The Consumption of Conventional and Nonconventional Medicines in an Italian Province: The Influence of Sociodemographic Factors and Health Beliefs

Abstract

Many studies have investigated the factors that influence the consumption of medicines. This article aims to compare how these factors affect both conventional medicines (prescription and over-the-counter (OTC) medicines) and nonconventional ones, also named as complementary and alternative medicines (CAM). A questionnaire was administered to a purposive sample of 4,074 inhabitants of the province of Mantua, Italy. Logical regressions were used to identify the variables influencing frequency of use. The consumption frequency of various types of medicines was associated not only with demographic aspects (such as gender, age, and education level) but also with everyday treatment strategies (such as self-medication habits and use of the Internet for medical aims) and health beliefs. From this last point of view, the use of conventional and nonconventional medicines is guided by 2 principal therapeutic attitudes, one aimed at removing all pathological aspects from everyday life and the other at contextualizing health problems within a broader philosophical search.

Keywords

conventional medicines complementary and alternative medicines health beliefs drug utilization

A pharmaceutical drug can be defined comprehensively as any chemical compound that may be used on or administered to humans to help diagnose, treat, cure, mitigate, or prevent diseases or other abnormal conditions. Taking into account the different medical cultures in the world, drugs may be based on the Western science approach or on a wider array of nonorthodox approaches. As the former are included in the Italian academic teaching and in the formal health care system, we define them as conventional medicines. According to the different paths of access for consumers allowed in the Italian welfare system, this group of medicines can be in turn divided in 2 categories: prescription medicines, drugs that require a prescription from a medical doctor; and over-the-counter medicines, drugs sold directly to consumers without any prescription.

The second type of drugs, which are based on approaches different from biomedicine, are defined here as nonconventional medicines. According to the Resolution 1206 of the Council of Europe (November 4, 1999), “On the status of nonconventional medicine,” and to the Italian guidelines of the National Council of the Italian National Federation of Colleges of Medical Doctors and Dentists (FNOMCeO), nonconventional medicines include acupuncture, homeopathy, phytotherapy, traditional Chinese medicine, anthroposophical medicine, homotoxicology, ayurvedic medicine, chiropractice, and osteopathy. The debate on the scientific effectiveness of these nonconventional medical disciplines is still open in Italy as elsewhere.¹ The Italian guidelines state that even if these approaches are different from the Western bioscientific medicine, they must be placed exclusively under the professional responsibility of medical doctors and nevertheless be regarded as medical practice. This second type of drugs can be considered equivalent to the well-known category of CAM (complementary and alternative medicine), even if there is a lack of a consistent operational definition due to the different national rules and research designs on this subject.²

The consumption of the 3 types of medicines cited above is widespread in Italy: in 2013, 48.6% of the population had taken medicine in the 2 weeks prior to the interview.³ Analysis of the social profile of consumers shows that specific curative behaviors emerge according to demographic and psychosocial characteristics or the priorities attached to health. Regarding demographic characteristics, the consumption of conventional and nonconventional medicines is correlated with gender, age, education, ethnic and cultural belonging, income, and state of health. However, as Stratton^4(p777) has observed, a limitation of many studies is their emphasis on correlates of prevalence rather than on explanatory factors.

A second body of studies identifies another set of factors affecting drug consumption which are associated with psychosocial variables: personality type, emotional state, perception and assumption of risk, perceived effectiveness of various types of medicine, checks on treatment procedures, coping strategies, and access to health information and self-medication in everyday life.

From a sociological perspective, it is possible to isolate a third group of variables associated with the cultural factors that influence the meanings underlying the consumption of medicines. This process can be based on different approaches to medicines. Part of the population, in fact, tends to place more trust in biomedicine⁵ and in pharmacology based on “conventional” medicine. However, increasing faith in CAM must be considered. Although differing from science-based medicine in terms of their epistemological bases, CAM claims to improve well-being by acting on a more complex interaction among biology, psychology, and the eco-social context.⁶ The integration of these 3 dimensions of health leads to the treatment or prevention of illnesses based on approaches which are also closely associated with spiritual and religious beliefs.⁷

Regarding the debate about the different explanatory variables of drug consumption, this article reports a comparative analysis carried out on the influence of the above-listed demographic, psychosocial, and cultural factors on the frequency of use of the 3 types of medicine cited: conventional prescription medicines; conventional nonprescription medicines—also known as OTC medicines; and nonconventional medicines. The analysis was conducted using a specific methodology—binomial logistic regression—applied to a selected set of variables. We chose this type of statistical analysis because it is recommended to explain the relationship between one dependent binary variable and more categorical independent variables, considered simultaneously.

The objective was to verify if the consumption of different types of medicines is influenced not only by sociodemographic factors or everyday treatment strategies, but also by different values and beliefs that condition the health and care approach. The reference territorial area was the northern Italian province of Mantua, where more than 400,000 people live.

Methods

Study Design

The study administered a questionnaire consisting of 42 closed-ended questions on the following topic areas: sociodemographic aspects (gender, age, educational qualifications, municipality of residence, civil status, and profession); consumption of medicines (type, therapeutic indication, frequency and method of administration, the occurrence of possible side effects, suspension and the reasons for it, and self-medication practices); and other aspects associated with the administration of medicines (satisfaction with health care professionals, the meaning given to the concept of health, and the use of the Internet as a source of health care information).

The research has been approved by Human Research Ethics Committee of the University of Trento (Institutional Review Board—IORG0007733—IRB00009280).

Data Collection and Sample

We used a non-probabilistic purposive sample consisting of individuals who had purchased any type of medicine in one of the pharmacies of the province of Mantua between September and October 2013. We collected data in pharmacies, because these are the only type of business in Italy authorized to sell prescription medicines. Together with other types of retail businesses (such as para-pharmacies and supermarkets), they also sell OTC and CAM. Of the 133 pharmacies located throughout the province, 129 took part in the research. We adopted a proportional quota sampling based on residence population: each pharmacy was given a share of interviews in proportion to the number of residents of the municipality in which it was located. The pharmacists directly administered the interviews by using the CAWI (computer-assisted web interviewing) method. They were trained both to administer the survey and to use the CAWI software. The actual sample consisted of 4,074 interviewees.

Measurements and Analyses

Data have been analyzed through the software SPSS© vers. 23. Three logistic regressions were run to estimate which of the selected variables most influenced the likelihood of frequently using (the responses were “often” and “regularly”) conventional prescription, conventional nonprescription (OTC), and nonconventional medicines (CAM). The same independent variables were included in the 3 regressions, while only the dependent variable was modified to compare the impact of the regressors on the frequency of consumption of the 3 types of medicine mentioned above. The method used was Maximum Likelihood Estimation (MLE).

The independent variables included in the logistic regression were as follows: gender (male/female); age groups (young adults = 18–45; mature = 46–60; elderly = over 60); educational qualification (recodified into 3 groups: low education = up to a middle school diploma; average education = vocational school or diploma; high education = bachelor or master degree); place of residence (Mantua or other municipalities in the province); treatment of disorders with previously purchased medicines (never/sometimes/often); definition of state of health (in balance and harmony with oneself and one’s body/no pains, illnesses or ailments/efficient from a psychophysical standpoint); and use of the Internet to search for medical information (no/yes).

We chose these variables adopting an inductive approach based on literature review. In other terms, we tried to explore some nonclinical dimensions considered important by scholars to explain differences in medicine consumption, and we attempted to analyze their combined effect.

Table 1 shows the distributions in absolute terms and the percentages of independent and dependent variables included in the regression.

Table 1.

Variables Included in the Logistic Regression: Absolute and Percentage Frequencies.

Variables	n	%
Gender
Male	1,758	43.2%
Female	2,312	56.8%
Age groups
Elderly = over 60	1,003	24.6%
Mature = 46–60	1,231	30.3%
Young adults = 18–45	1,835	45.1%
Education level
Low	1,037	25.5%
Average	1,965	48.3%
High	1,069	26.2%
Place of residence
Province of Mantua	3,540	86.9%
City of Mantua	533	13.1%
Treatment with previously purchased medicines
Never	1,397	34.3%
Sometimes	2,313	56.8%
Often	363	8.9%
Representation of health
No pain, illnesses, or ailments	1,488	36.5%
In balance and harmony with oneself and one’s body	1,743	42.8%
Efficient from a psycho-physical standpoint	841	20.7%
Use of Internet for medical information
No	1,398	34.4%
Yes	2,661	65.6%
Types of medicines purchased frequently (“often” and “regularly”)
Prescription medicines	2,089	51.3%
Over-the-counter medicines	713	17.5%
Nonconventional medicines	712	17.5%

Results

Influence of Sociodemographic Variables

The sociodemographic variables included in the analysis were gender, age group, education level, and place of residence (see Table 2).

Table 2.

Prescription Medicines, Over-The-Counter Medicines, and Nonconventional Medicines: Logistic Regression.

	Prescription Medicines No. 4,047 (99.3%)			Over-the-Counter Medicines No. 4,047 (99.3%)			Nonconventional Medicines No. 4,048 (99.4%)
	OR	95% CI	P	OR	95% CI	P–	OR	95% CI	P
Gender: Female	1.207	1.049–1.388	.008	1.258	1.061–1.493	.008	1.783	1.783–2.138	.000
Age: >60			.000			.000			.125
Age: 46–60	0.328	0.266–0.405	.000	0.653	0.520–0.822	.000	1.272	0.969–1.672	.083
Age: 18–45	0.130	0.105–0.161	.000	0.474	0.373–0.601	.000	1.087	0.828–1.426	.550
Education level: Low			.000			.302			.254
Education level: Average	0.712	0.591–0.859	.000	0.924	0.743–1.148	.474	1.227	0.952–1.580	.115
Education level: High	0.570	0.460–0.707	.000	0.817	0.630–1.061	.129	1.239	0.938–1.636	.132
Place of residence: Mantua	1.078	0.882–1.319	.461	0.850	0.657–1.100	.216	1.630	1.301–2.042	.000
Treatment with previously purchased medicines: Never			.000			.000			.004
Treatment with previously purchased medicines: Sometimes	1.540	1.325–1.79	.000	1.550	1.277–1.881	.000	1.058	0.875–1.281	.560
Treatment with previously purchased medicines: Often	1.628	1.258–2.106	.000	2.818	2.124–3.740	.000	1.614	1.205–2.163	.001
Definition of state of health: No pains, illnesses, or ailments			.000			.001			.000
Definition of state of health: Balance and harmony	0.720	0.614–0.844	.000	0.698	0.574–0.848	.000	1.962	1.594–2.415	.000
Definition of state of health: Efficient from a psycho-physical standpoint	0.704	0.582–0.851	.000	0.921	0.737–1.151	.469	1.310	1.013–1.693	.039
Internet: Search for health information on the Web	1.043	0.882–1.233	.623	1.353	1.099–1.665	.004	2.438	1.919–3.098	.000

All conditions being equal, for all 3 classes of medicines, female interviewees were more likely to consume medicines, but this likelihood was greatest in the case of CAM, since women had a 78% higher chance than men of consuming this type of pharmaceutical product regularly (OR = 1.782; P = .000). For prescription and OTC medicines, women were 20% (OR = 1.207, P = .008) and 26% (OR = 1.258, P = .008) more likely, respectively, to use the medicines surveyed more frequently than men.

Comparing age groups, significant differences emerged depending on the pharmaceutical class. For conventional medicines (both prescription and OTC), in fact, the likelihood of being a frequent consumer (respondents who had declared to use this kind of medicine “often” or “regularly”) increased with age. The 18–45 age group was 87% (OR = 0.130, P = .000) less likely to consume medicines requiring a prescription than the over-60 group. For the 46–60 age group, this likelihood became 68% (OR = 0.328, P = .000) lower, again compared with the elderly. In the case of OTC medicines, the probability diminished: young interviewees were 53% more likely (OR = 0.474, P = .000) to be frequent consumers than elderly ones, while for the mature group, the value was 45%, again with a positive sign (OR = 0.653, P = .000). The younger age groups were more likely to consume CAM frequently, but the relations were not significant (18–45: OR = 1.087, P = .550; 46–60: OR = 1.272, P = .083).

Education level influenced the consumption of prescription medicines towards an increased probability of frequent use among interviewees with low education qualifications (low education level: OR = 1.000; P = .000; average education level: OR = 0.712, P = .000; high education level: OR = 0.570, P = .000). This relation was confirmed for OTC medicines, but it was not statistically significant (low education level: OR = 1.000, P = .302; average education level: OR = 0.924, P = .474; high education level: OR = 0.817, P = .129). Frequent consumption of CAM, on the other hand, was more likely among interviewees with high educational qualifications; but in this case, too, the relation was not significant (low education level: OR = 1.000, P = .254; average education level: OR = 1.227, P = .115; high education level: OR = 1.239, P = .132).

As regards place of residence, living in the city as opposed to the province determined a significant relation only in the case of the consumption of CAM: interviewees who lived in Mantua were 63% more likely to use medicines of this type frequently (OR = 1.630, P = .000).

Self-medication

Does having medicines at home influence the tendency to self-medicate? The data suggest that having medicines at home influences the tendency to self-medicate, particularly regarding OTC medicines. Among those interviewees who stated that they used medicines purchased for a previous episode of illness, the likelihood of being frequent consumers of OTC medicines almost tripled (OR = 2.818, P = .000) compared with those who did not keep medicines. This trend was confirmed, albeit less markedly, in the case of prescription medicines (sometimes: OR = 1.540, P = .000; often: OR = 1.628, P = .000). With CAM, the relation was not a linear one, since the association between frequent use and the accumulation of medicines was only significant in the case of those interviewees who stated that they “often” kept a supply (OR = 1.614, P = .001), but not of those who admitted to “sometimes” using medicines purchased not for that episode of disease but for a health problem that they had in the past (OR = 1.058, P = .560).

Health Beliefs

Representations of the concept of health influenced the consumption of the various types of medicine. Interviewees who conceived of health in terms of a lack of pain, ailments, and illnesses were more likely to consume prescription medicines frequently than were those who defined health as a state of balance and harmony (OR = 0.720, P = .000) or as an expression of psycho-physical efficiency (OR = 0.704, P = .000).

Among interviewees who stated that they consumed OTC medicines on a frequent basis, the view of health as the absence of physical problems prevailed, although the representation of health as performance—the definition of health as “an efficient condition from a psycho-physical standpoint”—grew. However, the relation was not significant (OR = 0.921, P = .469).

Further distinctions emerge when considering the frequent consumption of CAM, which reflected a predominantly holistic view of health and to a lesser extent a performative one. Those interviewees who defined health as a state of balance and harmony with themselves and their body were almost twice as likely (OR = 1.962, P = .000) to use CAM frequently compared with those who saw health as the absence of illnesses, while those who gave it a definition linked to efficiency had a 31% higher likelihood (OR = 1.310, P = .039), again compared with those who interpreted health as a lack of ailments.

Use of the Internet to Search for Medical Information

In general, use of the Internet to search for information on health care resulted in a greater probability of frequent consumption of all medicines, especially OTC and CAM. Interviewees who used the Internet were 35% more likely to use those OTC medicines often (OR = 1.353, P = .004). Those who used the Internet to search for medical information were fully 243% more likely (OR = 2.438, P = .000) to use CAM compared with those who did not. Conversely, consulting the Internet for medical information did not significantly influence consumption of prescription medicines (OR = 1.043, P = .623).

Discussion

A comparison among the 3 logistic regressions makes it possible to identify certain variables conditioning the consumption of all 3 types of medicine. Other variables, conversely, tended to be associated with 2 prevalent therapeutic directions: on the one hand, the use of medicines based on CAM; on the other, the use of science-based treatments. Within the latter group, the frequency of use of prescription and freely available medicines had associations of differing intensity with the various regressors. Overall, however, a unitary and consistent meaning emerged with features different from those corresponding to CAM.

Among the variables associated with frequent consumption of all types of medicine, particularly OTC and CAM, there was the practice of self-medication, in the sense of using products already purchased with previous prescriptions.⁸ Further information in the questionnaire makes it possible to define the meaning of this result with greater precision. The large majority of the interviewees, in fact, stated that when they adopted this practice, it was for the same condition that had previously been diagnosed by their doctor. This was the case for 91.6% of the interviewees who purchased medicines on prescription, 91.2% of those who purchased OTC products, and 89.4% of those who purchased nonconventional medicines. We can therefore say that these were prevalently instances of the “self-management” of pharmacological treatment—which still related, however, to consultation with a doctor.⁹

We now consider the variables most frequently associated with the use of conventional medicines. As widely reported in the literature,^10,11 the frequency of use of these medicines is positively correlated with age. This holds for both OTC and prescription medicines.¹² As people grow older, in fact, the probability increases that they will suffer from more serious conditions that require more frequent consumption of the latter type of medicines.

A high level of use of prescription medicines is also associated with lower education levels,¹³ which may give rise to a greater likelihood of pharmaceuticalizing a wide range of day-to-day issues compared with more highly educated social groups.^14,15 Furthermore, to be kept in mind is a reduced awareness of alternative treatment methods or ones that lend themselves to self-medication.¹⁶

Besides sociodemographic aspects, an important factor relates to health beliefs. A “residual” approach (“not having pain, ailments, or illnesses”), on the basis of which the actor essentially refers his or her perception of health to the possibility of avoiding (or overcoming) all pathologies, correlates with prescription and OTC conventional medicines. This shows a therapeutic attitude based primarily on the need to prevent or remove the symptom effectively without framing the treatment within a lifestyle characterized by the integration among biological, psychological, and ecological dimensions.⁷ On the contrary, this “holistic” approach (“being in balance and harmony with oneself, one’s body, and one’s mind”), which is open to a more spiritual and philosophical attitude, correlates with the use of CAM.

Summarizing further variables associated with the use of CAM, it is necessary to consider gender. As a large body of literature has shown, women generally consume greater quantities of all types of medicines,^11,16 both conventional^12,17–21 and CAM.^2,6,22–27 Our results confirm this finding. But they also show that the association between women and CAM is comparatively stronger. As Sointu^28(p356) has pointed out, this can be linked to a conception of health and well-being that “conflicts with traditional discourses of other-directed femininity.” From this point of view, the use of CAM could re-empower an idea of agency that is at the center of care and attention,²⁹ seeking a balance among the biological, psychological, and social dimensions of the wellness.

In line with this theory, it should be pointed out that a second variable shown to be closely associated with the frequent use of CAM is the belief that health should be interpreted as a sense of harmony with oneself and one’s body. Therefore, a specific therapeutic approach arises, that frames the use of CAM within a vision of oneself and the world based in part on philosophical and spiritual premises.^6,30,31

Residence should also be included among the variables specifically associated with the frequent use of CAM: in our research, when an interviewee lived in the city center, he or she was more likely to use this kind of medicines. This correlation has previously been identified by other studies,³² but it is worth investigating further in the context of the specificities of the geographical area and the local welfare system.³³ In our case, it was presumably due to the greater availability in the urban area of practitioners adopting unconventional medical approaches and to the presence of pharmacies with a more diverse supply of medicinal products.³⁴

Another aspect of particular significance is the search for information on the Internet. Frequent use of the Internet significantly correlates with the consumption of medicines that do not require a prescription, such as OTC and CAM. When the gatekeeping function of doctors is not compulsory, people increasingly bypass medical consultations and directly access the information available on the Web³⁵ to take their treatment decisions independently.³⁶ Our study has shown, however, that this association is comparatively more significant in the consumption of CAM. Once again, this must be related to the particular features of the Italian health care system, which is characterized by an approach to treatment based predominantly on conventional medicines, and which has not fully recognized CAM, since these medicines and corresponding medical approaches are neither part of compulsory medical degree curricula nor contemplated in the range of services offered by the national health system.^1,37 Hence, the Internet becomes a tool to access non-mainstream information, allowing the use of medicines more aligned with personal health beliefs and interaction with doctors who practice these disciplines with more specific knowledge of the curative methods and with increased mutual communication. Our research showed, in fact, that when interviewees used CAM, they experienced a significantly more engaged and participatory care relationship with their doctors. Nonetheless, it remains to be verified whether the information available online is in fact not only accessible but also trustworthy and consistent with the desired course of treatment.^38,39

Limitations

The non-probabilistic nature of the sample limits the generalizability of the results to the reference population.

Conclusion

Summarizing the results, the frequency of consumption of various types of medicine (prescription, OTC, and CAM) is polarized around 2 main therapeutic attitudes based on conventional and nonconventional medicines, respectively. This distinction is founded on a plurality of social dimensions that relate not only to demographic aspects (gender, age, and education level), but also to curative strategies in everyday life (such as self-medication and the use of information from the Internet) and to health beliefs. When respondents consume conventional medicines, their purposes are to remove all pathological issues from everyday life; when CAM are consumed, they position health problems within a wider-ranging search of a philosophical kind, which integrates biological, psychological, and social dimensions. This latter approach is certainly useful as it addresses the disease by considering a wider range of factors and resources that can influence both therapy and prevention. However, since the effectiveness of complementary and alternative medicines has not yet been scientifically demonstrated,^40–44 close supervision by a physician trained also in scientific medicine remains necessary to avoid both false expectations and therapeutic errors.

Footnotes

Appendix

Acknowledgments

We want to express our gratitude to the association Federfarma-Mantua for supporting us in the implementation of the survey.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Davide Galesi is a lecturer of Sociology of Health in the Department of Sociology and Social Research at the University of Trento (Italy). His research topics refer to the consumption of medicines, the medicalization and pharmaceuticalization of everyday life, mental health and migration, ethnopsychiatry. His publications in English are the following: “Social Action” in Theorizing Sociology in the Digital Society, “Towards a closer connection between the education system and labour market in Italy” in International Perspectives on Migration, Population Changes, Education and Youth; “Towards the genomization of food? Potentials and risks of nutrigenomics as a way of personalized care and prevention” in Italian Sociological Review; “The pharmacologization of loneliness and insecurity” in SALUTE E SOCIETÀ; “Community governance between techniques of analysis and decision-making mediation” in SALUTE E SOCIETÀ; “New technologies for youth communication: a blended research design to study help relationships on the Internet” in International Journal of Multiple Research Approaches.

Linda Lombi, PhD in Sociology, is an assistant professor at the Catholic University of the Sacred Heart in Milan where she teaches Sociology and Methods (Faculty of Education Science). Her research interests focus on health sociology, citizen science, participatory medicine, digital narratives, digital research, and Big Data. She has authored “Psychotropic substances and Internet-based interventions: a critical review” in Salute e Società, and coauthored the following articles: “Sizing the Cannabis market: a demand-side and user-specific approach in seven European countries” in Curr Drug Abuse Rev, and “Melanoma attributable to sunbed use and tan seeking behaviors: an Italian survey” in Eur J Dermatol.

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