Health Policy 77 (2006) 166171

Self-medication with antibioticsDoes it really

happen in Europe?
Minna Heleena Vaa nanen , Kirsi Pietila, Marja Airaksinen
Division of Social Pharmacy, University of Helsinki, Viikinkaari 5 E, PL 56 Helsinki, Finland

Abstract
Aims and methods: The aim of this study was to determine whether antibiotics are used for self-medication in southern Spain,
a region belonging to European Union. The data were collected by a survey in the Costa del Sol region, Spain during 2002 by
using a convenience sample of 1000 Finns living permanently in the area (response rate 53%, n = 530).
Results: Antibiotics were used by 28% of the respondents during the previous 6 months before the query. Of the antibiotic users,
41% had bought their antibiotics without a prescription. Clearly the most common indication for antibiotic use was common
cold, with almost half (45%) of the antibiotic users reporting it as purpose of medication, followed by sore throat (17%). The
number of courses did not differ between prescription and non-prescription antibiotic users, most (64%) of the users having
used one course. Neither did the groups differ according to background variables used, including the frequency of experiencing
adverse reactions.
Conclusions: Unnecessary and unrational self-medication with antibiotics seems to be common in southern Spain among
Finnish immigrants. This may indicate that Spanish health care system, including community pharmacies are failing their
task in enhancing rational use of medicines. It is important that all the member countries within EU will take their
responsibility in promoting public health goals in their national policy, e.g., in minimising the antibiotic resistance for
expanding.
2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Antibiotic use; Rational use of medicines; Self-medication

1. Introduction
Antibiotic resistance is an extending, worldwide
problem, which may in worst case spread from hospitals towards people living in their natural surroundings.
The prevalence of antibiotic resistance varies between
different European countries [1,2], e.g., southern Euro

Corresponding author. Tel.: +358 405477577.

E-mail address: Minna.Vaananen@helsinki.fi (M.H. Vaa nanen).

pean countries have higher resistance rates than the

Nordic countries. According to the previous antibiotic
use studies, southern European countries also have high
antibiotic sales and prescribing rates [3,4]. The relationship between antibiotic use and resistance has been
clearly modelled in previous studies [57].
One of the major factors related to growing problem
of resistance is inappropriate use of antibiotics. The
European Union has set clear objectives to decrease
the resistance and antibiotic utilization rates in the

0168-8510/$ see front matter 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2005.07.001

M.H. Vaa nanen et al. / Health Policy 77 (2006) 166171

Union area [8]. Also, the WHO has created common

guidelines to promote the rational use of antibiotics
[9]. According to regulations in most of the developed countries, antibiotics should only be prescribed by
general practitioners. Therefore, general practitioners
have been regarded to be in key position in influencing antibiotic use, and antibiotics studies have been
focusing on their prescribing patterns [1012]. Less
attention has been paid to self-medication with antibiotics. Although community pharmacies in most of the
European Union countries are not legally allowed to
dispense antibiotics without a prescription, this is a
common practise at least in some of the countries,
e.g., in Spain. In Finland, antibiotics can be obtained
only by a prescription. The national antibiotic policy
has been based on therapeutic guidelines and analysis
of their implementation [13,14]. Finns as consumers
are used to a strict policy with access to and use of
antibiotics.
It is estimated that approximately 15,000 Finns
have permanently moved to Spain for health or some
other reasons. The population of Finnish immigrants
in Spain provides a good opportunity to study whether
the antibiotic usage patterns change when people move
to a country where it is a common practise for pharmacists to dispense antibiotics without a prescription
[15]. Although comparative studies of antibiotics consumption in different countries have been conducted
[4,16], these studies do not include information about
the self-medication with antibiotics. This kind of information would be extremely valuable, in particular when
implementing programs aiming at more rational use of
antibiotics, e.g., within EU. The aim of this study was
to determine the frequency of self-medication of antibiotics among Finnish adult population living in southern
Spain.

2. Materials and methods

2.1. Study population
This study is a part of a larger health and drug use
study carried out among Finns living in southern Spain,
Costa del Sol region. The age of this population varies
between 21 and 99 years (mean age 65 years) and the
time of residency in Spain between 1 and 49 years
(mean 8 years).

167

2.2. Data collection

The data were collected in Spring 2002 by using a
questionnaire to a convenience sample of Finns living
in Costa del Sol region. This 12-paged questionnaire
was distributed in two ways: half (500) of the questionnaires were dispensed with Finnish newspapers by
mail and the other half through Finnish associations
and outlets working in southern Spain. These associations (e.g., churches, cafes, restaurants, communities)
were instructed to deliver the questionnaires to people using their services. Participants were limited to
Finnish adults living permanently in Spain. It is possible that the same people received more than one questionnaire. A total of 533 questionnaires out of 1000 disseminated (53%) were returned. Three were excluded
because they were incomplete. Approximately, 34%
of the Finnish population living in Spain participated
in the study.
2.3. Questionnaire
The population was divided into antibiotic users
and non-users by asking Have you used antibiotics
during the previous 6 months? Those who answered
yes to this question were defined as users and continued answering the more specific questions about
their antibiotic use. Non-users did not answer the
antibiotic questions. The purpose of this categorisation was to ascertain the validity and minimise the
incidence of memory bias in questions about antibiotic use. Antibiotic users were asked whether they had
bought antibiotics by general practitioners prescription (prescription-antibiotics) or without prescription
(OTC). Those who had used both prescription and
OTC-antibiotics were categorised as non-prescription
antibiotic users.
The number of antibiotic prescriptions taken and
the name of the utilized products (whether remembered) were asked. The reasons behind the antibiotic use were asked by giving a list of the possible
indications. The last alternative was any other reasons respondents were instructed to specify. To gather
some information about the effectiveness of antibiotics, the users were asked whether the first antibiotic course relieved their symptoms. They were also
asked how many courses they had to take before
healing.

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M.H. Vaa nanen et al. / Health Policy 77 (2006) 166171

The occurrence of adverse reactions was determined

by giving a list of the possible adverse reactions the
respondents had experienced. The list included adverse
reactions known as usual for antibiotics and the last
alternative was any other adverse reaction the respondents were asked to specify.
Factors associated with antibiotic use were identified by asking questions about demographic and socioeconomic factors: sex, age, marital status, working
situation and smoking. In the analysis, the working situation was reclassified so that the pensioners and partial
pensioners were grouped together.
Two types of questions were asked to determine
health status of respondents. Respondents were asked
to categorize their health status as good, moderate or
poor. They were also asked whether they had suffered
from chronic morbidity.
The data were analysed with SPSS version 11.5 (statistical package for social sciences). Cross-tabulation
was used to compare differences between subgroups.
To examine the factors related to antibiotic use, statistical comparison was implemented by using logistic
regression analysis.

3. Results
3.1. Antibiotic use
Antibiotics were used by 28% (n = 145) of the
respondents during the 6 months period before the

query (Table 1). Almost one-third (31%) of the antibiotic users had bought their antibiotics without a prescription, and 10% reported concomitant use of prescription and non-prescription antibiotics. This means
that altogether 41% of the antibiotic users were using
antibiotics as self-medication.
Most of the antibiotic users (64%, n = 93) reported
the use of one course of antibiotics during the previous 6 months. Thirty percent had taken two or three
courses, and 6% had consumed four or more courses.
Statistical differences in the amount of courses could
not be found between prescription and non-prescription
antibiotic users. The first course was perceived to be
effective by 69% of the antibiotic users. About one-fifth
had used two or three courses and almost 10% four or
more courses before self reported recovery. Statistical
differences in the amount of courses could not be found
between prescription and non-prescription antibiotics.
Clearly the most common reason for antibiotic use
was the common cold (45% of the antibiotic users),
followed by sore throat (17%), bronchitis (10%), urinary track infection (10%) and dental infection (8%).
Self-medication was common for all the medical purposes listed in the questionnaire, the proportion being
the highest among those suffering from sinuitis, sore
throat and common cold (Fig. 1).
Antibiotics caused adverse reactions in 17% of the
users. The most common self-reported adverse reactions were stomach ache/diarrhoea (5%) and dermatological problems (4%). Statistical differences in the
prevalence of adverse reactions could not be found

Table 1
Characteristics of antibiotic use (% of those indicating use of antibiotics during 6 months before the query)
Respondents (n = 530)

Antibiotic users (n = 145)

Rx (%)

OTC (%)a

Total (%)

Use of antibiotics during the previous 6 months

Yes
28
145
No
72
380

59

41

100

Number of courses taken

1
23
4 or more

18
8
2

93
43
9

60
31
8

67
29
2

64
30
6

Adverse reactions
Yes
No

5
23

25
120

20
80

14
86

17
83

Rx = prescription; OTC = non-prescription.

a Also includes concomitant users of prescription and non-prescription antibiotics.

M.H. Vaa nanen et al. / Health Policy 77 (2006) 166171

169

between prescription and non-prescription antibiotic

users.
3.2. Factors related to antibiotic use

Fig. 1. Self-reported symptoms for antibiotic use (% of the antibiotic

users).

Chronic morbidity affected antibiotic use (p < 0.05)

(Table 2). No statistical differences in the amount of
antibiotic users could be found between gender, age,
marital status, working situation, self-reported health
or smoking.
According to background variables statistical differences could not be found between those who
had used prescription or non-prescription antibiotics.

Table 2
The factors related to the antibiotic use
%

Adjusted prevalence
ratios (95% CI)

Gender
Male
Female

28
27

1.00
0.939 (0.631.39)

NS

Age
Under 45
4554
5564
6574
Over 75

15
36
30
26
23

1.00
3.228 (0.63316.469)
2.446 (0.52311.433)
1.878 (0.4018.781)
1.549 (0.3027.951)

NS

Marital status
Unmarried
Cohabitation without marriage
Married
Divorced
Widowed

19
33
25
41
28

1.00
2.00 (0.577.04)
1.33 (0.414.32)
2.79 (0.7710.10)
1.60 (0.426.10)

NS

Working situation
Working
Pensioner
Other

22
28
35

1.00
1.40 (0.593.34)
1.83 (0.675.05)

NS

40

NS
0.64 (0.291.41)

Self-reported health
Poor
Fair
Good

23

1.00
30
0.45 (0.201.02)

Chronic morbidity
No
Yes

16
32

1.00
2.56 (1.554.23)

0.002

Smoking
No
Yes

26
34

1.00
1.255 (0.692.29)

NS

NS = non-significant. The logistic regression model analysis for antibiotic use.

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M.H. Vaa nanen et al. / Health Policy 77 (2006) 166171

Those who used non-prescription antibiotics parallel

with prescription analgesics, more often reported the
usage of more than one course of antibiotics before
recovering than those who had used non-prescription
or prescription-antibiotic separately. The number of
antibiotic courses needed was not connected to age,
gender, marital status, working situation, educational
background, smoking or the number of adverse reactions (p > 0.05). No connection could be found with
the factors measuring the respondents state of health,
such as the reported state of health and chronic diseases
(p > 0.05).

4. Discussion
Our data suggest that self-medication with antibiotics is common among Finns living in southern Spain.
Our data also suggest that there may be a lot of
unnecessary use of antibiotics, especially for common
cold and sore throat. This may indicate that Spanish health care system, including community pharmacies are failing their task in enhancing rational use of
medicines.
Our findings may indicate that traditions in health
services and their control play a crucial role in
actually assuring rational use of medicines. Common
self-medication with antibiotics in Spain might be a
consequence of poor implementation of and control
over the laws and regulations influencing prescribing,
and even more, influencing community pharmacy
services. Finns are not used to buy antibiotics without
a general practitioners prescription in Finland, but
in Spain the pharmacy system makes it possible. Our
study revealed, that the antibiotic use habits of the Finns
totally change when they move from strictly regulated
country to another, where buying the non-prescription
antibiotics is common. When comparing the results of
our study to the previous study done in Finland [17],
we find that antibiotic usage is only slightly higher
among Finns living in Spain (23% versus 28%), but
the indications for antibiotic use have become more or
less debatable. So, could the society stricter control on
antibiotic use be an answer to decrease inappropriate
antibiotic use? The pharmacy personnel should be
given clear instructions how to manage with patients
who feel the need of antibiotics, at least antibiotics
should not be the number one treatment for common

cold or sore throat. However, in many countries

pharmacies have become more and more business orientated and selling drugs has become the focus point of
the business in expense of the evidence-based practice.
The inappropriate use of antibiotics might as well be
a consequence of the behaviour of general practitioners
and promotional efforts of drug industry. People have
great expectations for antibiotics; they are supposed
to cure almost any illnesses [18]. The lack of time
and the patients high expectations of having antibiotics often push the general practitioner to prescribing,
despite a clear indication [19,20]. However, it is better
for the patients to show their symptoms to the qualified physicians than to buy them from the pharmacy
directly after the symptoms start occurring. The threshold for going to a physician is so high that people rarely
do that for minor symptoms and most of the antibiotics prescriptions are only given after the diagnosis
has been verified. It has been shown before, that educating general practitioners can reduce inappropriate
antibiotic use [4]. Though antibiotic use and prescribing might have decreased due to practitioners education
programme, the problem of self-medication still exists.
To achieve a significant decrease in antibiotic use, we
also need to design programmes for the lay people.
Programmes should be carefully designed, understandable and they should make public aware of the negative
effects of antibiotic use, especially in self-medication.
Antibiotic use studies have become important
mostly to prevent antibiotic resistance from expanding. Earlier work on antibiotic consumption has given
us reliable information about the connection of antibiotic use and the resistance rates. We had the possibility
to focus on studying antibiotic use in higher resistance
rate area, in southern Spain [7]. There are some limitations in our study: the possibility of bias due to the lack
of sample randomisation must be taken into consideration. It would have been more practical and accurate
to collect the data by sending the questionnaires by
mail to a randomised population, but we found that
impossible because of lack of any address registers of
the Finnish people living in southern Spain. On the
other hand, the results of our study can only be generalised to the Finnish immigrants living in southern
Spain, even though the total change in antibiotic usage
patterns among Finns might tell us something about the
effect of different regulation systems in medication use
in general.

M.H. Vaa nanen et al. / Health Policy 77 (2006) 166171

In conclusion, almost a third of our population had

used antibiotics during the previous 6 months. We
found that in almost 40% of the cases antibiotic use
was more or less inappropriate. Therefore, we find it
highly recommendable to invest in an expansive antibiotic education programme about the possible risks of
an inappropriate use of antibiotics directed towards
the lay people. Educating health care professionals is
not enough while the patients still have the possibility of making their own decisions as to whether use
antibiotics or not. It is important that all the member
countries within EU will take their responsibility in
promoting public health goals in their national policy,
e.g., in minimising the antibiotic resistance for expanding by requiring that antibiotics be available only by
prescription.

Acknowledgement
This study was supported by a grant from the Finnish
Pharmacy Association.

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