups &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05 to <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; that were also significantly associated with the frequency of self-medication&#44; which increased with higher educational attainment&#46; For the intermediate educational attainment group&#44; the OR was 1&#46;41 &#40;95&#37; CI&#44; 1&#46;05&#8211;1&#46;91&#41; and for the higher educational attainment group&#44; it was 1&#46;62 &#40;95&#37; CI&#44; 1&#46;22&#8211;2&#46;14&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We did not find a significant association between the socioeconomic level of the family &#40;assessed with a method similar to the one used for educational attainment&#41; and the frequency of self-medication&#58; low &#40;OR&#44; 1 &#91;reference&#93;&#41;&#44; middle &#40;OR&#44; 1&#46;18&#59; 95&#37; CI&#44; 0&#46;89&#8211;1&#46;56&#41; and high &#40;OR&#44; 1&#46;23&#59; 95&#37; CI&#44; 0&#46;92&#8211;1&#46;65&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">As for the number of children in the family&#44; there was a predominance of families with one or two children &#40;38&#46;1 and 41&#46;3&#37;&#41;&#44; with statistically significant differences &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; between each of these and families with three or more children &#40;20&#46;6&#37;&#41;&#46; The frequency of self-medication was significantly associated with the number of children&#58; it was more frequent in families with more children&#44; with an OR of 3&#46;14 for families with more than three children &#40;95&#37; CI&#44; 2&#46;21&#8211;4&#46;44&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The frequency of self-medication was also significantly associated with the sibling order of the patient&#58; it was greater the higher the sibling order&#46; This criterion was distributed in the sample with a predominance of first-born children &#40;56&#46;2&#37;&#41; with a significant difference compared to the other groups &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#46; Self-medication in second-born children corresponded to an OR of 1&#46;83 &#40;95&#37; CI&#44; 1&#46;38&#8211;2&#46;44&#41;&#44; and for third and subsequent children&#44; to an OR of 2&#46;32 &#40;95&#37; CI&#44; 1&#46;69&#8211;3&#46;20&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The frequency of self-medication was directly correlated to the age of patients&#44; although this association was only significant starting at age 6 years&#46; In our study&#44; 1&#46;8&#37; of patients self-medicated without parental involvement&#59; most of them were adolescents&#44; mainly females&#44; and nearly always due to treat menstruation symptoms&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The analysis of the duration of symptoms prior to seeking care found that it was of less than 6<span class="elsevierStyleHsp" style=""></span>h in 45&#46;3&#37;&#44; 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h in 25&#46;6&#37;&#44; and that the frequencies declined for other durations&#46; We found statistically significant differences &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41; between all duration groups&#44; and also a significant association between duration of symptoms and self-medication frequency&#46; Self-medication was more frequent with increasing duration of symptoms prior to seeking care&#58; the OR for a duration of 6&#8211;12<span class="elsevierStyleHsp" style=""></span>h was 4&#46;60 &#40;95&#37; CI&#44; 3&#46;20&#8211;6&#46;62&#41;&#44; and for durations of more than 24<span class="elsevierStyleHsp" style=""></span>h&#44; it was 12&#46;16 &#40;95&#37; CI&#44; 7&#46;83&#8211;18&#46;86&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The type of medication used was consistent with the reason for seeking care&#46; Antipyretic drugs &#40;56&#46;8&#37;&#41;&#44; cough medicine and mucolytic agents &#40;40&#46;3&#37;&#41; predominated over all other types &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; which included oral rehydration solutions &#40;6&#46;1&#37;&#41;&#44; bronchodilators &#40;5&#46;5&#37;&#41;&#44; topical agents &#40;4&#46;6&#37;&#41; and others &#40;22&#46;8&#37;&#41;&#46; Eighteen percent of patients were taking antibiotics&#46; Of all self-medicated patients&#44; 62&#46;6&#37; were taking a single drug&#44; 27&#46;8&#37; two drugs&#44; and 9&#46;6&#37; three or more drugs&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">As for the source of the medicines used&#44; the majority were left over from the treatment of previous illnesses &#40;84&#46;9&#37;&#41;&#44; with medicines obtained specifically to treat the current episode amounting to only 11&#46;9&#37; and medicines of a different source to 3&#46;2&#37;&#46; The choice of medication was based on a previous prescription for another child &#40;49&#37;&#41;&#44; a previous prescription for the same child &#40;44&#37;&#41; and a recommendation from outside the healthcare field &#40;7&#37;&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The issue of self-medication is an infrequent subject matter in the paediatric medical literature&#44; while it is addressed more commonly in the adult and family medicine literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">17&#8211;19</span></a> Many studies have been designed to assess the use of medication&#44;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">11&#8211;15&#44;20&#8211;25</span></a> but few have provided evidence on aspects as specific as the association between the mother&#39;s and the family&#39;s role and self-medication&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The percentage of patients that were receiving medication &#40;70&#46;3&#37;&#41; and of patients that were self-medicated &#40;32&#46;8&#37;&#41; in our study were consistent with those published by other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> There is wide variability owing to cultural influences and factors related to health care and social welfare&#46; A rate of self-medication of 34&#37; has been reported in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> which rose to 63&#37; when narrowed down to the use of antipyretics in particular&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">23</span></a> The percentage reported in Italy is 28&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">26</span></a> and in rural areas in Mexico&#44; 58&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In our sample&#44; the individual that decided on self-medication was the mother in 90&#37; of the patients&#44; similar to the 85&#46;1&#37; reported by other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">24</span></a> Consultation with a pharmacist is rare&#44; with a reported frequency in Spain of approximately 1&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> which was consistent with our findings&#46; Higher frequencies have also been described&#44; although they have been questioned by the very authors that reported them&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">27</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The association found between the number of children and the frequency of self-medication could be attributed to the experience acquired by the mother with previous children&#58; as they grow in years&#44; they feel &#8220;qualified&#8221; to treat symptoms already observed in previous children&#46; This hypothesis seemed even more plausible when we found that the frequency of self-medication increased with the patient&#39;s sibling order&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our data show that maternal educational attainment is associated with the frequency of self-medication&#44; which was greater in mothers with intermediate and higher education compared to mothers with basic education&#46; When we analysed data obtained from the ENS&#44; we found that adult women use emergency services less frequently when they have a higher education &#40;OR&#44; 0&#46;89&#59; 95&#37; CI&#44; 0&#46;81&#8211;0&#46;97&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Some authors<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">20&#44;28</span></a> have reported that children aged less than 4 or 5 years are the most medicated patients&#59; this does not necessarily contradict our results&#44; which show that medication &#8220;by proxy&#8221; is less frequent in children aged less than 2 years&#44; a finding that could be explained by the greater vulnerability perceived by mothers in younger children&#44; which would motivate mothers to medicate them by prescription as opposed to self-medication&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">We did not find data in the literature regarding the association between duration of symptoms and the frequency of self-medication&#46; The analysis of our data suggests that medication &#8220;by proxy&#8221; may delay seeking medical care&#44; which could result in the need for emergency services in cases in which the problem is not resolved with self-medication&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The higher frequency of visits within 6<span class="elsevierStyleHsp" style=""></span>h from the onset of symptoms found in our data &#40;45&#46;3&#37;&#41; was corroborated by the figure we obtained by analysing the data from the ENS<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> for patients aged 0&#8211;14 years&#58; patients sought care most frequently within 6<span class="elsevierStyleHsp" style=""></span>h starting at age 5 years&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We also did not find any references in the literature on the frequency of the use of combined drugs in medication &#8220;by proxy&#46;&#8221; A study of 336 children that visited the emergency department already medicated with one&#44; two or three or more drugs found that fewer patients had received two or more drugs compared to only one&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">20</span></a> These results are similar to those of our study when considering self-medicated patients alone&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The &#8220;home medicine cabinet&#8221;&#44; understood as the collection of medications kept at home&#44; most of which are left over from previous treatments&#44;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">29</span></a> is a tradition in our health culture&#44; and although its prevalence is variable&#44;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">40&#44;19&#44;29</span></a> we found it to be the main source of the medicines being used&#46; The source of these medicines is frequently a prescription made for a past treatment&#44; and less frequently its isolated purchase&#44; as most can be obtained over the counter&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Antibiotics deserve special attention&#44; as they are prescription medicines of which at least one container is found in 37&#37; of Spanish households&#46; In 85&#37; of these households&#44; the antibiotics had been prescribed by a physician&#44; even though only 30&#37; had a member that was being treated with antibiotics at the time they were surveyed&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">29&#44;30</span></a> In our study&#44; antibiotics accounted for 18&#37; of self-prescribed medicines&#46; Previous studies have found that 24&#37; of mothers self-prescribe antibiotics for their children and that 21&#37; save leftover antibiotics for future use&#44;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">31&#44;32</span></a> which may result in the use of antibiotics that are expired or at ineffective doses&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Using the data provided by the ENS&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">28</span></a> we analysed which pharmaceuticals had been consumed in the past two weeks by patients aged 0&#8211;14 years&#44; and found that 11&#37; had taken antibiotics&#44; of which 98&#37; had been obtained by prescription&#46; It is very likely that courses of treatment in which the actual dosage and duration were lower than those prescribed also contributed to medicine stockpiles&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">There is evidence of an association between maternal self-medication and more frequent self-medication of children&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">33</span></a> Our findings seem to confirm that the education mothers gain in the identification of symptoms through their experience with previous children allows them to acquire certain &#8220;competences&#8221; to indicate the administration of a medicine that they usually consider most appropriate on account of past prescriptions made by physicians for illnesses mothers consider to be similar&#46; This hypothesis also fits with the source of the medicines used for self-medication&#44; as 84&#46;9&#37; are left overs from previous treatments&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Self-prescribing or medicating &#8216;by proxy&#8217; is not an autonomous&#44; free and voluntary decision in the case of children&#46; On the contrary&#44; in this case it is based on the subjective interpretation of symptoms made by the mother or by a third person who is legally responsible for the minor&#46; Analysing this situation is of great importance in order to know the determining factors&#44; perceptions&#44; and realities related to this problem&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Our proposal is to perform a prospective observational study for analysing maternal and familiar determinant factors related to self-prescribing and self-medicating &#8216;by proxy&#8217; in paediatrics&#46; A validated survey was developed to be applied to mothers of children aged 0&#8211;14 who are users of the Paediatric Emergency Department in a hospital&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 1&#46;714 mothers were recruited in a random period of time&#46; This sample included 345 mothers who exclusively self-medicated their children &#40;case group&#41;&#44; and 1&#46;369 mothers &#40;control group&#41; who did not meet this requirement&#46; The overall percentage of medicating &#8216;by proxy&#8217; was 32&#46;8&#37;&#46; There is a significant association between self-medicating and educational level of the mother&#44; the number of children&#44; and the birth order among siblings&#46; Neither maternal age nor social-occupational level are related to this problem&#46; Most frequently used drugs include antipyretics and &#8216;anticatharrals&#8217;&#44; usually administered as a monotherapy&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our results seem to indicate that the educational level and the parental experience acquired with previous children could generate the required confidence in parents to choose the medication by themselves&#46; Almost 85&#37; of these drugs come from the &#8216;home first-aid kit&#8217;&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
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            "identificador" => "abst0015"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La autoprescripci&#243;n o medicaci&#243;n &#171;por poderes&#187; en el ni&#241;o no es una decisi&#243;n aut&#243;noma&#44; libre y voluntaria del paciente&#44; sino que se fundamenta en la interpretaci&#243;n subjetiva que hace de los s&#237;ntomas la madre o una tercera persona responsable del menor&#46; Analizar esta situaci&#243;n nos parece de vital importancia&#44; a fin de conocer condicionantes&#44; percepciones y realidades relacionadas con esta problem&#225;tica&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Nos planteamos analizar mediante un estudio observacional prospectivo condicionantes maternos y familiares relacionados con la autoprescripci&#243;n y medicaci&#243;n &#171;por poderes&#187; en pediatr&#237;a&#46; Desarrollamos una encuesta validada para madres de usuarios de 0&#8211;14 a&#241;os de un Servicio de Urgencias pedi&#225;tricas hospitalario&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En un periodo de tiempo aleatorio se selecciona a 1&#46;714 madres&#44; de las cuales 345 hab&#237;an automedicado exclusivamente a sus hijos &#40;grupo problema&#41;&#44; las otras 1&#46;369 &#40;grupo control&#41; no cumpl&#237;an con el requisito anterior&#46; La prevalencia total de medicaci&#243;n &#171;por poderes&#187; fue del 32&#46;8&#37;&#46; Hay unaasociaci&#243;n significativa entre la automedicaci&#243;n y el nivel de estudios maternos&#44; el n&#250;mero de hijos&#44; el orden que ocupa entre los hermanos&#46; Ni la edad materna&#44; ni el nivel sociolaboral de la familia se relacionan con el problema&#46; Los f&#225;rmacos utilizados con m&#225;s frecuencia incluyen antit&#233;rmicos y &#171;anticatarrales&#187;&#44; habitualmente como monoterapia&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestros resultados parecen indicar que el nivel educativo&#44; y la experiencia adquirida por las madres con hijos previos&#44; les genera la confianza suficiente para elegir los f&#225;rmacos&#44; que casi en el 85&#37; de los casos proceden del &#171;botiqu&#237;n dom&#233;stico&#187;&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Valenzuela Ortiz M&#44; S&#225;nchez Ruiz-Cabello FJ&#44; Uberos J&#44; Checa Ros AF&#44; Valenzuela Ortiz C&#44; August&#237;n Morales MC&#44; et al&#46; Automedicaci&#243;n&#44; autoprescripci&#243;n y medicaci&#243;n &#171;por poderes&#187; en pediatr&#237;a&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;86&#58;264&#8211;269&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CI&#44; confidence interval&#59; ESO&#44; Spanish compulsory secondary education&#59; OR&#44; odds ratio&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Number of children &#40;reference group&#58; 1 child&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>2 children&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;47 &#40;1&#46;82&#8211;3&#46;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3 or more children&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;14 &#40;2&#46;21&#8211;4&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Sibling order &#40;reference group&#58; first child&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Second child&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;83 &#40;1&#46;38&#8211;2&#46;44&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Third or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;32 &#40;1&#46;69&#8211;3&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Patient age &#40;years&#41; &#40;reference group&#58; 3&#8211;6 years&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;90 &#40;0&#46;66&#8211;1&#46;23&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;47 &#40;1&#46;10&#8211;1&#46;97&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>11&#8211;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;12 &#40;1&#46;28&#8211;3&#46;49&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;51 &#40;1&#46;51&#8211;8&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Duration of symptoms prior to emergency department visit &#40;hours&#41; &#40;reference group&#58; &#60;6</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">h&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>6&#8211;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;60 &#40;3&#46;20&#8211;6&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>12&#8211;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;32 &#40;4&#46;31&#8211;9&#46;27&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;16 &#40;7&#46;83&#8211;18&#46;86&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;77 &#40;14&#46;30&#8211;46&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Maternal educational attainment</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">&#40;reference group&#58; primary&#47;ESO&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intermediate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;41 &#40;1&#46;05&#8211;1&#46;91&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Higher&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;62 &#40;1&#46;22&#8211;2&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Maternal age &#40;years&#41; &#40;reference group&#58; &#60;20 years&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>21&#8211;30&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;01 &#40;0&#46;66&#8211;6&#46;49&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Family socioeconomic status</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">&#40;reference group&#58; low&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Middle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;18 &#40;0&#46;8&#8211;1&#46;56&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;23 &#40;0&#46;92&#8211;1&#46;65&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Association between the frequency of self-medication and various factors&#46;</p>"
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      "titulo" => "References"
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                0 => array:3 [
                  "comentario" => "ISBN 9243541358"
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                    0 => array:2 [
                      "titulo" => "Atenci&#243;n Primaria de Salud &#40;Alma-Ata-URSS-1978&#41;&#46; Serie Salud para todos&#44; n&#46;&#176; 1"
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                        "editorialLocalizacion" => "Ginebra"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2016.06.005

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2024 November	13	7	20
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2023 December	150	38	188
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2023 October	130	49	179
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2023 August	70	14	84
2023 July	76	27	103
2023 June	46	31	77
2023 May	106	33	139
2023 April	62	12	74
2023 March	128	33	161
2023 February	86	17	103
2023 January	52	24	76
2022 December	99	32	131
2022 November	116	34	150
2022 October	106	38	144
2022 September	72	36	108
2022 August	75	47	122
2022 July	69	41	110
2022 June	59	56	115
2022 May	95	40	135
2022 April	121	49	170
2022 March	157	63	220
2022 February	161	43	204
2022 January	214	53	267
2021 December	121	47	168
2021 November	172	48	220
2021 October	286	82	368
2021 September	87	50	137
2021 August	78	51	129
2021 July	57	47	104
2021 June	114	55	169
2021 May	90	49	139
2021 April	252	62	314
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2021 February	115	19	134
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2020 December	121	36	157
2020 November	177	21	198
2020 October	113	27	140
2020 September	83	25	108
2020 August	104	22	126
2020 July	113	26	139
2020 June	129	22	151
2020 May	144	28	172
2020 April	186	23	209
2020 March	80	28	108
2020 February	57	23	80
2020 January	106	25	131
2019 December	53	33	86
2019 November	91	27	118
2019 October	126	25	151
2019 September	74	18	92
2019 August	63	26	89
2019 July	53	27	80
2019 June	25	35	60
2019 May	89	27	116
2019 April	104	37	141
2019 March	80	23	103
2019 February	35	13	48
2019 January	31	22	53
2018 December	92	25	117
2018 November	107	28	135
2018 October	128	34	162
2018 September	113	11	124
2018 August	2	0	2
2018 July	2	0	2
2018 June	5	0	5
2018 May	9	0	9
2018 April	19	0	19
2018 March	34	0	34
2018 February	14	0	14
2018 January	37	0	37
2017 December	39	0	39
2017 November	37	0	37
2017 October	30	0	30
2017 September	46	0	46
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