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Mitchgam 5821B '1 I Uflwmw : ..ux:.¢.:.u¢."u.11* ‘ " I This is to certify that the thesis entitled OVER THE COUNTER DRUG USE AMONG A SAMPLE OF MICHIGAN'S ELDERLY CONSUMERS: ITS RELATIONSHIP TO SOURCES OF INFORMATION presented by Susan M. Evonne Brown has been accepted towards fulfillment of the requirements for Master's degree in Family Ecology Date November 9, 1979 0-7639 cess- .. . . 4:3; ovmnur FINES I’VE“. ,1,\"z¢:;g.~., ILL-fur“ to buck 1'0? t0 rem 0V9- Qyfiv, LI.L-‘.$ checkuu; 1 om your record. ARE "73¢ PER DAY I OVER-THE-COUNTER DRUG USE AMONG A SAMPLE OF MICHIGAN'S ELDERLY CONSUMERS: ITS RELATIONSHIP TO SOURCES OF INFORMATION By Susan M. Evonne Brown A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Family Ecology 1979 ABSTRACT OVER-THE-COUNTER DRUG USE AMONG A SAMPLE OF MICHIGAN'S ELDERLY CONSUMERS: ITS RELATIONSHIP TO SOURCES OF INFORMATION By Susan M. Evonne Brown This research examined relationships between the subjective impor- tance placed on certain sources of over-the-counter (OTC) drug informa- tion and the extent of OTC drug use among a sample of Michigan's elderly consumers. The influence of selected demographic, attitudinal and behavioral characteristics on. the observed relationships between tin: extent of OTC drug use and the importance of information sources was examined. The role of these variables in predicting over-the-counter drug use and discriminating 'between. levels of’ drug 'use (non-users, moderate users and heavy users) was also assessed. Data used in this research were drawn from a previous study, Senior Citizens’ Substance Use Survey, sponsored by the State of Michigan Office of Services to the Aging and Office of Substance Abuse Services. The original study had a stratified cluster sample of 384 persons age 60 and older. Data was obtained through personal interviews during November, 1977 to March 1978. Funding for this research report was provided by the Office of Services to the Aging. Data in this research were drawn from tin: original sample and new variables were created to test some of the hypotheses. Susan M. Evonne Brown One-way ANOVA revealed that importance placed on doctors, pharma- cists and oneself as sources of OTC drug information were positively and significantly related to OTC drug use. Significant differences were found between OTC drug users and non-users with respect to the impor- tance placed on sources of OTC drug information. Users placed signifi- cantly more importance on sources than did non-users. Overall, the analyses revealed 'that, ill general, tin: importance scores for all five OTC drug information sources were positively related to each other and to increased OTC drug use. A factor analysis of the importance scores revealed two underlying factors accounting for the observed interrelations of the original scores. These two factors were the importance of professional sources and the importance of' non- professional sources of OTC drug information. Consequently, these two factors were used in place of the original scores for the five sources. The importance placed on professional sources for OTC drug informa- tion increased with OTC drug use, while the importance placed on non- professional sources was significantly greater for users than for non- users of OTC drugs. The relationship between OTC drug use and the importance of non-professional sources was qualified by race and marital status. Whites placed greater importance (n1 non-professional sources with increased OTC drug use. Among non-whites, moderate users placed greatest importance on non-professional sources. Increasing importance was placed on non-professional sources with increased OTC drug use among those who were married and living with their spouse. For those who were widowed, single, separated or divorced, the importance of non-profes- sional sources did not vary significantly among non-users, moderate or heavy users of OTC drugs. Susan M. Evonne Brown The relationship between OTC drug use and the importance of profes- sional sources for OTC drug information was not qualified by other variables. However, the importance of professional sources was signifi- cantly related to several variables. Those who placed more importance on professional sources were found to be white, living in urban areas, between the ages 60 and 70, to have been engaged in a skilled occupation and were relatively more active. OTC drug use was related to two demographic variables. The t-test revealed that OTC drug use was somewhat greater among whites than among non-whites, and that OTC drug use was significantly greater among rural residents than among urban residents. Sex, age and whether a person lived alone cnr*with others were not significantly related to OTC drug use. OTC drug use was found to be negatively related to two attitudinal variables. Respondents who were less satisfied with the way they spend their time and those who ranked their life low on a scale from worst possible to best possible made more use of OTC drugs. Health status was not related to OTC drug use in this study. Multiple regression and discriminant analysis produced basically the same set of predictor variables. The factors which were most pre- dictive of increased OTC drug use in this elderly sample were increased age, widowed marital status, rural residential location, low ranking of life, and increased importance placed on both professional and non- professional sources for OTC drug information. The discriminant analysis jproduced. two significant. discriminant functions. One dimension primarily discriminated between non-users and heavy users. Heavy users were found to be more likely than non-users to be of a marital status other than widowed, to give a low ranking to Susan M. Evonne Brown their life, place greater importance on professional information sources, and to place greater importance on non-professional information sources. The second dimension primarily discriminated between moderate and heavy users of OTC drugs. Heavy users, more than moderate users, were more likely 11) be non-white, older, widowed, separated, single or di- vorced, living alone, spending more time watching television, and to have been engaged in a white collar occupation. ACKNOWLEDGEMENTS I would like to acknowledge the State of Michigan Office of Services to the Aging for providing the funding which made this research possible. Also making possible this research experience was the invalu- able assistance of many others. I would like to express my heartfelt thanks to some of those for their tremendous contributions. Dr. Marilyn Nagy, for her guidance through my master's program and whose high standards and criticism contributed much to myself as well as to this thesis. Dr. Dennis Keefe, who was willing to take on this research as a co-investigator, helping shape the proposal and direct the research, for his patience and time with this project. Dr. Leonard Reid for his helpful suggestions on the thesis, parti- cularly in regard to the review of literature. Victor Battistisch, my statistician for his immeasurable help with the data analyses. Ms. Mary James of the Michigan Office of Services to the Aging, for providing the data for this study and for her encouragement and per- severance in seeing this project through. Ms. Jane Meyer Church for her tremendous patience in typing this thesis and in working with me. I would like to give special personal thanks to my mother for her continuing love and support, to Deon Gines-Schweitzer for her friendship and encouragement, to Linda Salcedo for her example and understanding, and especially to my good friend Saud Qusti for his criticisms and support in my endeavors. ii TABLE OF CONTENTS LIST OF TABLES . LIST OF FIGURES. Chapter I. INTRODUCTION. Statement of the Problem. Objectives of the Study . Significance of the Research. Limitations of the Study. Definitions . . . . II. REVIEW OF LITERATURE. Self-medication in the General Population . Research Related to the Elderly, Non- institutionalized Drug Consumer . Sources of Information Used by Elderly Consumers and Sources of Influence in Self- medication . Summary . III. METHODOLOGY . Description of Original Study . . Procedures for Senior Substance Use Survey. Sampling. . Description of the Sample . Summary . . . . . . Generalizability. Data Collection . Validity and Reliability. . . Data Reduction and Score Construction . Variables . . Contextual Variables. Hypotheses. Analysis of the Data. Statistical Methods . Computer Programs . iii Page ix 0—1 QWNChLfl 10 10 15 22 28 29 29 3O 30 32 38 39 4O 41 41 41 43 46 49 49 52 TABLE OF CONTENTS (Continued) Chapter Page IV. RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Relationships Between the Extent of OTC Drug Use and Demographic Contextual Variables. . . . . . . . . 53 Relationships Between the Extent of OTC Drug Use and Attitudinal Contextual Variables. . . . . . . . . 56 Relationships Between the Extent of OTC Drug Use and the Importance of Information Sources . . . . . . . 57 Elaboration of Relationships Between the Extent of OTC Drug Use and the Importance of Information Sources . . . . . . . . . 6O Interrelationships of Importance Placed on Information Sources . . . . . . . . . 60 Elaboration of the Relationships Between the Extent of OTC Drug Use and the Importance of Professional and Non-Professional Information Sources . . . . . . . . . 64 Effects of Demographic Contextual Variables . . . . . . 64 Effects of Attitudinal Contextual Variables . . . . . . 71 Effects of Behavioral Contextual Variables. . . . . . . 72 Predictive Analysis of Over-the-Counter Drug Use. . . . . 73 Multiple Regression Analysis. . . . . . . . . . . . . . 73 Discriminant Analysis . . . . . . . . . . . . . . . . . 76 V. SUMMARY, CONCLUSIONS AND IMPLICATIONS . . . . . . . . . . . 81 Summary of Findings . . . . . . . . . . . . . . . . . . 81 Conclusions and Implications. . . . . . . . . . . . . . . 86 Limitations . . . . . . . . . . . . . . . . . . . . . . . 94 Recommendations . . . . . . . . . . . . . . . . . . . . . 95 Research and Policy . . . . . . . . . .‘. . . . . . . . . 97 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 GLOSSARY OF TERMS. . . . . . . . . . . . . . . . . . . . . . . . . 105 APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 A. Questionnaire derived from original Seniors and Substance Abuse Task Force Health Practices Questionnaire . . . . . . . . . . 107 B. Measures of Central Tendency for OTC Drug Use Variables . . . . . . . . . . 114 C. Measures of Central Tendency for Variables Used In Information Source Scores. . . . . . . . . . . . . 116 D. Rationale and Procedures for Choosing and Dichotomizing Information Source Variables. . . . . . . . 119 E. Importance Scores for Information Sources . . . . . . . . . 123 iv Table 10. 11. 12. 13. 14. 15. 16. 17. 18. LIST OF TABLES Age of Respondents . Respondents' Location of Dwelling. Respondents' Type of Dwelling. Marital Status of Respondents. Members of Respondents' Household, Excluding Boarders . Number of Members of Respondents' Household. Years of Retirement for Primary Wage Earner. Occupation or Former Occupation of Primary Wage Earner. Respondents' Annual Family Income. Respondents' Years of Education. Annual Family Income of Respondents (Modified) Respondents' Health Status . Respondents' Satisfaction with the Way Their Time is Spent. . . . Respondents’ Ranking of Life on a Scale of 1 to 10 (Worst Possible to Best Possible). Number of Activities in which Respondents Are Actively Engaged . Number of Hours Per Day Respondents Spent Watching Television. . . . . . . Number of Hours Per Day Respondents Spent Listening to the Radio . . . . . . Number of Hours Per Day Respondents Spent Reading Newspapers or Magazines. Page 32 33 34 35 35 36 36 37 38 38 43 44 44 44 45 45 46 46 Table 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. LIST OF TABLES (Continued) Mean Differences in OTC Drug Use by Sex. Mean Differences in the Extent of OTC Drug Use by Race . Mean Differences in the Extent of OTC Drug Use Between Urban and Rural Residents . Mean Differences in the Extent of OTC Drug Use Between Single Member Families and Larger Families. Mean Differences in Importance of Sources of Information by Extent of OTC Drug Use . Intercorrelations of Information Source Importance Scores. Varimax Rotated Principal Components Factor Matrix of Information Source Importance Scores . Analysis of Variance in Importance of Professional Information Sources by Level of OTC Drug Use . Analysis of Variance in Importance of Non- Professional Information Sources by Level of OTC Drug Use . Summary of Analysis of Variance in Importance of Non-Professional Information Sources by Race and Level of OTC Drug Use . Mean Differences in Non-Professional Information Sources by Race and Level of OTC Drug Use. Summary of Analysis of Variance in Importance of Non-Professional Information Sources by Marital Status and Level of OTC Drug Use . Mean Differences in Importance of Non-Professional Information Sources by Marital Status and Level of OTC Drug Use . vi Page 54 55 55 56 59 6O 62 63 63 65 65 68 69 Table 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. LIST OF TABLES (Continued) Summary of Analysis of Variance in Importance of Non-Professional Information Sources by Time Spent with Print Media and Level of OTC Drug Use . Mean Differences in Importance of Non- Professional Information Sources by Time Spent with Print Media and Level of OTC Drug Use . Summary of Multiple Regression by Extent of OTC Drug Use. . . . . . . . Summary of Discriminant Analysis by Level of OTC Drug Use. Centroids of Groups in Discriminant Space. Standardized Discriminant Function Coefficients. Multiple Classification Analysis of Levels of OTC Drug Use . OTC Drug Use Variables - Measures of Central Tendency . Respondents' Satisfaction with Their Knowledge Regarding OTC Drugs. Respondents' Perception of Pharmacist's Qualifications . Circumstances Under Which Respondents Seek an OTC Drug Instead of a Prescription. Importance of Sources to Respondents in Choosing an OTC Drug for the First Time. Categories of Drugs Taken at Suggestion of Certain Information Sources. Importance Scores for Self (Stored Information) as Sources of Information. Importance Scores for Doctors as Sources of Information . Importance Scores for Pharmacists as Sources of Information . vii Page 72 73 75 78 79 8O 80 114 116 116 117 117 118 123 123 124 Table 48. 49. LIST OF TABLES (Continued) Importance Scores for Friends and Relatives as Sources of Information. Importance Scores for Market Dominated Sources as Sources of Information. viii Page 124 125 Figure LIST OF FIGURES Variables of the Study . Interactive Relationship Between Race, Importance of Non-Professional Information Sources and Level of OTC Drug Use. Interactive Relationship Between Marital Status, Importance of Non-Professional Information Sources and Level of OTC Drug Use. Interactive Relationship Between Time Spent Reading Newspapers or Magazines, Importance of Non-Professional Information Sources and Level of OTC Drug Use. ix Page 48 67 7O 74 CHAPTER I INTRODUCTION The human organism is, philosophically speaking, constantly searching for a perfect balance of health, which today includes easing the pressures of the reality and stress of life (Post and McGrath, 1976, p. 17). Maintaining or achieving balance in health requires that corrective action be taken to restore, maintain or elaborate the health state in the human organism. Man has always had to cope with this because it essentially determines the viability of his existence (Post and McGrath, 1976). Health care resources in the environment can be utilized to facilitate corrective action in one's health balance. In the United States, major ‘users of' health care are the elderly. The elderly outspend, both in absolute and relative terms, other age groups in the category of health care (Bureau of Labor Statistics, 1976). Certain ailments, especially chronic ones are more prevalent among the elder- ly. One or more chronic conditions is suffered by eighty-six percent of persons age 65 or older (HEW, 1972). Some of these chronic condi- tions, including heart disease, arthritis, high blood pressure and gastrointestinal disease, can be relieved or controlled through the proper use of drugs (Lenhart, 1976; Lofholm, 1978). An increase in chronic diseases results in an increased consump- tion of drugs and, per capita, the elderly use more drugs than younger people. In 1967, while constituting 10% of the population, the elder- ly received roughly one-fourth of all prescriptions written (HEW, 1968) and it is probably safe to assume that their share of the non- prescription drug market was at least as large (Lofholm, 1978; Peter- sen and Whittington, 1977). According to Brady (1978) the latter expenditure likely represents a larger number of single doses taken per dollar spent than the former. Medication, whether prescribed by the physician or used directly by the layman, is important in the relief of suffering and in the prevention and cure of disease (Keefer, 1965). Those drugs used directly 137 the layman provide therapeutic benefits for minor self limiting illnesses, relieve medical practitioners of extra burden and can save the expense of a doctor’s visit. This latter benefit is cited by Lenhart (1976) as a factor in over-the-counter (OTC) drug use among the non-institutionalized elderly, where the cost of a doctor or clinic visit may seem prohibitive when weighed against a small fixed income. Part of this small fixed income is budgeted for health care, yet it has been estimated that 50% of the elderly consumer's total drug and health care budget is an unnecessary expenditure because of the over use of drugs and health related products (Brady, 1978). Over use and even normal use have been cited as producing medical complications in the elderly (Lenhart, 1976; Holloway, 1974; Wynne and. Heller, 1973). Increased use of drugs also increases the potentiality of complex and little understood interactions (Wynne and Heller, 1973). While in the purchase and use of prescription drugs, the elderly patient is complying with the physician's orders, in the case of non-prescribed drugs, the elderly patient is diagnosing his own ail- ment and prescribing. Lofholm (1978) says that these conditions for self-medication can be quite different from those leading to medica- tion with prescribed drugs. In looking at conditions for self-medication, the environment must be taken into account. The environment can foster or inhibit these conditions. In America, legal drug use is sanctioned for a variety' of' problems. Our society' actually' fosters conditions for self-medication. Medications are publicly available so that the slightest need for self-medication can be gratified at almost any time and in almost any place (Friend, 1964). The relatively easy access of the American public to the purchase and use of over-the-counter medi- cations is Iun: without risk. In a three-year study of adverse drug reaction hospitalizations at the University of Florida Hospital Medi- cal Service, non-prescribed drugs were found to be the cause of eight- een percent of these hospitalizations (Caranasos, Stewart and Cluff, 1974). Rabin and Bush (1976) note that concommitant use of prescribed and non-prescribed drugs, which has the potential for adverse drug reactions, is common in the population. Concerns are being expressed regarding the safety of self directed use of certain medications (Friend, 1964; Mandel, 1965; Sunshine, 1965). These concerns exist in part because there: is limited. extant information. concerning self- medicating behaviors (Johnson, Pope, Campbell, and Azevedo, 1976) or concerning the factors that influence the purchase of over-the-counter remedies (Mandel, 1965). The orientation of our society' towards drugs has come under criticism. Bernstein and Lennard (1973) point to what they term a "medicalization of the human condition." Such human conditions as rage, anxiety, insomnia, sadness and obesity are now "medical" prob- lems and chemical cures are promoted for them. Along these lines, Bourne (1973) posits that the extensive use and potential for drug abuse in the aging has resulted from the creation of "chemical solu- tions" for the emotional problems and needs of the elderly. The role of mass media in society's orientation is noted by Coombs, Fry and Lewis (1976) in their book Socialization and DruggAbuse. Mass media are a significant part of the socialization process of every individual -- directly through what he consumes and indirectly through media influence on physi- cians or those who influence him; his 'gatekeepers' (p. 8). Not only is nmss nmdia, e.g., advertising, influencing the indi- vidual consumer but also doctors, pharmacists, friends and relatives of that consumer. Encouragement to purchase and use non-prescription drugs is given by advertising as well as the retail marketing system. Accord- ing to Wynne and Heller (1973), the level of drug advertising and promo- tion seems to encourage drug use among the elderly. Additionally, the elderly have been cited as being susceptible to this advertising of non-prescription drugs (Plant, 1977) as well as of assorted vitamins, health foods and over-the-counter remedies (Brady, 1978). James (1979) surveyed professionals such as doctors, pharmacists, nurses, dentists, and those in the service of aging and substance abuse agencies in the State of Michigan regarding seniors’ substance use problems. She found that seniors' lack of knowledge was perceived by professionals an; the most significant factor contributing to seniors' medication problems. Current modes of advertising were perceived as one of the second most influential factors contributing to seniors’ medica- tion problems. However, virtually nothing is known regarding seniors’ information sources for gaining knowledge about OTC drugs. How influen- tial are certain information sources in the use of OTC drugs? Are advertising or market-dominated sources very influential or important to the elderly? Is the importance of information sources significantly related to over-the-counter drug use? Is the importance of certain information sources predictive of over-the-counter' drug; use? Aging brings with it a loss of roles in society and a concurrent lessening of opportunities for obtaining information in conjunction with such roles. Any reduction in the information available to a consumer puts him or her at a disadvantage in the marketplace. It is therefore important to understand the information sources that are important in the use of OTC drugs if those who serve the aged are to facilitate the elderly OTC drug consumer’s adaptability in the complex marketing environment. Statement of the Problem Despite the increased consumption of drugs among the elderly with the potential for adverse or untoward effects and the specious drain on a meger budget, virtually no information exists on the elderly drug consumer outside the institutional setting. With specific regard to OTC drug use, there is limited extant information on the population in general, and what was found on the elderly had to be extrapolated from broader studies. Further, sources of information and influence have not been explored with regard to the purchase and use of OTC drugs by the elderly consumer. Realizing that the applicability of the scant information available on drug use among the elderly to an elderly population other than that studied is questionable, the State of Michigan undertook its own study. Under the auspices of the Governor’s Task Force on Seniors and Substance Abuse, James (1979) undertook the study in 1977. The extensive nature of the study and budget constraints allowed only for a broad and general analysis of the data gathered. The absence of further analysis of the data leaves the problem of a lack of information on Michigan’s elderly OTC drug consumers and the sources of information and influence on their over-the-counter drug use. Objectives of the Study The purpose of this study was to further analyze the data gathered on OTC drug use in the Senior Citizen’s Substance Use Survey (James, 1979), in order to further one of the objectives of the original study. This objective was "to assess the amount of information seniors possess about. the substances they' use and the sources. of that information" (James, 1979, p. 2). The study attempted to identify sources of infor- mation and influence which were related to OTC drug use among a sample of Michigan’s elderly population. It attempted to discover whether the sources of information and influence deemed important by the elderly differ significantly among subgroups of the sample classified by their drug use. Contextual variables of an attitudinal, behavioral and demo- graphic nature were explored for their effect on differences and rela- tionships found. Further, variables were explored for their importance in predicting OTC drug use and discriminating levels of OTC drug use. Specific research objectives were: 1) To examine the relationship of the importance of information sources to over-the-counter drug use. 2) To examine the differences in the inmortance of information sources among subgroups of the sample classified by level of OTC drug use. 3) To examine the relationship of certain demographic and atti- tudinal characteristics to over-the-counter drug use. 4) To explore the effects of contextual variables on the rela- tionships found between over-the-counter drug Luna and. the importance of information sources. 5) To further explore the importance of both. the contextual variables and variables of the importance of information sources in predicting OTC drug use and in discriminating OTC drug users. Significance of the Research Michigan’s population of persons over age 60 is estimated to grow from 12% (1970 Census data) to 16% of the population by the year 2000. The rate of growth for this portion of the population is projected to be 20% more than that of the general population of Michigan (Verway, 1978). Faced with :1 growing elderly population, those concerned with helping the elderly are seeking to better understand the problems facing aging persons and how to best solve and hopefully alleviate or minimize such problems. The misuse and over use of over-the-counter drugs is one such problem. This study provides a better understanding of the nature and extent of non-prescribed drug use among the elderly. Further, the role played by sources of information and influence in elderly consumers’ purchase and use of OTC drugs may be better understood. This study can be of use in designing programs for disseminating information to elderly consumers in order for them to make informed non-prescription drug choices. It can be of potential use in helping providers of services to the aging to better understand the sources of influence on the aged and perhaps to utilize them. It can also serve as a guide to further research in the area of the non-institutionalized elderly OTC drug consumer. Limitations of the Study Any research done subsequent to the original study is limited by the original study as well as the choice of the research topic. The following limitations apply to this study: 1) The study will be limited to specific types of non-prescrip- tion drugs as specified in the original Seniors and Substance Abuse Study. These| OTC drugs are: antitussives, internal analgesics, diarrhea remedies, antacids, laxatives, cold remedies, vitamins and tonics, decongestants and sleep aids. 2) The study will be limited to examining only certain sources of information and influence which may be important to the elder- ly in the purchase and use of over-the-counter medications. These sources are doctors, pharmacists, friends and relatives, self (stored information), and market-dominated sources. 3) The findings of the study are limited to the counties involved in the study and counties similar to those counties due to the non-randomness in selection of the counties. Definitions Elderly, elderly men and women, elderly consumer . . . non-institu- tionalized persons 60 years or older. Non-institutionalized persons . . . persons run; residing 111 an institution or hospital. OTC drug . . . a drug which can be purchased over the counter without a prescription. OTC drug use . . . the use of drugs purchased over the counter without a prescription. OTC drug type . . . the specific category of non-prescription drug including antacids, antitussives, internal analgesics, diarrhea reme- dies, sleep aids, vitamins and tonics, cold remedies, decongestants, and laxatives. Sources of OTC drug information . . . an individual or a communica- tion organization (Schramm, 1955) which can provide OTC drug informa- tion, including doctors, pharmacists, market dominated sources, friends and relatives and oneself (stored information). CHAPTER II Review of Literature The literature pertinent to this study is grouped into three cate- gories: (1) research related to self-medication in the general popu- lation, (2) research related to the non-institutionalized elderly drug consumer, and (3) research related to sources of influence in self- medication and to sources of information used by the elderly consumer. Those unfamiliar with the pharmacological terms used may wish to review the Glossary of Terms. Self-medication in the General Population The history of self-medication dates back to earliest times (Leake, 1965). From home remedies and patent medicines to today’s ’supermarket’ of over-the-counter or non-prescription medicines, people have tried to relieve their minor ailments. Leake (1965) concludes that there is some psychological value in being able to do something to relieve illness, whether one's own or that of a family member. The widespread use of such therapeutic agents over the years indicates that sufficient relief of symptoms is obtained for their continued use (Grollman, 1965). Indeed, self-medication has been and continues to be integral to American health care. Its necessity and benefits are recognized. As Burney (1965) notes: "There is a recognition that all the needs of the commu- nity cannot be fulfilled by existing or even projected health resources and that self-medication has a distinct contribution to make..." (p. 942). 10 11 Self-medication provides for management of relatively minor medical problems rapidly, cheaply and conveniently, without unnecessary visits to the doctor (Mandel, 1965). This in turn results in time, money and energy savings for the consumer. Additionally, it eliminates further burdening of the health care system. It is estimated that without self-medication, there would be a detrimental effect on the quality of health care. Ten to twenty times as many doctors would be needed and billions of dollars would be needed to put into the health care system (Hollis, 1965). Self-medication has come to be viewed as an inherent right (Keefer, 1965) and legislation has developed to protect the consumer’s right to, and safety in, self-medicating. Self-medicating is a frequent and widespread activity among the general population (Johnson, et. a_l_., 1976). According to Pratt (1973) self-medicating will continue to be a widespread activity due to a variety of social forces fostering individ- ual and family control over medication use in the United States. Self- medication is the essential means by which the typical ills of most persons are treated (Knapp and Knapp, 1972). This is reflected in the fact that public and private expenditures for non-prescription drugs by 1972 amounted to $3 billion (Social Security Administration, 1972). It is also reflected in the number of OTC drugs on hand in American house- holds. Knapp and Knapp (1972) reported a mean of 17.2 non-prescribed drugs in the home, from the 234 households they surveyed. Roney and Hall (1966) reported a mean of 24.4 non-prescribed drugs in the 86 households they surveyed. Rabin (1972), in his review of prescribed and non-prescribed medi- cine use, found the data available suggest that the nature and extent of non-prescribed drug use can vary with such factors as age, sex, race, 12 residential location, education zuui social class. Drawing on cross- national and national studies, he generalized that women consume more non-prescribed medicines than men, one-member families consume more than larger families, urban residents consume more than rural residents and that whites spend more on non-prescribed medicines than non-whites. Increasing age and educational level were associated with higher non- prescribed drug consumption. Also, individuals with chronic illnesses spend nunm: for non-prescribed medicines than those without such ill- nesses. It is interesting to note that findings in British studies are similar to U.S. studies on non-prescribed medicine use despite the British system of socialized medicine. Theoretically, monetary cost is not a prohibitive factor in visiting British doctors. However, as Hollis (1965) points out, there are other prohibitive factors, such as the long waiting periods and. the extensive clerical, work, required. Jefferys, Brotherson, and Cartwright (1960) found 39% of the adults in their study had taken a non-prescription pain reliever during the pre- vious four weeks and 16% had taken a non-prescription laxative. Two British studies (Wadsworth, Butterfield, and Blaney, 1971; Dunnell and Cartwright, 1972) found that as the number of symptoms increased, use of non-prescribed drugs increased. They also found race, age, sex and social class to be related to non-prescribed drug use. Non-prescribed medicines have been the subject of few studies and the primary correlate generally used has been illness (Bush and Rabin, 1976). The relationship of non-prescribed medicine use to health status and health related activities was investigated by Johnson, Pope, Camp- bell and Azevedo (1976). Data from a 1970-1971 interview survey of a 13 sample of members of the Kaiser Foundation Health Plan of Oregon were used. Completed interviews (2,603) were obtained from subscribers and their enrolled spouses. Questions were asked concerning present health status, recent experience with symptoms, behavior when ill and customary health and health-related practices. Subjects were also asked if, for slight illnesses, they take medicines which do not require a prescrip- tion and if so how frequently. Ninety percent of survey participants reported using medications which do not need a prescription. Almost one-half reported taking such medications occasionally or very often. Use of non-prescribed medicines was positively related to experiencing a number of self-limiting symp- toms, specifically tiredness, aches/pains, headaches, upset. stomach, depression, sore throat/runny nose and diarrhea/constipation. The taking of OTC drugs was related to the use of certain practitioners. About 30% of survey participants reported asking pharmacists for advice. This behavior had a moderately positive association with the use of OTC drugs. Three measures of health status were derived from the survey data; perceived health status, physical health index and mental health index. For each of the measures, it was the dichotomy, poor health versus not poor health, rather than degree of impairment, that provided the strong- er association with reported use of non-prescribed medicines. This study included an analysis of types of behaviors involved in health seeking or health maintenance activities. Seeking knowledge or information through reading health-oriented articles had a low positive association with the use of OTC drugs, while reading medical or health- oriented books was not associated with OTC drug use. 14 Knapp and Knapp (1972) explored the decision-making process in self-medication in response to illness or injury. A longitudinal panel of Columbus, Ohio, residents, preselected to exclude most of the elderly population, was used. Two hundred and seventy-eight households that remained on the panel an average of 30 weeks of out of the 37-week period were included in the preliminary analysis. The wife was the primary source of data and was responsible for keeping behaviorial diaries. Illness and injury incidents were reported and at least one drug was reported used in over 90% of the cases. Non-prescribed medi- cines were used in over 70% of the cases and both prescribed and non- prescribed products were used in 11% of the incidents. The number of OTC drugs on hand at the beginning of the diary reporting period showed large differences by social class. For OTC drugs purchased during the diary period, slight social class differences were found with upper class persons reporting more in both cases. The illnesses for which drugs were reported taken included colds, headaches, ear and throat problems and gastrointestinal problems. For their analy- sis, each illness situation was classified on the basis of the sequence of significant events reported in the diary. Illness sequences were classified into nine strategies of response to an illness situation. It was found that in a distribution of over 2,800 illnesses, 60% were categorized as ’non-prescribed drug exclusively’ response strategy to illness. Bush and Rabin (1976) undertook an analysis of data from the World Health Organization/International Collaborative Study of Medical Care Utilization, which was done in 1968-1969. The sample consisted of 3,481 non-institutionalized non-transient residents. Questionnaires were 15 completed (M1 the tune of health services, morbidity, content of recent physician visit, fiscal resources and social relationships and atti- tudes. Vitamins, although included in the questionnaires, were excluded from analysis, confining the analysis to morbidity-related medicines only. The information on the use of particular categories of drugs was based on a two-day rate of use; yesterday or the day before. Substantial variation by age and sex were found among persons using morbidity related non-prescribed medication. While illness rates in- creased over age 44, use of OTC medicine declined. Females were found to have generally higher rates of OTC use than males; however, almost all of the sex related differences were accounted for by non-prescribed pain relievers. Cough and cold remedies and. skin. ointments ‘varied little by age and sex while laxatives and stomach remedies were more likely to be used by adults. The categories, pain relief, vitamins, cough or cold remedies, skin ointment or salve and laxative or stomach remedies accounted for almost all non-prescribed drug use in the popula- tion studied. They found that economic class alone appeared to have little effect on rates of use. Across economic classes, non-whites were less likely to be OTC drug users than whites. The healthy as well as those experi- encing both mild acute illness and severe levels of illness were all likely to use OTC medicines. They concluded that persons may not per- ceive themselves as deviating from a state of health even when they seek relief from self-medication. Research Related to the Elderly, Non-institutionalized Drug Consumer Drug use has received a great deal of attention in American society due to widespread use and misuse of such substances. However, the 16 elderly drug user has been neglected in this area of study (Petersen and Whittington, 1977). While the medical literature is replete with infor- mation concerning drug problems and considerations, it deals primarily with the elderly as patients (Holloway, 1974). Petersen and Whittington (1977) reviewed drug use research on the elderly and found that most of the studies concerned alcohol use. They also noted that most of these studies used a patient population. The remaining studies that they found in their review dealt with elderly persons admitted as patients to hospitals for treatment of acute drug reactions. Drug use among the elderly seems not to be a focus of research until the elderly drug user becomes a patient. Yet, ninety-five percent of the people over 65 in the United States live in varying degrees of self-sufficiency in. the community' and are generally responsible for their own medication (Plant, 1977). There is little that has been written (n1 self-medication iii the elderly population, although self- medication may be an important factor in the maintenance of an indepen- dent lifestyle (Lofholm, 1977). No research has been found that speci- fically deals with OTC medicine use among the non-institutionalized elderly. However, some data have been gathered along with prescribed drug and other substance use data. Two studies were found which dealt with drug use in the general population. Data on the elderly have been extracted from them. Mellinger, Balter and Manheimer (1966) studied patterns of psychothera- peutic drug use among adults in San Francisco. Drug use was analyzed by age and by prescription and non-prescription usage. The use of over- the-counter drugs was found to be the same for both men and women over age 60, although prescription drug use was higher for women than men in 17 that age group. Chambers (1971), in a statewide survey of New York residents, assessed the incidence, prevalence and extent of use of 17 categories of psychoactive drugs. Several relationships between age and regular use of such drugs were found. The oldest age group (50 and over) was found to have the largest percentage of regular users of barbituate sedative-hypnotics, minor tranquilizers, non-barbituate sedative-hypnotics and major tranquilizers. Since 1974, three significant studies have focused on legal drug use among the non-institutionalized elderly. In the first of these, Doyle (1976) carried out a study for the Cathedral Foundation of Jack- sonville, Inc. The study concerned medication use and misuse among a large sample of older persons living in the community of Jacksonville, Florida. Data were collected on the respondents’ relationships to their physician as well as information about drug use. Four hundred and five interviews were completed. Doyle found that 62% of his respondents indicated that they use over-the-counter medications. Information was obtained on the type of OTC medication that they were using. Of those reporting, 25% reported using laxatives; 19% reported using internal analgesics, 17% reported using cold medicines, 10% reported using antitussives, 9% reported using vitamins and 21% reported using other OTC medicines. He went on to conclude that 84% of the population studied indicated that their pharma- cist had no knowledge of the over-the-counter preparations that they were taking or the reasons for this use. Seventy percent of the popula- tion studied indicated that they do not question their pharmacist con- cerning cost, contents or side effects of medicines being prescribed or taken. 18 A secondary, informational instrument was administered by Doyle to a small volunteer sample of 15 elderly residents living in a retirement complex. Although the sample was very small, the in-depth information provided is valuable. It was found that 53% felt they did not know enough about their medications and 73% wished to know about their medi- cation’s side effects. However, for obtaining information, there was no statistically significant resource felt to be most helpful. Highest response for an information resource was for health journals while none responded "your doctor." Television, radio, newspaper zuul magazine advertisements were not mentioned as helpful information sources. This was collaborated by the fact that the majority of respondents felt that medication information in advertisements is either "not" or "definitely not" accurate. Inferences could be made from the data that the elderly in the sample were largely left to their own devices for health and medical education. When a question or problem arose concerning medications, about half consulted their doctor and less than half consulted a friend, relative or used their own judgment. When buying an OTC drug for the first time, one-third responded that their choice was based on ads, two-fifths responded that choice was based on the druggist and over half ’ as the basis for their responded "friends, relatives, or ’don’t know” choice. Price and packaging were not reported as influencing factors in choice. Among this sample, the category of OTC medication most fre- quently taken was pain relievers followed by antacids, antihistimines, joint and muscle preparations, hemorrhoidal. preparations, and. bowel stimulants. Sleep aids and diet aids were not mentioned as non- prescription drugs that were taken. 19 The second study since 1974 focusing on legal drug use among non- institutionalized elderly was done by Guttman (1977). This study was carried (nu: in the Washington, D.C., Standard Metropolitan Statistical Area in 1976. Participation was voluntary for respondents and there was a high rate of refusal. A total of 447 out of a targeted sample of 1200 interviews were obtained from non-institutionalized, community living elderly persons. A relatively high educational level was the only major difference found between the study sample and the total elderly popula- tion in the United States. A decision-making theoretical framework was used in the study. The study looked for the effects of knowledge, ability, needs, living ar- rangements and age on the drug use decisions of the elderly. Respond- ents were asked to report on drugs used within the 24-hour period pre- ceding the interview. Sixty-two percent reported using prescription drugs. Use of prescription drugs was positively related to both age and knowledge of resources. Those using more prescription drugs tended to be less satisfied with their lives and tended to have a lower perception of themselves :hi terms of intelligence and capability. These people also tended to use more over-the-counter drugs. Sixty-nine percent of the respondents reported. using lover-the- counter drugs. Over half of all OTC drugs reportedly used were iden- tified as internal analgesics. Most OTC drugs were reported as obtained from a drugstore. One-sixth of the respondents said that they consulted a physician about their use of OTC medications and a small percentage sought advice from other professionals, spouses or friends. The majori- ty, well over two-thirds, relied on their own judgments and thought they 20 knew the function of the OTC drugs used. Significant negative correla- tions were found between OTC drug use and health; age; and life satis- faction. The users of both OTC and prescription drugs tended to be less healthy and less satisfied with life than those reporting no drug use. There was no strong single predictor of OTC drug use in the elderly found in this study. Decision-making in resource utilization was not statistically related to drug taking behavior. Guttman (1977) concluded the data lent support to the claim that non-institutionalized elderly persons are, as an aggregate, knowledge- able and responsible consumers of legal drugs. His conclusion, however, must be taken with caution. His sample has a relatively higher educa- tional level than the nation’s elderly in general and there was a high refusal rate among his sample. The specific data on which he bases his conclusions are self-reportive and therefore subject to bias. The third and most recent of the studies focusing on legal sub- stance use among the non-institutionalized elderly was carried out by James (1979) who sampled. Michigan’s senior citizens. Data for the present research were taken from this study, and sample specification and data collection procedures are elaborated in Chapter III. Primary information gathered from seniors included prescription medication practices, OTC medication practices, social drug usage and use of home remedies. Indirect information was gathered through mail surveys of individuals directly serving the aged, including physicians, nurses, dentists, pharmacists and those involved in the areas of substance abuse and aging. A questionnaire was developed for each of these seven target groups. Data from lxfifll the mail surveys and the interviews were dis- cussed concurrently in the report. 21 James (1979) found that females werer more likely' to 'be taking prescription medicines than men and to be taking a greater number than men. She found that those in suburban areas were more likely to be taking prescription drugs and more of them than those from rural areas. Age was also found to be positively related to use and number of pre- scription medicines. Income and education were significantly related to the number of prescription drugs used. Those seniors with an annual income of under $6,000 and those with 10 or less years of formal educa- tion used more prescription medicines than those with 10 or more years of formal education and annual incomes of over $6,000. In the area of OTC medication, 48% of the seniors reported using one or more OTC medications about once a week. The categories of non- prescription drugs most frequently used were antacids, internal anal- gesics, laxatives and decongestants. The seniors typically did not discuss their use of OTC drugs with either their doctor or pharmacist. Through comparison of the physician mail surveys and the senior inter- views, a lack of communication was found which was apparently not rem- edied by information from other sources. Thirty percent of the seniors were not aware of the pharmacist's qualifications as a source of infor- mation. The physician was perceived an; the person most qualified to give information on drugs by both the mail survey participants and the senior interview participants. In seeking an OTC drug instead of a prescription drug, the sugges- tions of the doctor and the pharmacist were reported as influential. However, while the doctor was reportedly highly influential, the pharma- cist was reported less influential than the respondent’s own judgment that the ailment was not serious. For choosing the OTC drug in first 22 time buying situations, doctors again were at the top of the list as being ’very important.’ The pharmacist was not considered important to the same degree as the doctor but was next in influence. James found that price seemed to be a somewhat influential factor in choice of an OTC drug for the first time. Packaging and advertising, although not considered as important as price, were slightly more important than friends and relatives in choosing an OTC drug for the first time. James (1979) concluded that a significant proportion of seniors in Michigan encounter problems related to their use of prescription and over-the-counter medications and that they are not sufficiently well informed about the medications that they use. Sources of Information Used by Elderly Consumers and Sources of Influence in Self-medication Consumer behavior, in this case the purchase and use of non-pre- scription drugs, involves a decision-making process. Information is the basic ingredient of decision-making (Paolucci, Hall, and Axinn, 1977). It serves to reduce uncertainty in the decision-making process and provides a basis for making consumer decisions. The perception and use of information is critical. to the individual’s adaptability' to 'the marketing environment. Theoretically, the consumer needs complete information in order to make rational decisions. In reality, consumers function in the market- place without complete information. Information may be unavailable, inadequate, inaccessible, incomplete or even incorrect. While informa- tion may be available, it may not be perceived by the consumer. If information is available and perceived by the consumer, the cost of obtaining the information may outweigh the perceived benefits that the 23 information may provide. Paolucci, et. 31. (1977) also note that infor- mation, in complex environments, becomes increasingly difficult to assimilate because messages from many sources become mixed. In order to sort out the messages, the importance or significance attached tx> the source of information by the consumer may play an im- portant part. If the source of information or influence is deemed important or significant, especially in regard to the decision at hand, information from that source will likely be used. On the other hand, if the source is not deemed important, information from that source may be ignored. According tn) Schramm (1955), a source is the first of three elements required for communication, the others being a message (infor- mation) euui a destination (receiver). Radio, television, magazines or newspapers are generally thought of as sources of information. However, as Dichter (1966) points out, several ways of influencing people co- exist with cn: go beyond these sources. A variety of past and present factors influence consumers, including the environments with which they interact. These environments can in large part influence the kinds of decisions that an individual makes (Paolucci, et. al., 1977). The process of aging brings with it changes which ultimately affect the individual’s interaction vfijjl environments. Social, psychological and biological changes contribute to a (Hummection of life space and hence reduce opportunities for interaction. Role attrition, accompanied by a reduction in social involvement are catalyzed by declines in bio- logical functioning and in physical energy (Rosen and Neugarten, 1960). The reduced activity level of older adults is of interest because it affects their information. exposure ,patterns (Phillips znui Sternthal, 1977). 24 Contracted life space and reduced activity level would seem to result in greater exposure to and reliance on mass media sources of information. A limited number of gerontological studies lend support to this contention. Graney' and. Graney (1974) conducted. a ILongitudinal study among a group of elderly women (age 62 to 83 at first contact). The data on communication activities substitution suggest that tele- vision viewing and reading serve as substitutes for declining social participation.:h1 other areas. Schramm (1969) observed that media con- sumption activities composed 45% of leisure time for persons over age 65, while significantly less time was spent in this pursuit by younger adults. He also found that exposure to television and newspapers showed a marked increase beyond age 60. Evidence also exists that older pe0ple (age 60 and over) consider information as the most important criterion in their selection of media. This group ranks newspapers as the most important medium (Steiner, 1963). Other changes occur in the selection of personal and informal in- formation sources. For the elderly, members of the extended family constitute a: very substantial portion of interpersonal contacts, and therefore can serve as important sources of information for the elderly (Phillips and. Sternthal, 1977). In. the gerontology' literature, the limited information that exists suggests that the extended family serves as a major source of advice and support for a variety of decisions faced by adults over age 60 (Fredrick, 1973; Payne, 1960). Besides the family, friends constitute an important reference group. According to Rosow (1970; 1967), people over age 65 tend to develop friendship patterns with persons of similar age, sex, marital status and social class. He found the development of friendships and 25 interaction patterns depends on the local concentration of peers, given the reduced mobility of this age group. Hence, the deficit in informa- tion brought about by problems and conditions associated with aging is at least partially compensated for by increased mass media exposure and maintained contact with extended family. While mass media, friends and relatives are important sources of information for the elderly, the source deemed important in purchase decisions depends to some extent on the product involved. Decisions involving products with high perceived risk generate relatively more information seeking, generally from ’expert’ sources of information. Over-the-counter drug products are of this type where the advice of or information from a doctor or pharmacist may be sought to reduce the perceived risk involved in their purchase. Information sources utilized in choosing over-the-counter medications can.ln: of significant impor- tance, yet surprisingly, advertisers and marketers have not gathered data (”1 consumers' self-medication decisions (Engel, Knapp, and Knapp, 1966). An exploratory study was conducted by Engel, gt. gt. in 1966 to look at sources of influence in the acceptance of new products for self-medication among a sample of housewives. They found respondents to be quite cautious in pursuing new self-medication strategies and to show a tendency to search for additional information. The findings verified the risk-reducing role of ’brand’ names in OTC drug acceptance. Clear- ly, respondents placed greatest confidence in a doctor’s recommendation. This seems to be consistent with James’ findings of the importance given to the doctor‘s suggestion. While drug advertising was not regarded as a good source, as was the case in both Doyle’s (1976) and James’ (1979) 26 findings, the mention and usage of ’branded products’ seems to attest to the impact of advertising. Engel, gt gt. noted that the consumer apparently values the infor- mal channel of communication with friends and relatives as a source of information, although with precautions. The impetus apparently came from those seeking the information rather than from the source simply ’volunteering’ information. The pharmacist was considered by the re- spondents to be an expert in his field and was frequently mentioned as a source Cd? information. Respondents expressed concern that the pharma- cists are becoming increasingly unavailable to the public as a source of information. This is probably due to the demise of the ’friendly neigh- borhood corner drugstore pharmacist’ and the rise of the discount phar- macy with clerks to serve the public. The need for more authoritative information was found to increase with the seriousness of the ailment. No specific information on elderly OTC drug consumers and their sources for information..1”00) accounting for 58.2% of the variance in source impor- tance ratings. These two factors can be taken as ”source variables” accounting for the observed interrelations in the original importance scores for information sources (Nie, g. gl., 1978, p. 469). The two factors were rotated to a varimax criterion to obtain the simplest factor structure (Harman, 1967, pp. 98-99). The results of the factor analysis are presented in Table 25. 62 Table 25 Varimax Rotated Principal Components Factor Matrix of Information Source Importance Scores Information Source FACTOR l FACTOR 2 (Non-Professional) (Professional) Doctors - .07267 .60866 * Pharmacists .32036 .46239 * Self .32030 .35282 Friends/Relatives .41728 * .07027 Market-Dominated .71264 * .04334 Relative Percent of Variance 68% 32% * Highest factor loading for variable. The two factors basically distinguish between the importance placed on non-professional sources, such as market-dominated sources and friends and relatives (Factor 1), and the importance placed on profes- sional sources, such as the doctor zuul pharmacist. (Factor 2). The importance of self as a source of information loaded highly on both factors as, to £1 lesser extent, did the importance of the pharmacist. The importance scores for the five information sources (doctors, pharma- cists, friends and relatives, self, and market-dominated) were all significantly related to the extent of OTC drug use. To determine if a significant relationship existed between an individual’s OTC drug use and the two factors (importance of professional sources of OTC drug information and importance of non-professional sources of' OTC drug information), one-way analyses of variance were used. A linear relationship was found between the importance of profes- sional information sources and OTC drug use (Table 26). Increasing 63 importance is placed on professional sources as OTC drug use increased. However, the importance placed (n1 non-professional sources differed significantly between non-users and users, as shown in Table 27. The difference between moderate and heavy OTC drug users was not signifi- cant. Table 26 Analysis of Variance in Importance of Professional Information Sources by Level of OTC Drug Use Source DF SS MS F Between Groups 2 23.78 11.89 26.30* Within Groups 381 172.31 .452 Total 383 196.10 Means Non-Users -.341a Moderate Users .059b Heavy Users .281C Note: Means not sharing subscripts differ at the .05 level or beyond, Scheffe exact test. *p 4.001 Table 27 Analysis of Variance in Importance of Non-Professional Information Sources by Level of OTC Drug Use Source DF SS MS F Between Groups 2 14.37 7.19 12.85* Within Groups 381 213.11 .56 Total 383 227.49 Means Non-Users -28Oa Moderate Users .088b Heavy Users .180b Note: Means not sharing subscripts differ at the .05 level or beyond, Scheffe exact test. * p ‘1 .001 64 Elaboration of the Relationships Between the Extent of OTC Drug Use and the Importance of Professional and Non-Professional Information Sources Two-way analysis of variance: was used. to 'test. for' interactive relationships between contextual variables and the extent of OTC drug use on the importance placed on professional and non-professional sources of OTC drug information. It was also used to test for main effects Cd? the contextual variables (n1 the importance of information sources. However, since time differences 111 cell frequencies were un- equal and nonproportional, the unweighted means ANOVA procedure (Myers, 1972) was used. Since these effects were not hypothesized, a posteriori contrasts were used to compare subgroup means using the Scheffe multiple compari- son test. This is an exact probability test for unequal subgroups and is (nu: of the most conservative simple effects tests. The results of these tests are presented below with discussion. Effects of Demographic Contextual Variables Two demographic variables, race and marital status, were found to have an interactive effect with OTC drug use on the importance placed on non-professional sources (If OTC drug information. Additionally, three demographic variables demonstrated main effects on the importance of professional sources of (In: drug information. These were age, urban/ rural residential location and occupational status. Rggg - As shown in Table 28, race was not significantly related to importance placed on non-professional sources, while OTC drug use was significantly related to the importance of non-professional information sources. The interactive relationship between race and OTC drug use on the importance of non-professional information sources, although not strong, was significant (p ¢:..10). 65 Table 28 Summary of Analysis of Variance in Importance of Non-professional Information Sources by Race and Level of OTC Drug Use Source of Degrees of Sum of Mean of Variation Freedom (DF) Squares (SS) Squares (MS) F Value Race (R) 1 .064 .064 1.00 OTC Drug Use (D) 2 7.41 3.704 6.53* R x D 2 3.14 1.570 2.77# Within Subjects 366 207.73 .567 * p <1 .05 #p<:.10 Race seems to have a moderate effect on the relationship between the importance of non-professional information sources and the extent of OTC drug use. The effect is revealed in the mean differences presented in Table 29. Table 29 Mean Differences in Non-Professional Information Sources by Race and Level of OTC Drug Use Race Drug Use Level White Non-White Non Use -.234 -.407 ab 3 Moderate Use .065de .447d Heavy Use .213Cd -.129abC Note: Means not sharing subscripts differ at the .05 level or beyond, Scheffe Multiple Comparison Test. 66 The relationship of the importance of non-professional sources to the extent of OTC drug use for whites was linearly related. Importance placed on non-professional sources increased with OTC drug use. How- ever, the significant difference here was between non-users and heavy users of OTC drugs. For non-whites the importance of non-professional sources was curvilinearly related to OTC drug use. Importance of non- . professional sources was significantly greater for moderate users than either non-users or heavy users of OTC drugs. Means for use groups, however, do not differ significantly between whites and non-whites as shown in Figure 2. Thus, the importance of such information sources as friends, relatives and market-dominated increased with OTC drug use for whites, while the importance of these sources was greatest for moderate users and less for non-users and heavy-users among non-whites. Race demonstrated a main effect on the importance of professional information sources. Whites and non-whites differed significantly in the importance placed on professional sources of information. White elderly persons had a mean of .113 and non-white elderly persons had a mean of -.684. The F value (1, 366) was 4.44 with a probability of less than .05. While whites placed some importance on professional informa- tion sources, non-whites placed significantly less importance on profes- sional information sources, regardless of their level of OTC use. Thus, the importance of such sources as doctors and pharmacists was greater for whites than for non-whites. Marital Status - The importance: of'1non-professional information sources was not significantly related to either marital status or OTC drug use. However, the importance of non-professional sources of OTC drug information was significant for the interaction of marital status and OTC drug use, as shown in Table 30. 67 White Importance of Non-Professional 0 Information Non-White Sources Non- Moderate Heavy Users Users Users LeveIs of OTC Drug Use FIGURE 2 Interactive Relationship Between Race, the Importance of Non-Professional Information Sources and Level of OTC Drug Use 68 The relationship between the importance placed on non-professional sources of OTC drug information and the level of OTC drug use is linear for persons who are nmrried and living with their spouse (Table 31). Importance placed on non-professional sources increased vdill higher levels of OTC drug use. Significant differences were found between non-users and heavy users. However, for widowed persons and those of other marital statuses the importance of non-professional sources of information was not related to OTC drug use. Virtually no variation occurred among users in the importance placed on non-professional infor- mation sources as a consequence of widowed or ’other’ marital statuses, such as single, divorced, or separated. Thus, the relationship between the extent of OTC drug use and the importance of market-dominated sources and friends and relatives differs between persons who are mar- ried and living with their spouse and persons who are widowed and of ’other’ marital statuses (Figure 3). Table 30 Summary of Analysis of Variance in Importance of Non-Professional Information Sources by Marital Status and Level of OTC Drug Use Source of Variation D.F. S.S. M.S. F Marital Status (M) 2 .061 .030 1.00 OTC Drug Use (D) 2 .762 .371 1.00 M x D 4 9.867 2.467 4.43* Within Subjects 369 205.42 .557 * p 41;.05 69 Table 31 Mean Differences in Importance of Non-Professional Information Sources by Marital Status and Level of OTC Drug Use Married Living Other Drug Use Level with Spouse Widowed Marital Status Non Use -.274 -.327 -.O83 a a ab Moderate Use .021ab .188ab .046ab High Use .310b .150ab -.016ab Note: Means not sharing subscripts differ at the .05 level or beyond Scheffe Multiple Comparison tests. Agg - Although no interactive relationship was found for age, it was significantly related to the importance of professional sources of OTC drug information. Persons above the median age of 70 differed significantly from those age 60 to 70 in the importance placed on pro- fessional information sources. Those persons age 60 to 70 placed con- siderably more importance on professional sources than those older than the median age of 70. The mean for the younger age group was .303 and for the older age group, it was -.234. The F value (1, 370), 6.903, was significant at the .05 level. Location of Dwelling - The area in which respondents resided was related to the importance placed on professional sources of OTC drug information. Urban residents placed more importance on professional information sources than did rural residents. Urban residents had a mean of .061 while rural residents had a mean of -.375. The F value (1, 372) was 2.90, which was significant at the .10 level. 70 Married, living with Importance spouse Widowed of Non-Professional 0 'Other’ marital Information status Sources Non- Moderate Heavy Users Users Users Levels of OTC Drug Use FIGURE 3 Interactive Relationship Between Marital Status, the Importance of Non-Professional Information Sources and Level of OTC Drug Use 71 Occupational Status - The importance of professional information sources for OTC drug information was curvilinearly related to occupa- tional status. Unskilled or semi-skilled workers placed the least importance on these sources, with a mean of -.455. Skilled workers placed the most importance on professional sources with a mean of .254. White collar workers were intermediate in the importance placed on professional sources with a mean of .100. The F value (2, 351) was 3.79 which is significant at the .10 level. Effects of Attitudinal Contextual Variables Only one contextual variable of an attitudinal nature was signifi- cant in the two-way analysis of variance. The number of activities in which an individual is actively engaged was significantly related to the importance 'the individual places (n1 professional information sources. Activity Level - Those persons who were relatively more active, that is they were actively engaged in five or more social activities, differed significantly from those persons who were engaged in less than five social activities in the importance placed on professional informa- tion sources. Those who were actively engaged in fewer social activi- ties placed less importance on professional information sources, while those who were actively engaged in many social activities placed more importance on professional information sources. The mean for the less actively engaged was -.185 and for those more actively engaged it was .769. The F value (1, 378) was 11.62 with a probability of less than .001. 72 Effects of Behavioral Contextual Variables The one contextual variable of a behavioral nature that was sig- nificant in two-way analysis was time spent reading newspapers or maga- zines. It demonstrated an interactive relationship with level of OTC drug use on the importance: of ‘non-professional information sources. Time Spent with Print Media - Means for all subgroups did not differ significantly except between those who spend 5 hours or less with newspapers and magazines and those who spend 5 or more hours, among non-users of OTC drugs (Table 33). The extreme mean for those who spend 5 or more hours with print media must be viewed with caution because of the small number (2) in this subgroup. In general, subgroups did not differ significantly in the importance placed on non-professional infor- mation sources (Figure 4). The interactive effect of time spent with media, when closely examined demonstrates that in essence the linear relationship does not exist because the extreme mean accounting for the linear relationship is produced from a very small number in the subgroup. Table 32 Summary of Analysis of Variance in Importance of Non-Professional Information Sources by Time Spent with Print Media and Level of OTC Drug Use Source of Variation D.F. S.S. M.S. F Print Media (P) 3 1.707 .569 1.00 OTC Drug Use (D) 2 .651 .325 1.00 P x D 6 10.948 1.825 3.185# Within Subjects 367 210.18 .573 # p ¢:?.10 73 Table 33 Mean Differences in Importance of Non-Professional Information Sources by Time Spent with Print Media and Level of OTC Drug Use Drug Use 0 - 1 1 - 2 2 - 5 5 or More Level Hour Hours Hours Hours Non Use -.212 -.340 -.320 .947 a a a b Moderate Use -.168 .245 .168 -.242 ab ab ab a High Use .173ab .200ab .218ab .088ab Note: Means not sharing subscripts differ at the .05 level or beyond Scheffe Multiple Comparison test. Predictive Analysis of Over-the-Counter Drug Use While the importance of information sources was significantly related to over-the-counter drug use, its relative importance in pre- dicting over-the-counter drug use has not yet been ascertained. In order t1) determine those variables of importance in predicting over- the-counter drug use among the elderly population studied, multiple regression and discriminant analyses were performed on the data. These approaches are complementary. Both are a means of deriving a linear combination (H3 variables that maximize predictability. The difference is that multiple regression is designed for predicting scores along a continuum while discriminant analysis is designed to maximize discrimi- nation between a set of discrete groups. Multiple Regression Analysis The multiple regression analysis produced five ‘variables which accounted for most of the 23 percent of precitable variance in OTC drug use. The importance placed on professional information sources, the 74 Importance of Non-Professional 2-5 hours 1-2 hours Information 0.] hour 5 or Sources more hours Non- Moderate Heavy Users Users Users Levels of OTC Drug Use FIGURE 4 Interactive Relationship Between Time Spent Reading Newspapers or Magazines, Importance of Non-Professional Information Sources and Level of OTC Drug Use 75 importance pdaeed (n1 non-professional information sources, ranking of one’s life, rural residential location, and age were the most important predictors of the extent of OTC drug use. The importance placed on professional sources alone accounted for 11% of the variance in OTC drug use, which amounts to almost half of the variance accounted for by the regression equation. Contextual variables, other than the three already mentioned, account for very little of the variance. The multiple re- gression summary is presented in Table 34. Table 34 Summary of Multiple Regression by Extent of OTC Drug Use Standardized Variables Correlation Regression Coefficient (Beta) Professional sources .33977 .325 * Non-professional sources .25514 .181 Ranking of life -.17146 -.178 Location of dwelling .13525 .131 Age .02186 .114 Time spent with radio .12344 .075 White collar occupation -.07038 -.068 Widowed -.O626O -.123 Family status -.02808 -.068 Education -.05861 -.072 Income .01571 .056 Activity level .07033 .037 Time spent with print .04144 .030 Married living with spouse .02332 -.057 Satisfaction with how time is spent -.O9792 .020 Health .00930 .014 Forced retirement -.00815 -.007 Race -.O8142 .005 R = .486 R2 = .236 1: (18, 354) = 6.09 p 4 .001 7'“ Regression coefficient a .30. 76 Discriminant Analysis The results of the discriminant analysis are presented in Tables 33 through 36. Those variables with significant univariate F ratios were the importanee of professional information sources, the importance of non-professional information sources, age, whether one is widowed or not widowed, and the ranking of one’s life from worst possible to best possible. These discriminant analysis predictor variables do not differ fnmn the highest multiple regression predictor variables other than in one case. While residential location. is run: of' the 'best. predictor variables in multiple regression, it is replaced in the discriminant analysis by widowed or non-widowed marital status. Two dimensions of discrimination. were found in the analysis. Dimension 1 primarily discriminates between non-users and heavy users of (HE) drugs, while Dimension 2 primarily discriminates between moderate users and heavy users of OTC drugs (Table 36). The variables which best discriminate (discriminant coefficient £2:.30) between non-users and heavy users of OTC drugs are the importance of professional and non- professional information sources, whether an individual is widowed or not, and the ranking by individuals of their life from worst possible to best possible. The importance of professional sources had the largest coefficient, followed by the ranking of an individual’s life, the impor- tance of non-professional sources and whether the individual is widowed or not widowed. For discriminating between moderate and heavy users of OTC drugs, there were seven variables with coefficients greater than or equal to .30 (Table 37). The variables, in order from largest coefficient to smallest coefficient are age, whether the individual is married and 77 living with their spouse or the individual is widowed or of ’other’ marital status, whether one resided in a single member family or in a larger member family, the number of hours spent watching television, whether an individual is widowed or not widowed, whether the individual is/was in a white collar occupation or the individual is/was in a skilled or unskilled/semi-skilled occupation, and race. Predictive ability of the analysis was very good with 57 percent of the known cases correctly classified (Table 38). Each of the groups were also predicted about equally well. 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Standardized Discriminant Function Coefficients Table 37 Variable Dimension Dimension 2 Non-professional .368* .014 Professional .817* .088 Sex .019 .054 Race .197 .311* Time spent with TV .058 .381* Education .171 .153 Family status .083 .437* Time spent with radio .077 .233 Time spent with print .069 .035 Location of dwelling .127 .178 Married, living with spouse .159 .555* Widowed .338* .320* White collar occupation .078 .318* Skilled occupation .126 .085 Income .001 .293 Age .093 .880* Activity level .125 .016 Satisfaction with how time is spent .092 .226 Health status .108 .002 Ranking of life .440* .241 Forced retirement .151 .215 * coefficient a .30 Table 38 Multiple Classification Analysis of Levels of OTC Drug Use N of Predicted Group Membership Group Name Cases Non-Users Mod. Users High Users Non-users 60 32 (53%) 11 (18%) Moderate users 85 15 (18%) 23 (27%) Heavy users 67 10 (15%) 42 (63%) 57.1% of known cases correctly classified 2 X = 53.776 p 4: .001 CHAPTER V Summary, Conclusions and Implications This chapter presents a summary of the findings as well as con- clusions and implications of the research. The first part presents a summary of the findings preceded by a brief overview of the research. The second part includes conclusions and implications that can be drawn from the research. In the last part, recommendations and suggestions for research and policy are made. Summaty of Findings This research examined relationships between the subjective impor- tance placed on certain sources of over-the-counter drug information and the extent of OTC drug use among a sample of Michigan’s elderly consum- ers. Further, the influence: of certain. contextual ‘variables (e.g., demographic, attitudinal and behavioral characteristics) on the observed relationships between the extent of OTC drug use and the importance of information sources was examined. Finally, the utility of these vari- ables in predicting over-the-counter drug use and discriminating between levels of drug use (non-users, moderate users and heavy users) among Michigan’s elderly consumers was assessed. Data from the Senior Citizens’ Substance Use Survey, conducted by the State of Michigan Office of Services to the Aging and Office of Substance Abuse Services, were used. Indices of importance of infor- mation sources and of the extent of OTC drug use were created from 81 82 variables in the original study. It was hypothesized that the impor- tance an individual placed on doctors, pharmacists and self (an individ- ual’s own stored information) as sources of OTC drug information would be positively related to the extent of over-the-counter drug use for the individual. These hypotheses were supported. An additional hypothesis that there would be significant differences between users and non-users of OTC drugs in the importance placed on various sources of OTC drug information was also largely supported. The importance placed on doc- tors, pharmacists, self, and market-dominated sources as sources of OTC drug information was significantly greater among users than non-users. Further, the importance of doctors was also significantly greater among heavy OTC drug users than among moderate users. The importance of friends and relatives as a source of OTC drug information, however, did not differ significantly between moderate users and non-users, although heavy users placed significantly more importance on this source than either moderate or non-users. Relationships between the extent of OTC drug use and certain con- textual variables of a demographic and attitudinal nature were also hypothesized. The hypotheses concerning relationships of tin: demo- graphic contextual variables to the extent of over-the-counter drug use were generally not supported. However, race was found to be marginally related in the predicted direction to the extent of over-the-counter drug use, with whites’ OTC drug use being somewhat greater than non- whites’. Also, urban/rural residential location was significantly re- lated to the extent of OTC drug use, but in the opposite direction of that predicted. Elderly rural residents made significantly more exten- sive use of OTC drugs than elderly urban residents. 83 Two of four hypothesized relationships between extent of OTC drug use and attitudinal contextual variables were statistically signifi- cant. An individual’s satisfaction with the way his/her time is spent and an individual’s ranking of his/her life on a scale from worst pos- sible to best possible were both negatively related to the extent of OTC drug use. Overall, the analyses revealed that the importance scores for all five information sources were significantly related to increased OTC drug use and that the importance scores for individual information sources were generally significantly and positively related to each other. As a consequence, a principal components factor analysis of the importance scores for the various information sources was performed. This analysis produced two factors: the importance of professional information sources (doctors and pharmacists), and the importance of non-professional information sources (market-dominated and friends and relatives). The importance of professional information sources was linearly related to the extent of OTC drug use (i.e., increased signifi- cantly between non-users and moderate users, and between moderate and heavy users), while the importance of non-professional information sources only differed significantly between non-users and users of OTC drugs, with moderate and heavy users not differing from each other. The influences of contextual variables on these relationships were also explored. Significant interactive effects were observed between the level of OTC drug use and the factors of race, marital status, and time spent reading newspapers or magazines on the importance of non- professional information sources. Whites placed increasing importance on non-professional information sources with increased drug use. For 84 non-whites, moderate users placed the most importance on non-profession- al information sources. Elderly persons who were married and living with their spouse placed increasing importance on non-professional information sources with increased drug use. However, 1km: widowed persons or those of another marital status, the importance of non- professional information sources did not vary significantly among non- users, moderate users, or heavy users. The interactive effect of time spent reading newspapers or magazines was found to come from one group with only two members, hence the interactive effect was discounted. Main effects (Hi the importance of professional sources were found for race, age, urban/rural residential location, occupational status :uul activity level. Whites, urban residents, those age 60 to 70, those who were in skilled occupations and those who were relatively more active placed more importance on professional information sources than non- whites, rural residents, those age 71 or older, those who were relative- ly less active and those in semi-skilled, unskilled or white collar occupations. Multiple regression and discriminant analysis were used to deter- mine the best set of predictor variables for an individual’s extent and level of OTC drug use. Each of these analyses produced basically the same set of predictor variables: the importance of professional infor- mation sources, the importance of non-professional information sources, age, and an individual’s ranking of his/her life from worst possible to best possible. However, the multiple regression also showed urban/rural residential location as a predictor, while discriminant analysis showed widowed marital status (whether one is widowed or not) as a predictor variable. Thus, those factors whiCh were most predictive of OTC drug 85 use in this elderly sample were increased age, widowed marital status, rural residential location, low ranking of life, and increased impor- tance placed on both professional and non-professional sources for OTC drug information. The discriminant analysis [produced. two significant. discriminant functions. One dimension primarily discriminated between non-users and heavy users with four variables: the importance of professional infor- mation sources; the importance of non-professional information sources; whether an individual was widowed or not; and an individual’s ranking of his/her life from worst possible to best possible. Thus, heavy users are more likely than non-users to be of a marital status other than widowed, place a low ranking of their life, place greater importance on professional information sources, and place greater importance on non- professional information sources. The second dimension primarily discriminated between moderate and heavy users of OTC drugs. There were seven variables which best dis- criminated between these two groups: age; whether the individual was married and living with their spouse or not; whether an individual resided in a single member family or in a larger family; the number of hours spent watching television; whether an individual was widowed or not widowed; whether an individual was in a white collar occupation or not; and race. Thus, heavy users, more than moderate users were more likely to be non-white, older, widowed, separated, single or divorced, living alone, spending more time watching television, and to have been engaged in a white collar occupation. 86 Conclusions and Implications Clearly the importance elderly persons place on sources of OTC drug information increases with their use of non-prescription drugs. This is particularly true of the importance placed on professional information sources such as doctors and pharmacists. The importance of ‘these sources increases with increased OTC drug use. With regard to such non-professional sources as friends and relatives and market dominated sources, elderly persons who are OTC drug users place more importance on these sources than those who are non-users. The importance placed on both professional and non-professional sources for OTC drug information were the two best predictor variables of over-the-counter drug use among the factors examined. These variables were also important in discrimi- nating non-users from heavy users of OTC drugs, while factors other than these were important in discriminating moderate from heavy OTC drug users. The importance of professional sources, which alone was highly predictive of OTC drug use, was significantly associated with several contextual variables. White respondents placed more importance on professional information sources than non-whites. White elderly persons may have had relatively more interaction and/or positive experiences with doctors or pharmacists, perhaps because the cost of doctors or clinic visits may have prevented and may continue to prevent non-whites from contacting doctors or pharmacists as much as whites. Also, since professionals, for the most part, are white, it may be that non-whites have not felt at ease to interact with professionals. This may explain white elderly placing more importance on professional sources of OTC drug information than non-white elderly persons. 87 Respondents age 60 through 70 placed more importance on profession- al information sources than those age 71 or older. It is possible that relatively younger elderly persons are experiencing a transition from middle age accompanied by aging processes, which older persons have already experienced, and therefore place more importance on doctors and pharmacists for advice and information on OTC drugs to cope with these transitional processes. Relatively older elderly persons may not per- ceive professional sources as important for OTC drug information due to severity of health problems, and may perceive these sources as more important for prescription drug information. Older persons may be hesitant to ’bother’ doctors for' information. about. non-prescription drugs while relatively younger older persons may perceive this ’bother’ as part of what the doctor is paid for. Elderly urban residents placed more importance (n1 professional information sources than their rural counterparts. The fact that there are generally more professionals available from which to obtain OTC drug information in urban areas than in rural areas may in part account for this phenomenon. Urban residents may be more used to making use of professionals than rural residents. Rural residents may be more used to medicating themselves, perhaps through tradition, and hence may not place as much importance on professional sources. Elderly persons who were engaged in skilled occupations placed more importance on professional OTC drug information sources than those who were engaged in unskilled or semi-skilled occupations. Those who were engaged in white collar occupations placed intermediate importance on professional information sources. Elderly persons who were engaged in 88 unskilled or semi-skilled occupations may not feel comfortable in commu- nicating their need for OTC drug information to ’professionals’ perhaps because of a lack of money, education or status. Elderly persons who were white collar workers may place an intermediate amount of importance on these sources because they understand the value of professional information but perceive themselves as comparable to professionals in terms of money, education or status. Elderly who were engaged in skilled occupations may feel comfortable in communicating with profes- sionals and place a great deal of weight on information professionals give because professionals have relatively more education, money or status. The importance of professional information sources was also greater for persons who were engaged in five or more activities every two to three weeks than for those engaged in less than five activities every two to three weeks. It is likely that those actively engaged in many pursuits have a desire to remain active and seek information from doc- tors and pharmacists to remain that way. Also, those who are less actively engaged may be experiencing more, or greater, chronic condi- tions which keep them from activities. These persons may be more con- cerned with doctors and pharmacists as prescription drug information sources. Thus, those who place the greatest importance on professional information sources concerning OTC drugs tend to be white, urban resi- dents age 60-70, who were engaged in a skilled occupation, and who were actively engaged in a number of pursuits. The relationship between the importance of non-professional sources of OTC drug information and the extent of OTC drug use was qualified by 89 two variables; race and marital status. The observed relationship was that the importance of these sources was significantly different for users and non-users regardless of race or marital status. However, the relationship between the importance of non-professional information sources and moderate and heavy OTC use exhibited different patterns for whites and non-whites. Non-white elderly persons differed primarily in the importance placed on non-professional sources between non-users and moderate users, while white elderly differed primarily between non-users and heavy users. Additionally, the interaction of marital status and over-the-counter drug use affected the importance placed on non-profes- sional sources of information. Elderly persons who were married and living with their spouse placed increasing importance on non-profession- al information sources with increased drug use. For widowed persons and those (Hf ’other’ marital statuses the importance of nonrprofessional sources differed significantly between users and non-users. While the literature provided some testable hypotheses between drug use and demographic variables, interestingly, none of the hypothesized relationships between the extent of OTC drug use and demographic vari- ables in this study were supported. Although age was hypothesized to be negatively related to the extent of OTC drug use, this relationship was not found; the correlation between age and the extent of OTC drug use was .04. However, both multiple regression and discriminant analysis revealed that age was associated with OTC drug use, albeit at a weak level. Thus, the present study indicates a weak relationship between increasing age and the extent of OTC drug use. The findings do not support Guttman’s (1977) findings among elderly respondents that age is negatively related to OTC drug use. 90 The James study (1979), among the same population as the present study, showed age to be associated with increased prescription drug use. Thus, age, in the present sample, is associated with an increased con- sumption of both OTC and prescription drugs. An increase in chronic conditions associated with aging may have lead to the observed increased use of drugs. No significant relationship was found between sex and OTC drug use. The hypothesized relationship was that women consume more OTC drugs than men. This relationship was found by two previous researchers among general populations (Bush and Rabin, 1976; Rabin, 1972). The relation- ship does not appear in the present elderly population, and the present data, in fact, lean toward the opposite direction. It may be that men do not or will not perceive illness as seriously as women do, and take OTC medications as an alternative to prescription medications. Con- versely, women may be taking more prescription medicines rather than more OTC drugs because they perceive problems associated with aging to be more serious. This contention. receives some support from..James (1979), in her study of the same population. She found women more likely to In: currently taking prescription medicines and more of them than men. White elderly persons did tend to consume somewhat (p ‘1 .10) more OTC drugs than non-whites. This finding lends some support to the same finding in general populations (Bush and Rabin, 1976; Rabin, 1972). Lesser use of OTC drugs among non-whites likely reflects past and pres- ent economic conditions for elderly non-whites. Due to economic condi- tions, non-white elderly may have relied on other means than those provided by the market place, such as home remedies, and they may be 91 continuing this pattern. Also, because of economic conditions, they may be more likely to be recipients of Medicaid, which provides for payment of prescription drugs. Problems associated with aging may make the difference in patterns of OTC drug use for white and non-white elderly less significant than those found in general populations. Respondents in urban areas were hypothesized to use more OTC drugs than their rural counterparts. The elderly respondents in the present sample demonstrated the opposite pattern: rural residents used signifi- cantly more OTC drugs than urban residents. Rural residential location was also significant in the multiple regression as predictive of OTC drug use. These findings concerning OTC drug use among elderly urban and rural residents differ from Rabin’s (1972) summary of OTC drug use findings 111 the general population, which found urban residents to be heavier users than rural residents. It is possible that rural residents have less contact with doctors to obtain prescription medications than do urban residents. Also, the availability of places to purchase drugs is much greater in urban areas, both in numbers and proximity. Rural‘ areas provide fewer of such places with relatively less proximity. It may be that rural consumers use more OTC drugs because they can be purchased in numbers so that many trips are not necessary to obtain refills as is the case with prescription medications. A substitution of types of drugs also may be indicated. Among the same population as the present study, James (1979) found elderly urban residents more likely to be taking prescription medications and more of them than elderly rural residents. Respondents who lived alone (in single member families) did not use significantly more OTC drugs than those who lived with others (in larger 92 families). Although the hypothesis was not supported, the results were in time direction predicted. This variable was somewhat important in discriminating heavy users from moderate users, with heavy OTC drug users more likely than moderate users to be living alone. Findings in general population studies (Rabin, 1972) that one member families con- sume more than larger families were somewhat supported, although not strongly, in this study among the elderly. The hypotheses of relationships between OTC drug use and attitudi- nal contextual variables were supported in two cases and not supported in two cases. The less satisfied respondents were with the way they spend their time, the more OTC drugs they used. Also, respondents who used more OTC drugs gave lower ranking to their life, i.e., that it was the worst possible or close to the worst possible life one could have. Lower ranking of one’s life was a significant predictor variable in both multiple regression and discriminant analyses. It was also significant in distinguishing heavy users from non-users of OTC drugs. These find- ings lend support to Guttman’s (1977) findings that elderly OTC drug users tended to be less satisfied with life than non-users. It may be that OTC drugs play a role in helping dissatisfied elderly persons to cope with life. The number of activities that are often (every 2 to 3 weeks) en- gaged in was not related to OTC drug use. It was hypothesized that more active individuals would be less likely to use OTC drugs. It may be recalled, however, that more active individuals placed more importance on professional sources than less active individuals for information about OTC drugs. Active persons would be less likely to have complica- tions to hinder them and potentially less use for OTC drugs. However, 93 it may be that OTC drugs are used only for minor ailments which do not affect one’s level of activity. A significant negative relationship was not found 'between. the extent of OTC drug use and perceived health status. Those who perceived themselves as less healthy were not more likely to take OTC drugs than those who perceived themselves as healthy. The finding by Guttman (1977) that elderly OTC drug users tend, by self-report, to be less healthy was not supported. However, this study used only one self- report question on health while Guttman used several. Thus, his find- ings may be more reliable. The absence of a relationship does tend to lend support to the conclusion, made by Knapp and Knapp (1972) in a study among the general population, that persons may not perceive them- selves as deviating from a state of health even when they seek relief from non-prescribed medication. In general, then, elderly persons who made more extensive use of OTC drugs in this sample were rural residents, those who were dissatis- fied with their life, and those who were dissatisfied with the way they are spending their time. The predictive analyses in this study also revealed that older, widowed, rural residents who are dissatisfied with their lives and who place importance on both professional and non- professional sources of OTC drug information are likely to use OTC drugs extensively. Heavy users of OTC drugs can be discriminated from both non-users and moderate users, although by different factors. Heavy users placed greater importance on both professional and non-professional sources for OTC drug information than non-users. Heavy users in the present sample were also generally married and living with their spouse or of a marital 94 status other than widowed, and were not satisfied with their lives, ranking their lives low on a worst to best possible scale. Non-users were generally widowed and were more satisfied with their lives. Be- tween heavy users and moderate users, different discriminating variables were found. Heavy users tended to be non-white, older, widowed, living alone, were engaged in a white collar occupation, and spend a consider- able amount of time watching television. Moderate users tended to be white, younger, married and living with spouse, residing with others in larger families, were in other than a white collar occupation and spend little time watching television. Limitations This study used a group of OTC drug information sources which are not exhaustive or exclusive. Friends and relatives as well as the individual (self) could get information about OTC drugs from doctors, pharmacists or market dominated sources. Also, the creation of impor- tance scores for these sources using different variables or a different method could yield other results. The variables of OTC drug use, used in another way than creating an OTC drug index, could have produced different and more specific results. The use of OTC drug types rather than overall OTC drug use could be as- sessed. Also, another method of creating the index could have yielded different overall results. The questions of the original study on OTC drug use were somewhat difficult to interpret. Number of OTC drugs taken in a category (see Appendix A; question 78) was asked for the period of a year. However, the frequency of use of a category of a drug was asked for the period of a week. A person could have taken five different types of OTC cold remedies in a year, but these would not 95 necessarily be taken concurrently. The question regarding frequency of use of EH1 OTC drug could have had different response categories. For instance, persons may only take cold remedies twice a year for each of their colds. So, on the average, they take cold remedies less than once a week. However, a question arises as to how many and with what fre- quency the cold remedies are taken during the period they are consumed. More precise questions on OTC drug use might have produced a more pre- cise interpretation of OTC drug use itself as well as of relationships between OTC drug use and other factors. Very few of the demographic variables were found to be related to OTC drug use. Perhaps measures of socio-economic status and of family typology (marital status, family members and number in household) might have proven more relevant in this study. Also, since OTC drugs are generally taken for health-related reas- ons, and health was not a factor found to be significant in this study, it may be that a different, more detailed question or additional ques- tions about health would have yielded different results. Such questions clarifying health status might have been useful in producing significant results. Recommendations This study supports the conclusion of James (1979, p. 62) that educational and treatment efforts directed toward OTC drug use among the elderly should focus on a different population than efforts directed toward prescription. medication usage. Elderly' populations 111 urban areas should receive different. emphasis than. those in rural areas. Education and treatment programs in urban areas should put an emphasis 96 on prescription drug usage and those in rural areas should put an em- phasis on OTC drug usage. Health care providers in rural areas should be alerted to the more extensive use their senior clientele make of non-prescription drugs. ihi general, this study supports recommendations that educational programs be directed at the total elderly' population. Educational programs aimed at the general elderly population should make use of doctors and pharmacists for presenting factual OTC drug information. One method for presenting information could be through a program on community public television. This method might better reach. rural residents and those who are not able to participate in programs that might be offered by local agencies. However, the focus could be dif- ferent for whites and non-whites due to their differing OTC drug use patterns and differing importance placed on information sources. Repre- sentatives of minority organizations could be contacted to hold infor- mational programs on self-medication for their senior members or for senior minority groups. Doctors and pharmacists should be made aware of the importance placed by senior OTC drug users on the OTC drug information that doctors and pharmacists provide. It is clear that seniors value doctors and, to a lesser extent, pharmacists as sources of OTC drug information. Yet there is a need for seniors to be educated in making use of these sources, especially pharmacists, and for professionals to be educated in providing information to seniors. Educational programs should focus on the role of the pharmacist and doctor in fulfilling seniors’ needs for information about medications. Programs for seniors should also provide information on alternative sources of OTC drug information. Although it 97 was not assessed, it is doubtful that seniors are aware of the role of local agencies in providing information and educational programs or materials. Elderly consumers of OTC drugs should be educated to be better consumers of health care and to utilize their doctors and pharmacists as sources of drug information. Elderly consumers should demand and re- ceive better or more information on OTC drugs. Such information should be available from packaging and advertising as well as from doctors and pharmacists. Efforts should be made on the part of doctors and pharma- cists to alert their senior clientele about the availability of OTC drug information from them. Efforts should be made from marketing to include information on decreased dosages for older persons and potential drug interactions. It might be worthwhile to include a statement on packages such as ”If you have questions about this drug, ask your pharmacist.” Treatment programs for elderly OTC drug users must take into ac- count that heavy users are likely dissatisfied with their past and present life. Efforts might be directed towards helping aging individ- uals to cope with their lives. Seniors may be using chemical cures for emotional problems. It may be that treatment programs would do well to focus on aspects that provide a fuller life for seniors. Providing programs which intergrate seniors into the nminstream of life, giving them a sense of worth and self-esteem might provide more long-term benefits than educating seniors in OTC use. Research and Policy Future research is needed on the role information sources play in over-the-counter drug use. The present study looked at the importance placed on information sources and the extent of OTC drug use. Actual 98 use of information sources and its relationship to OTC drug use needs to be explored. Measures of use of information sources may provide more differentiation among information sources than did measures of the importance of information sources. Future research on self-medication among non-white populations is indicated. Medicating oneself may be more significant for a number of reasons to non-whites, and especially to non-white elderly. Is the more extensive use of OTC drugs related to the lesser importance placed on professional information sources? Are there obstacles between profes- sionals and non-whites which prevent communication about medication? Research into characteristics of life satisfaction which might contribute to over-the-counter drug use should be explored. Are there certain psychological satisfactions with life which contribute to an elderly individual’s use of OTC drugs? What roles do lifestyle and personality play in the elderly’s use of OTC medications? What role do support systems, such as families, religious organizations, local agen- cies and local aging programs play in the extent of OTC use or in the lack of OTC use? The lack of research on the elderly in general pre- sents many aspects for exploration in their relationship to the extent of OTC drug use. In sum, self-medication is integral to American health care, but also integral to this is the protection of the consumer. Protection of elderly consumers in the area of non-prescription drugs must be a con- certed effort on the part of business, government and health care ser- vice policy makers. Policy makers concerned with the area of non- prescription drugs should involve seniors in planning and implementing policy. Policy must be sensitive not only to seniors’ economic and 99 physical health needs, but also to their psychological health needs. It should be directed at the needs of the whole person, not isolated parts. The concerns of the elderly will soon be the concerns of greater and greater numbers and proportions of the American population. Those who make policy must take this into consideration and plan for the health of cum: aging nation. By realizing the implications and imple- menting changes now, policy can move toward benefiting present and future generations of older Americans. Time -- it waits for no one. REFERENCES REFERENCES Bernstein, A., and Lennard, H.L. Drugs, doctors and junkies. 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GLOSSARY OF TERMS GLOSSARY OF TERMS Cardiovascular drugs: drugs which have an effect on the heart and circulatory system Chronic ailment: persistent or frequently recurring pathological con- dition Drug interactions: drugs interacting with various substances or phen- omena producing untoward effects, i.e., drug-drug or drug-food interactions increase or decrease the effect of a drug or food, drug-lab interactions interfere with a lab test, and drug-disease interactions result in a worsening of the disease Gastrointestinal drugs: drugs which have an effect on the stomach and intestines, i.e., the digestive system Morbidity, morbidity related: disease state or illness, also typical of disease Non-compliance: not following the advice and/or directions either for a drug regimen given by a health care professional, or for drug taking instructions on the label of OTC drugs OTC, over-the-counter, non-prescribed drugs or medications: medications or drugs which can be purchased without a prescription Psychotherapeutic drugs: drugs which have 21 medical effect (n1 a per- son’s mental state Psychotrophic, psychoactive drugs: any drug which has an effect on the mind; these drugs include psychotherapeutic drugs Self-medication, self-medicating: the selection and usage by an indi- vidual of a non-prescribed medicine. (It can also mean the administration of a prescription drug by a patient) DRUG TYPES Antacids: used to neutralize acidity in the stomach Antitussives: used for cough suppression Cold remedies: used 13) provide relief of the symptoms of a cold Decongestants: used 11) prevent the formation of watery secretion in the nasal passages and promote drainage 105 106 Diarrhea remedies: used to decrease gastrointestinal motility and adsorb bowl irritants Internal analgesics: used to provide relief from minor pain Laxatives: used to promote stool formation and elimination; there are five different kinds: bulk type, surface active/stool softener, lubricant, saline and stimulant/irritant (the latter type is considered to be potentially addictive in the sense that if used often, the bowel will not respond to normal stimulation and will need the stimulation provided by these laxatives) Sleep aids: primarily antihistimines, used to promote drowsiness Vitamins and Tonics: vitamins are essential for the maintenance of normal metabolic function, used to ensure against. vitamin deficiencies and for such ill-defined complaints as Fpoor appetite’ or ’lack of energy;’ tonics frequently contain bitters, which are thought to improve appetite, vitamins and iron preparations APPENDICES APPENDIX A Questionnaire derived from original Seniors and Substance Abuse Task Force Health Practices Questionnaire APPENDIX A Questionnaire derived from original Seniors and Substance Abuse Task Force Health Practices Questionnaire Items in the Questionnaire Used in Creation of the Variables of this Study Items 78a and 78b, all nine categories of OTC drugs, were used to create the dependent variables in this study. Those items used for the creation of the independent variables included items 28 (2 alterna- tives), 60 (4 alternatives), 73 (all alternatives used except ’other’), 74 (all alternatives used except ’other’), 77 and 78c (all nine cate- gories for response were used). Items 3-6, 12-20, 22, 23, 25, 29, 31, and 95-97 were used for the contextual variables. QUESTIONNAIRE ITEMS 3) Race: 1. White 2. Black 3. Spanish American 4. American Indian ___ 5. Oriental ___ 6. Other 4) Sex: ___ 1. Male ___ 2. Female 5) Location of Dwelling: ___ 1. Urban and Suburban ___ 2. Rural 6) Type of Dwelling: 1. Boarding Home 2. Apartment Complex (more than four units); predominantly seniors 3. Apartment Complex (four or fewer units); predominantly seniors 107 108 4. Apartment Complex (more than four units); not predominantly seniors 5. Apartment Complex (four or fewer units); not predominantly seniors 6. Single Family Home 7. Mobile Home 8. Other, Specify 12) WHAT IS YOUR PRESENT AGE?: ___ ___ (years) 13) WHAT IS YOUR MARITAL STATUS?: ___ 1. Single 2. Widowed 3. Divorced 4. Legally Separated 5. Married, living with spouse 6. Married, living separately ___ 7. Not married, cohabiting 14) WHO ARE THE OTHER MEMBERS OF YOUR HOUSEHOLD (excluding boarders):? 1. None 2. Husband/Wife 3. Children 4. Grandchildren 5. Other Relatives 6. Friends 7. Other, specify 15) Number of Household Members ___ ___ 16) WHO (IS/WAS) THE PRIMARY WAGE EARNER IN YOUR FAMILY?: _ 1. Self ___ 2. Spouse 17) 18) 19) 20) 22) 109 (Asked about primary wage earner) ARE YOU/IS YOUR SPOUSE RE- TIRED?: O. No ___ 1. Yes Ft retired: HOW LONG (HAVE YOU/HAS YOUR SPOUSE) BEEN RETIRED?: ___ 99. N/A ___ (Years) (Code 00 for less than 1 year) Ft retired: WAS RETIREMENT COMPULSORY?: ___ 9. N/A ___ O. No 1. Yes (Asked about primary wage earner) WHAT (IS/WAS) (YOU/YOUR SPOUSE’S) PRIMARY OCCUPATION71 1. Unemployed, solely on welfare, allotment 2. Unskilled (e.g., manual laborer, janitor, dishwasher, waitress, garbage collector) 3. Semi-Skilled (e.g., assembly line worker, bus, cab or truck driver, housekeeper, bartender, hospital aide) 4. Skilled/Foreman (e.g., heavy equipment operator, policeman, postman, beautician, baker, carpenter, chef, lumberjack) 5. Clerk, etc. (e.g., bank teller, secretary, salesman, bookkeeper) 6. Proprietor, Manager, etc. (including farmer, rancher, small business owner, real estate broker) 7. Professional (e.g., doctor, lawyer, teacher, C.P.A., clergy) 8. Other, specify: WHAT IS YOUR CURRENT HOUSEHOLD INCOME?: Annual Monthly 1. s 0 - 1,999 $ 0 - 166.58 2. 2,000 - 3,999 166.59 - 332.25 (ltperson poverty) 110 3. 4,000 5,999 332.26 499.91 (2 person poverty) ___ 4. 6,000 7,999 499.92 666.58 ___ 5. 8,000 9,999 OR 666.59 833.25 ___ 6. 10,000 11,999 833.26 999.99 ___ 7. 12,000 13,999 1,000.00 1,166.58 ___ 8. 14,000 15,999 1,166.69 1,333.25 ___ 9. 16,000 17,999 1,333.26 1,499.99 10. 18,000 19,999 1,500.00 1,666.58 11. 20,000 & Over 1,666.59 & Over 23) WHAT WAS THE HIGHEST GRADE OF FORMAL EDUCATION YOU COMPLETED? 28) IN WHICH OF THE FOLLOWING AREAS ARE YOU SATISFIED WITH YOUR KNOWLEDGE, AND IN WHICH WOULD YOU LIKE TO LEARN MORE ABOUT MEDI- CATIONS?: (Code: O=don’t know/don’t care; 1=satisfied with present knowledge; 2=would like to learn more) (Read alternatives) When to seek the help of a professional (e.g., doctor, pharmacist) about using over-the-counter medications When to use over-the-counter medications 29) HOW MUCH TIME DO YOU SPEND A DAY (read alternatives)?: (Code: O=O-1 hour; 1=1-2 hours; 2=2-5 hours; 3=5-8 hours; 4=over 8 hours) Watching television Listening to the radio Reading newspapers and/or magazines 111 III CURRENT HEALTH AND MEDICAL ATTITUDES AND PRACTICES 31) GENERALLY SPEAKING, HOW WOULD YOU RATE YOUR CURRENT HEALTH?: ___ 1. Not well most of the time 2. Losing your health 3. Pretty healthy 4. Moderately healthy 5. Very healthy IV OVER-THE-COUNTER MEDICATION INFORMATION AND PRACTICES 73) UNDER WHICH OF THE FOLLOWING CIRCUMSTANCES WOULD YOU BUY AN OVER- THE-COUNTER MEDICATION INSTEAD OF SEEKING A PRESCRIPTION?: (Code: 1=definitely not; 2=probably not; 3=don’t know; 4=probably would; 5=definitely would) (Read responses; probe it necessary tg clarify answer) ___ You feel your ailment isn’t that serious You can’t reach your doctor and need a substitute Your doctor suggested it Your pharmacist suggested it ___ They are less expensive than prescription They are cheaper than a visit to doctor Other, specify: 74) WHEN BUYING AN OVER-THE-COUNTER MEDICATION FOR THE FIRST TIME, HOW IMPORTANT ARE EACH OF THE FOLLOWING IN HELPING YOU TO CHOOSE THE ONE YOU DO?: (Code: 4=very important; 3=moderately important; 2=somewhat important; 1=not important) (Read responses; ptobe it necessary tg clarify answer) ___ Packaging ___ Advertisements you have.seen The price The pharmacist Your doctor 77) 78) 95) 112 Friends or relatives ___ Other, specify: DO YOU THINK YOUR PHARMACIST IS QUALIFIED TO GIVE YOU USEFUL INFORMATION ABOUT PRESCRIPTION MEDICATIONS, OVER-THE-COUNTER MEDICATIONS, OR BOTH?: ___ 0. Neither 1. Over-the-counter only 2. Prescription only 3. Both prescription and over-the-counter ___ 9. Don’t know WHICH OF THE FOLLOWING OVER-THE-COUNTER MEDICATIONS HAVE YOU TAKEN IN THE LAST YEAR?: (Show list to respondent or read list tg him/her: Record information reqfiested below tp chart) (a) Number of OTC drugs taken in this category: (b) How often taken: (Code: 00=1ess than once a week; 1=about once a week; 2=2-3 times a week; 3=4-5 times a week; 4=every or nearly every day) (c) Taken at suggestion of: 1=self; 2=advertisement; 3=friend/ relative; 4=pharmacist; 5=doctor Antacids Diarrhea Remedies Antitussives Laxatives Cold Remedies Vitamins & Tonics Internal Analgesics Decongestants Sleep Aids HOW SATISFYING DO YOU FIND THE WAY YOU ARE SPENDING YOUR LIFE THESE DAYS?: 5. Completely satisfied 4. Moderately satisfied 3. Somewhat satisfied 2. Not very satisfied 1. Not at all satisfied 96) 97) 113 SUPPOSE YOU HAD TO RATE YOUR CURRENT LIFE ON A SCALE OF 1 TO 10, WITH 10 REPRESENTING THE BEST POSSIBLE LIFE FOR YOU AND 1 REPRE- SENTING THE WORST POSSIBLE LIFE FOR YOU, HOW WOULD YOU RATE YOUR CURRENT LIFE?: 1: 2: 3: 4: 5: 6: 7: 8: 9: 10 HOW OFTEN HAVE YOU ENGAGED IN EACH OF THE FOLLOWING ACTIVITIES DURING THE PAST YEAR?: (Code: 5=once a week or more; 4=every two or three weeks; 3=6-12 times a year; 2=1-5 times all year; 1=never or hardly ever) (Read alternatives) A. Club meetings, activities (e.g., union, AARP, etc.) B. Senior activities (e.g., senior center, congregate meals, etc.) C. School activities (e.g., classes, lectures, continuing education) D. Outdoor activities (e.g., walking, camping, gardening, etc.) E. Playing active sports (e.g., golf, baseball, swimming, etc.) F. Recreational and/or cultural events (e.g., dinner, night- clubs, concerts, plays, museums, fairs, sporting events) G. Visiting friends, relatives, neighbors H. Working on hobbies or pastimes (e.g., weaving, knitting, woodworking, painting or sculpture) I. Housework including cooking J. 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