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Encouraging Self-Care in a Primary Care Setting

Families and individuals take an important responsibility for their own healthcare. The extent to which they do this depends on the knowledge available within the family and social network. In the years before the introduction of the National Health Service, the extended family contained people with the knowledge to handle many acute conditions and most childhood diseases at home. Until the 1850s, any outside health care advice for ordinary people would have come from an apothecary. Gradually, around the turn of the century, specialist pharmacists became more widespread in the community. These community pharmacists made up prescriptions, and would help and advise with appropriate non-prescription treatment. Only after exhausting this route, with no improvement in symptoms, would a doctor be consulted. The individual and family delivered most care at home without medical intervention.

The NHS, while generally improving health care in the UK, has heavily reinforced the doctor's role in treatment. The NHS and the media have encouraged this trend. This has undermined people's confidence in their ability to care for many of their own health problems. But now there are many proven and effective treatments available over the counter in pharmacies without prescription. The advent of well-advertised advances in some medical specialities has also contributed to people losing the confidence to treat their common everyday ailments at home.

In the last two years however, the Government has introduced several initiatives aimed at rebuilding the self-care skills within the family. The NHS White Paper 'The new NHS - Modern, Dependable' specifically states that this means providing 'easier and faster advice, and information for people about health, illness and the NHS so that they are better able to care for themselves and their families: The public health White Paper 'Saving Lives' puts the focus on a 'Healthy Citizens' programme. This includes three elements. The first provides information for people to act on at home supported by self-care booklets, and NHS Direct by telephone and on-line. The second teaches children in school to look after their own health and common ailments and trains them in resuscitation techniques. The third develops the self-care management skills of people with chronic medical conditions.

These initiatives need to be examined within the context of current public attitudes and behaviour. Success will need the public to gain access to reliable health information when and where they need it. One of the main sources of reputable self-care information is PAGB, the trade association representing manufacturers of OTC medicines and food supplements.

Everyday Healthcare

In 1996, the British Market Research Bureau International was independently commissioned by PAGB to assess consumer attitudes and behaviour with regard to health in general and minor ill-health in particular. In the year-long study (1), 2000 consumers were interviewed face to face in their homes. They were specifically asked about the minor ailments they had suffered, what they had done about them and why. 58% of adults said they had consulted their family doctor in the last twelve months for minor/common ailments.

Tiredness 40
Headache 33
Muscle aches/pains 29
Sleeping problems 23
Stiffness in joints 22
Back problems 20
Bruises 17
Stress/anxiety 17
Feeling low/depressed 16
Minor cuts and grazes 16
Colds 14
Arthritis 14
Acne 12
Hangover 12

Adults in the study suffered an average of 5.2 ailments in the two weeks prior to the study. Women reported more problems than men, (5.7 and 4.8 respectively). Teenagers (15-19 year-olds) reported an average of 6.2 ailments and those aged 65 and over an average of 4.6 ailments.

91% of respondents reported suffering from at least one sort of ailment. The most commonly reported ailments are listed to the right:

There is clearly a great deal of minor ill health in the community. Dealing with these ailments is a significant problem not only for the individual suffering symptoms but also for those providing and funding health care services.

 

Based on the findings of this study, the most common response to minor ailments is to do nothing - the 'wait and see' approach. The next most common response is to use an over-the-counter (OTC) medicine. The third is to use a prescription medicine already in the home, prescribed for chronic or recurring ailments. A visit to the doctor was fourth.

Used nothing
46%
Used prescription medicine already in home
14%
Saw doctor/dentist
10%
Used OTC medicine
25%
Used 'home remedy'
9%

The study also asked whether people were consulting health professionals other than their doctor. In only 1% of ailments was a pharmacist's advice sought; 1% of ailments were taken to a nurse or health visitor and 2% were taken to some other health professional:

 

It is important in a debate around self-care and self-medication to look very carefully at the amount of minor illnesses presented at a doctor's surgery and assess the implications of such healthcare behaviour. The BMRB study demonstrated that 10% of minor ailments are taken to the doctor. This equates to 8% of the population visiting their doctor per year, or a minimum of 96 million GP consultations a year. But what happens as a result of these consultations? Almost two thirds of the consultations conclude in a prescription being written. An OTC recommendation was made in only 5% of cases.

BMRB calculated that consultations concluded in a prescription seven times more frequently than an OTC recommendation. These data beg the questions, 'Why are people going to the GP with minor conditions?' and 'Why are GPs writing prescriptions for minor conditions?'

Prescription 65%
Do nothing/come back if no improvement 17%
Other general advice 14%
Referred elsewhere 13%
OTC recommended 5%
Advice about diet 3%

The BMRB study shows that in the vast majority of cases, people know the ailments they are experiencing and what to do about them.

People will appropriately self-medicate when they are familiar with the circumstances, they have used the OTC medicine successfully before and it is available at home.

It can be seen from the tables below that viral infections and hayfever are the minor ailments most likely to be taken to the doctor.

  This table shows all the actions that people say they take when they have a minor ailment.
Headache
16
55
17
Athlete's foot
28
34
33
Lip problems
26
37
26
Migraine
11
41
28
Period pains
33
33
16
Common cold
36
32
23
Flu
12
35
24
Sore throat
27
25
21
Indigestion
19
30
17
Acne/pimples/spots
50
26
16
Hangover
52
30
3
Hayfever
35
13
21
Cough
42
21
12
 
Headache
3
15
1
3
Athlete's foot
3
8
1
3
Lip problems
2
8
5
3
Migraine
9
32
2
3
Period pains
2
8
0
20
Common cold
7
9
4
12
Flu
34
13
6
13
Sore throat
18
11
1
5
Indigestion
10
26
1
12
Acne/pimples/spots
4
8
2
4
Hangover
0
5
-
13
Hayfever
7
30
3
1
Cough
11
20
3
3

Qualitative research through focus groups (2), conducted in 1994, revealed that people's perceptions of OTC treatment are mainly formed by their experience of analgesics and cold remedies. They do not understand how the medicines work, nor do they know the normal progression of a cold or viral illness. They are often confused about whether they have a cold or flu. They worry about masking symptoms of an underlying disease or of becoming addicted to the medicine. They are concerned that if they use OTCs then the medicine will not work when they really need it, that it will lose its potency. They think that OTC medicines relieve symptoms and do not cure and that only the doctor has the 'cure' for all these reasons, people try to minimise their use of medicines. However, if symptoms are 'persisting' - which they define as lasting for between four and seven days (typically seven for a cold) - they believe that they must consult the doctor.

People's expectations at this point shift entirely to the GP and the 'cure: However, the 4-7 day period for self-medication is often too short for a GP to differentiate between self-limiting ailments and serious disease. In most cases, the GP would expect people to try self-medication for about two weeks before presenting at the surgery.

The BMRB study shows that consumers believe the pharmacist is a good source of advice (86%), that people should ask the pharmacist rather than the doctor (61%) and that it is more convenient to ask the pharmacist (56%).

The study also shows:

  • that consumers think it is important to have OTC medicines for minor problems (79%)
  • that the medicines you can buy are just as effective as those from the doctor (67%)
  • that 86% said they would again buy the same OTC medicine they had previously used.

Nevertheless, the doctor is still the place they go for reassurance, and the expectation of a 'cure'.

In a number of GP focus groups, conducted by McMaster Cawte in 1994 (3), GPs acknowledged the importance of treating minor ailments through self-medication. They assumed that by the time the patient approached their doctor they had exhausted all efforts to deal with the symptoms in this way. This was explored further in the study conducted by Bradley et al in 1996, 'Attitudes and Behaviour of Doctors and Patients with regard to Over-The-Counter Medicines' (4). In this study, conducted in six practices and with a patient sample of 2,324 patient responses, Bradley et al found that patients view a GP recommendation of OTC medication more positively than the GPs making the recommendations think they do.

An indication for change comes from the results of the Bradley et al study. The study found that GPs were very conservative, cautious and even reticent in making OTC recommendations. They would often write a prescription in addition to making an OTC recommendation to avoid upsetting the patient.

The majority of the patients, on the other hand, either said that the GP should routinely ask about prior OTC use (51.6%) or that it would be a good idea sometimes (16.2%). On their GPs making an OTC recommendation, again the majority of patients either said that the GP should do this routinely (16.8%) or that it would be a good idea (44.3%). Only 5.6% said they would be upset by their GP recommending an OTC.

If the GP made an OTC recommendation, 54.1% of patients said they would automatically follow this, 29.5% said they would seek advice from the pharmacist, 2.5% said they would ask a relative or friend and 13.9% said they would decide for themselves. This demonstrates a high level of patient acceptance of GPs making OTC recommendations.

The above research supports the proposal that the GP consultation should include the following:

  • Ask whether self-medication has already been tried and the product taken
  • Ask the dosage and duration of prior self-medication that was attempted
  • Consider providing a leaflet and/or an OTC recommendation

The direct benefits for the GP of a more detailed consideration of self-medication are:

  1. The patient will be confident that the full history of the condition has been discussed and any potential embarrassment over using a 'non-doctor' product removed.
  2. The correct use of OTC medications can disseminated. Therefore a longer duration of use or a more appropriate OTC medication may be recommended and any misunderstanding to its use and effects be corrected.
  3. A recommendation for an OTC medicine becomes a real option in the consultation.
  4. The kind of sharing of knowledge and understanding in the consultation promotes deeper and more effective patient-doctor relationship.

A shift in this direction might allow the patient-doctor relationship to move to a more adult-to-adult footing.

References: (1) BMRB Everyday Healthcare Study of Self-medication in Great Britain, October 1997 (2) The HPI Research Group OTC Medicines and Consumers, May 1994 (3) McMaster Cawte Associates, OTC recommendation by GPs, April 1994 (4) Bradley CP, Riaz A, Tobias RS, Kenkre JE and Dassu D, Pati, Patient attitudes to over-the-counter drugs and possible professional responses to self-medication. Family Practice 1998; 44-50

 

 
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Copyright PAGB (Proprietary Association of Great Britain) - 2003 - All Rights Reserved. PAGB has made every effort to ensure the information contained in this site is as accurate and up to date as possible. However you should always read the label before you take a medicine for the first time as it is important that medicines are used correctly and according to the instructions. All OTC medicines are effective and safe when used properly. None of the information given in this directory should be construed to be advice or recommendation of a particular medicine. PAGB cannot accept responsibility for errors or omissions.