SELF-MEDICATION AMONG NURSING WORKERS FROM PUBLIC HOSPITALS

Este estudo investigou a prevalência de automedicação e fatores associados entre trabalhadores de enfermagem. Realizou-se estudo epidemiológico seccional que abrangeu 1509 trabalhadores de enfermagem de dois hospitais públicos no Rio de Janeiro, Brasil. Os medicamentos foram identificados e classificados de acordo com o Anatomical Therapeutic Chemical Index. A prevalência de automedicação foi 24,2%, o grupo anatômico mais referido foi o sistema nervoso e o grupo terapêutico incluiu os analgésicos. A prevalência foi mais alta entre os mais jovens, aqueles com distúrbios psíquicos menores, não hipertensos, os que não faziam exercícios físicos, os que referiram doença ou ferimento nos últimos 15 dias, aqueles com maior número de doenças autodiagnosticadas, enfermeiros, de vínculo temporário, e os que referem maior envolvimento com o trabalho. A automedicação é prática frequente na equipe de enfermagem e está associada a diversos fatores que deveriam ser considerados em estratégias que buscam melhores condições de saúde entre eles.


INTRODUCTION
Self-medication is a common form of selfcare and consists of consuming a product on one's own initiative in an attempt to relieve perceived symptoms or diseases (1) .It can be also defined as the "use of medication without prescription, medical guidance or follow-up" (2) .The major use of this practice has been associated with the following factors: female, young, higher education and income levels, knowledge of medication, and lack of access to the health system (3)(4)(5) .
T h e c o n s u m p t i o n o f d r u g s w i t h o u t p r e s c r i p t i o n i s a p h e n o m e n o n o f i n c r e a s i n g relevance, motivated by a complex set of factors that are associated with values that predominate in modern society.Among these factors, the increased supply of alternative medication and the availability, unrestricted selling and propaganda of p h a r m a c e u t i c a l p r o d u c t s i n t h e m e d i a a r e noteworthy (6) .
Among health workers, there are factors related to the working environment and conditions and access to medication.Nursing workers handle several types of medications in their daily practice and the easy access can favor self-prescription and self-medication (7) .Even having theoretical and practical knowledge about these substances and t h e i r i m p l i c a t i o n s , t h e s e p r o f e s s i o n a l s a r e oftentimes trying to get rid of uncomfortable situations to better endure their workday (8) .The reality of nursing workers, who often have more than one job, coupled with the complex work performed at hospitals, leads to the conclusion that these professionals might face difficult moments or crises, making the consumption of medications a way to facilitate their lives (8) .
Inappropriate self-medication can cause undesirable consequences and effects, iatrogenic diseases and mask progressive diseases (3) .It therefore represents an important problem that has to be acknowledged and prevented.
Although Brazilian studies have investigated the phenomenon of self-medication, the majority describe it among the elderly (4)(5)(9)(10)(11) . Among he few studies that investigate self-medication among health workers, the author and collaborators (3) are h i g h l i g h t e d .T h e s e s t u d i e s i d e n t i f i e d a 3 2 % prevalence of self-medication for nurses, below only that identified for physicians (43%).Articles about the use of benzodiazepines among nursing students (12) and workers (13) were found in nursing publications, however, studies of self-medication among nursing workers were not found.questionnaire. Thepilot test was carried out with 120 nursing workers from a federal public hospital with a social and functional profile similar to that of the nursing professionals addressed in this study.
Data collection was carried out during w o r k i n g h o u r s b y t r a i n e d i n t e r v i e w e r s .
Questionnaires were then reviewed, coded and independently typed up by two people using Validate (Epi-Info 2000) so as to identify and correct inconsistencies in data entry.
Information about the use of medication was collected through two questions included in the questionnaire: "did you take any medication (allopathic or homeopathic medication, home remedies, etc) in the last seven days?".If yes, the following question was: "which medication(s) did you take in the last seven days and who suggested it (them)?"(There were seven choices for answers.)Medications were identified and had their active principles separated and classified according to the Anatomical Therapeutic Chemical Index (ATC/DDD Index) developed by the World Health Organization Collaborating Centre for Drug Statistics Methodology (14) .According to this index, medication is classified in 14 large groups designated by a letter, given the agency or system in which the drug act in the anatomic group (for example, A -digestive tract and metabolism

RESULTS
T h e s t u d y p a r t i c i p a n t s p r e s e n t e d t h e following characteristics: 86.6% were women, 40.1% were 46 years or older, 44.2% were married, 39.5% reported to be mixed (in terms of ethnicity), 56.7% had a bachelor's degree, 52.3% were nursing auxiliaries and 46.2% reported a per capita family income below 700.00 reais * .
T h e p r e v a l e n c e s e l f -r e p o r t e d u s e o f medication without medical prescription was 24.2%.
T h e a v e r a g e n u m b e r o f d r u g s u s e d i n s e l fmedication was 1.41 (varying from 1 to 8 reported drugs) whereas 71.9% reported the use of only one and 28.2% reported the use of one or two medications in the last seven days.3).
In terms of occupational variables, selfmedication prevalence was lower among nursing auxiliaries and technicians when compared to nurses.
In addition, the highest prevalence were found among those who were not public employees and those who reported not being able to stop thinking about work even when they were off duty (Table 4).Prevalence ratio (PR) and respective confidence intervals (CI); association was considered when intervals do not include the value 1

DISCUSSION
The prevalence of self-medication reported by the studied nursing workers was 24.2%, below that identified among nurses in the basic health care network in Pelotas, RS, Brazil (32.4%) (3) , though this study evaluated the use of medication in the last 15 days.The frequencies were also below those found in a study of residents in Santa Maria, RS, Brazil (53.3%) (15) and in another that evaluated selfmedication in elderly people in Salgueiro, PE, Brazil (77%) (9) .However, the prevalence found in this study was higher than that observed in adult populations of other countries, such as Spain (12.7%) (6) .The most consumed medications were those for the nervous system (46.7%),while the most used subgroup was analgesics (43.4%), a pattern described by several authors (3,5,9,15)   .The results presented here were different from those of another study (11) that identified medications for the cardiovascular system as the most used therapeutic category.However, it involved elderly people, an age when the prevalence of cardiovascular disease is high.The findings of this study are relevant when it comes to the category of nursing workers because the excessive use of analgesics might be a reflection of poor working conditions, with minimum rest, which leads to fatigue and the need for medication, and consequently, selfmedication.Another factor possibly related to the use of analgesics could be the prevalence of musculoskeletal disorders already reported among nursing workers (16-17)   .Prevalence ratio (PR) and respective confidence intervals (CI); association was considered when intervals do not include the value 1 Other studies (4)(5)(6)9) reported different results such as: more frequent self-medication among women, which can be explained by the fact that women usually seek health services more frequently and take better care of themselves.
In general, the consumption of medication increases as people get older (4,9) .However, selfmedication tends to be higher among younger people (3,5-6)   .This pattern was also identified in this study.
Marital status was not associated with selfmedication among the studied nursing workers.The association between this variable and self-medication did not reach a consensus in literature.For example, results similar to those of this study were reported by another Brazilian study (5) that addressed a population of elderly people.However, a Spanish study identified a higher level of self-medication among adults who live alone (6)   .
Similar to this study's results, people with higher levels of education tend to self-medicate themselves more frequently (3,6) .The reasons have been attributed to the following factors: more knowledge about medication, higher economic status, less confidence in physicians and a greater feeling of personal autonomy in the face of decisions about their own health (6) .
Studies have shown that self-medication is associated with the presence of less severe signs and symptoms of acute characteristics such as pain and fever.Chronic diseases that in general involve medical follow-up favor the use of prescribed medication (10) .
Corroborating these findings, a higher level of selfmedication was found among those who reported a disease or injury in the last 15 days and lower level among hypertensive individuals.Additionally, a higher consumption was found among those classified with minor psychiatric disturbances, among those dissatisfied with their sleep patterns and those with a higher number of self-diagnosed diseases.These aspects deserve more specific studies so as to understand how getting ill is related to the use of medication among nursing workers.
Similar to this study's results, other studies reveal that individuals with low physical activity present a higher consumption of medication (9) .Although one cannot establish a cause-effect relation based on cross-sectional studies, we know that physical activity is associated with improved health.
This study evidenced higher frequencies of self-medication among nurses.Another Brazilian Self-medication among nursing workers… Barros ARR, Griep RH, Rotenberg L. study (3) had already described a higher prevalence of self-medication among professionals with a bachelor's degree (including nurses) when compared to professionals with only secondary education completed.
The high prevalence found among those who were not public employees can be attributed to the age of the studied population.Although the difference for age was not presented in this study's analysis, the reported group was much younger than the public employees.
It is noteworthy that such a high prevalence was identified among professionals excessively involved with their work, who are unable to stop thinking about their work even when they are off duty.
The importance of occupational stress is acknowledged as a risk factor for workers' diseases (3,6) .Therefore, studies that better clarify the influence of the psychosocial work environment on the use of medication are needed.
This study's findings should be evaluated considering the main limitations of cross-sectional studies, which do not permit establishing a clear temporal relation between events, hindering the establishment of cause and effect.One can also assume some degree of underestimation of information about the use of medication, due to forgetfulness or because participants did not want to report the use of certain drugs.Some medications could not be identified according to the adopted classification, because some participants did not provide sufficient information since they would have to recall the names or active substances of medications.

CONCLUSIONS
The issue "self-medication" is controversial in relation to the benefits and harms it causes to workers' health.This practice can be favored by factors such as easy of access to drugs and difficult of access to health services (as users of health services), whether due to a lack of time or money to pay for health insurances or because they find selfcare difficult.
Self-medication is an old, universal problem of large proportions.Although it is very difficult to eliminate such a practice, it is necessary to provide guidance to the population in general about the use of medications in order to discourage unbridled consumption.
The potentially dangerous effects of selfmedication might be underestimated by nursing workers.This subject should be addressed in schools and in strategies focused on improving the health of workers.

METHOD D a t
a w e r e o b t a i n e d t h r o u g h a c r o s ssectional epidemiological study carried out in two public hospitals in Rio de Janeiro, RJ, Brazil: a large g e n e r a l h o s p i t a l a n d a r e f e r e n c e c e n t e r f o r maternal-infant health.The study was based on census data and included all nurses, nursing technicians and auxiliaries who worked directly with nursing care, regardless of the work contract.The following exclusion criterion was used: nursing workers not providing care such as: head nurses and workers from the supply center.Of the 1,687 e l i g i b l e n u r s i n g w o r k e r s , 1 , 5 0 9 ( 8 9 .4 % ) participated in the study.A questionnaire with structured questions was used and it addressed, among other aspects, the following: (i) sociodemographic data, (ii) characteristics related to work, (iii) reported diseases and symptoms -high blood pressure, hospitalization, sleep and digestive disorders and minor psychiatric disturbances and (iv) the use of prescribed medication and self-medication.Three stages of pre-tests were carried out to refine the Self-medication among nursing workers… Barros ARR, Griep RH, Rotenberg L.

t h r o
u g h t h e P e a r s o n ' s C h i -s q u a r e ( l e v e l s o f significance were set at 5%, that is, p<0.05) and prevalence ratios and their respective confidence interval at 95%.Each employee signed a free and informed consent agreement authorizing the use of data in research.The Project was approved by the Ethics Research Committees of the involved institutions and also submitted to and approved by the National Research Ethic Committee (CONEP -Brasília) because it involved international cooperation (Process nº 1318/2004).

Table 1 -
Distribution of the frequency of drugs consumed in self-medication in the last seven days among nursing workers, Rio de Janeiro, Brazil 2007 Results of the analysis of association between reported self-medication and the variables considered in the study are presented on Tables 2, 3 and 4. In terms of sociodemographic variables, we observed that the prevalence of self-medication was higher among young people and those with the highest level of education (Table2).In relation to evaluated health conditions, we observed a greater prevalence among workers with minor psychiatric disturbances (depression and

Table 3 -
Prevalence of self-medication and prevalence * Pearson's Chi-square test; significant at <0.05 ** Prevalence ratio (PR) and respective confidence intervals (CI); association was considered when intervals do not include the value 1