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Access to care and medication use among the ambulatory elderly in Rio de Janeiro, Brazil

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Access to care and medication use among the ambulatory elderly in Rio de Janeiro, Brazil
Creator:
Miralles, Maria Andrea
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English
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x, 245 leaves : ill. ; 29 cm.

Subjects

Subjects / Keywords:
Drug prescriptions ( jstor )
Health care industry ( jstor )
Health care services ( jstor )
Medications ( jstor )
Older adults ( jstor )
Patient care ( jstor )
Pharmacies ( jstor )
Pharmacists ( jstor )
Physicians ( jstor )
Symptomatology ( jstor )
Drug Therapy -- Aged -- Brazil ( mesh )
Health Services Accessibility -- Brazil ( mesh )
Patient Compliance -- Aged -- Brazil ( mesh )
Self Medication -- Aged -- Brazil ( mesh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1992.
Bibliography:
Includes bibliographical references (leaves 232-244).
General Note:
Typescript.
General Note:
Vita.
Statement of Responsibility:
by Maria Andrea Miralles.

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ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL















By


MARIA ANDREA MIRALLES


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


1992














To

Naly G.













ACKNOWLEDGEMENTS

Several individuals and institutions are responsible

for the successful completion of this project. This project

would not have been possible without the support of the

Institute of Social Medicine at the State University of Rio

de Janeiro (IMS/UERJ). A special debt of gratitude is owed

to Dr. Renato P. Veras, coordinator of the Brazilian Old Age

Survey (BOAS), the first comprehensive survey of physical

and mental health of the Brazilian elderly, for his

generosity and encouragement. The present project on

medication use in the elderly was able to take advantage of

the extensive preliminary work of the BOAS team of

identifying the sample and training interviewers.

Especially appreciated are the efforts of Sidney Dutra

Silva, field coordinator on both projects. The continuity

provided by this was of immeasurable benefit.

Also at IMS/UERJ, special thanks are extended to Gerson

Noronha Filho, M.D., Ph.D., Director of the Department of

Planning, Antonio Cesar Lemme, M.D., and other members of

the Study Group on Quality of Care and Patient Satisfaction.

The receptivity and vitality of this group provided for a

stimulating intellectual exchange of ideas and research

experiences.







Many thanks are extended to the interviewers: Nelson

Lopes de Azevedo, Ana Lucia Barbosa, Marcelo Bessa, Marco

Aurdlio P. Carvalho, Vanderlei R. de Carvalho, Liane

Esteves, Edmeire 0. Exaltagdo, Angelica Fonseca, Ver6nica

Hamilton, Herminia Helena da Silva, Marta Cristina Nogueira,

Cristina A. M. Souza, and Eduardo Vilarin. Also, for help

with drug coding and data entry checking, thanks to Ligia M.

Soares, M.D., and Alexei Soares.

The elderly participants in this study who graciously

opened their doors to be interviewed provided a powerful

stimulus to completing the project, especially when train

trips and bus rides seemed tedious and interminable, and the

days too hot and dusty, or too hot and humid. Their

expressed interest in the subject and willingness to share

their thoughts and experiences, sometimes for hours at a

time, was extremely rewarding. In particular, there will

always be a special place in my heart for Dona Maria, Senhor

Ary, Dona Olinda, Dona Engragada, and Senhor Antonio.

An important source of professional and moral support

for this project was the Conselho Federal de Farmdcia, the

Brazilian national professional pharmacy association. I am

deeply grateful and honored to have had the opportunity to

participate in some very exciting discussions regarding the

future of community pharmacy practice in Brazil. For this,

I thank Luiz Italo Niero, Thiers Ferreira, M. Cristina F.

Rodrigues, Vicente T. de Araujo Junior, and other directors







of the various regional offices. I hope that this project

will help to guide the Conselho in its efforts to meet the

difficult challenges ahead.

For keeping their doors open, permitting countless

hours of extemporaneous teaching, special recognition is

extended to Dr. Charles H. Wood, sociologist/demographer,

Dr. Otto Von Mering, Director of the Center for

Gerontological Studies, Richard A. Angorn, J.D., R.Ph., and

Paul Doering, M.S.P., Director of the Drug Information

Center, at the University of Florida, and to Dr. Howard Eng,

at the University of Arizona, Health Sciences Center.

Through gestation to conclusion, this project was met

with encouragement and support from all of the faculty,

staff, and fellow students of the Department of Pharmacy

Health Care Administration at the University of Florida,

especially committee members Drs. Carole L. Kimberlin,

Charles D. Helper, and Donna Berardo. A great debt of

gratitude is due to Dr. Kimberlin. An exceptional mentor,

her unwavering patience, willingness to explore new ideas,

and high principles are to be emulated.

Finally, thanks to my husband, Glducio Ary Dill6n

Soares, friend and companheiro for more than a decade.














TABLE OF CONTENTS


page

ACKNOWLEDGEMENTS ...................................... iii

ABSTRACT .............................................. viii

CHAPTERS

1 MEDICATION USE AND THE ELDERLY IN BRAZIL........ 1

Introduction.................... ..................... 1
Background: Medication Use in the Third World... 5
The Political and Economic-Infrastructural
Context...................................... ..... 6
The Social and Cultural Context.................. 10
Theoretical Framework ............................ 13
Health Services Utilization and Medication
Use......................................... ...... 13
Conceptualizing Access to Care................... 16
Access to Care and Medication Use.............. 20
Research Questions ............................... 23
Significance........................................ 24
Summary.......................................... ...... 28

2 MEDICAL AND PHARMACY SERVICES IN BRAZIL.......... 31

Health Care in Brazil ........................... 31
The Public Sector ............................. 32
The Private Sector ............................ 38
Health Services Utilization in Rio de Janeiro.... 41
The Pharmaceutical Industry in Brazil............. 46
The Private Sector ............................ 48
The Public Sector ............................. 51
Economic and Social Aspects of Drug Use........... 55
Pharmacies and Drugstores ........................ 58
Pharmacy Practice and Self-Medication............. 63
Conclusion.......................................... 65

3 METHODOLOGY ..................................... .. 65

Building a Medication Use Model for Brazil...... 65
Predisposing Variables ........................ 66
Enabling Variables ............................ 72
Need Variables................................. .. 75
Use Variables.................................. .. 77









Area .......................................... 78
Instrument Development........................... 78
Item Selection ................................ 78
Interviewer Training and Instrument Pilot..... 80
The Sample...................................... 83
Study Areas..................................... 86
Copacabana.................................... 86
Meier......................................... 89
Santa Cruz.................................... 89
Analysis Strategy................................ 91
Summary......................................... 92

4 RESULTS......................................... 94

Sample Characteristics........................... 94
Descriptive Results.............................. 97
Health Status.................................. 97
Medical and Medical Expenses................. 101
The Role of the Physician..................... 104
The Role of the Pharmacy...................... 108
The Role of the Pharmacist.................... 114
Medication Use................................. 119
Measures ........................................ 124
Access Measures............................... 125
Attitude Measures............................. 130
Correlates of Medication Use..................... 131
Modeling Medication Use.......................... 137
Prescription Medication Use.................. 137
Non-Physician Prescribed Medication Use...... 140
Correlates of Medication Use for Areas.......... 142
Modeling Medication Use for Areas............... 149
Prescription Medication Use for Areas........ 149
Non-Physician Prescribed Medication for
Areas .................................... 151
Summary......................................... 154

5 DISCUSSION AND CONCLUSION........................ 156

Medication Use Among the Brazilian Elderly..... 156
Health Services Utilization and Medication
Use......................................... 161
Patient Population Characterisitcs
and Medication Use......................... 162
Access to Care and Medication Use........... 164
Limitations...................................... 166
Policy Implications............................. 170
Health Care and Medication Use among the
Elderly................................... 173
Pharmacy Health Care......................... 177
Conclusion..................................... 181


vii









APPENDICES

A ITEM SELECTION CANDIDATES ...................... 184

B INSTRUMENT ............ .......................... .. 198

C LETTER OF INTRODUCTION TO STUDY PARTICIPANTS... 223

D ACCESS TO CARE AND ATTITUDE MEASURES............ 225

REFERENCES ............................................ 232

BIOGRAPHICAL SKETCH ................................... 245


viii













Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL

By

Maria Andrea Miralles

August, 1992

Chairman: Carole L. Kimberlin, Ph.D.
Major Department: Pharmacy Health Care Administration

This study examines physician and non-physician

prescribed medication use of an increasingly important

segment of Brazilian society--the elderly. The elderly are

a rapidly growing segment in many developing countries,

including Brazil. Although the hazards associated with

medication use in the elderly have been well documented in

several developed countries, little is known about geriatric

drug use in the developing countries.

Medication use was modeled as a function of individual

and community level factors in the Municipio of Rio de

Janeiro, Brazil. The variables examined are based on a

behavioral model for health services utilization adapted to

medication use in the Brazilian context. Variables include

predisposing sociodemographic characteristics, enabling

variables reflecting aspects of access to care, and need for








care variables. Access to care was analyzed according to

the dimensions of perceived availability, affordability, and

acceptability of medical and pharmacy services. The

importance of these variables and their interrelationships

were examined for elderly residents in three socioeconomic

areas of Rio de Janeiro (N=436).

The rate of prescribed medication use in the sample was

found to approximate that of elderly populations in the

developing world, but self-medication was not as prevalent

as expected. Need variables were the most important

predictors of use in all areas. Age, gender, and income

were the most important predisposing variables in predicting

prescribed drug use. Household size and attitudes towards

lay advice about drugs were significant predictors of self-

medication.

Access to pharmacy services was not a significant

factor in predicting medication use. Although access to

medical care was not significant in predicting self-

medication, acceptability of medical services was the most

important access variable explaining prescribed drug use.

However, separate area analysis revealed that access to care

was not relevant for either prescribed or nonprescribed

medication use in the high SES area, and different

dimensions were important for each area. The value of

smaller area studies in understanding medication use is

borne out. Directions for further research and the role of

the pharmacy practice in Brazil are discussed.














CHAPTER 1
MEDICATION USE AND THE ELDERLY IN BRAZIL


Introduction

Medications play a significant, albeit somewhat

insidious, role in both the preventative and curative

spheres of health care: "properly" used, they may save lives

and contribute to an improved quality of life; misuse or

abuse, however, is associated with increased costs of care

and decreased quality of life. It is because of these

characteristics that the demand for modern medicines, their

availability, and their proper use are of global concern

(WHO, 1980).

The central issues of medication use in most developing

countries revolve around two related concerns about access

to medicines: the scarcity of "essential medicines"

(restricted access), and the popular use of a broad spectrum

of legend and non-legend medications outside the purview of

medical supervision (unsupervised access). In particular,

self-medication, the use of medicines without the

recommendation or guidance of a qualified health care

professional, often extends beyond the use of non-legend,

over-the-counter medications (OTCs) to include many legend

drugs that are designed to be taken under medical supervision.









The unsupervised access to medications is an indicator

of a larger set of factors that includes access to medical

and pharmacy services, as well as alternative sources of

medications. The receipt of a physician's prescription

implies access to medical services, whereas the relationship

is not so straightforward with self-medication. The

purchase of pharmaceuticals, with or without a prescription,

is dependent upon access to a commercial source of

medications, directly through pharmacies or drug peddlers,

or indirectly through another party.

The relationship between access to medical services,

commercial and alternative sources of medications, and

medication use is a crucial issue in many developing

countries (Van der Geest and Hardon, 1990). Where there are

significant barriers to medical care, pharmacies may

represent a significant alternative health care resource.

However, for the same reasons, the ill-prepared or

irresponsible pharmacy may pose a serious potential health

threat through the promotion of inappropriate self-

medication with potent pharmaceuticals.

The primary goal of this study was to examine physician

and non-physician prescribed medication use of an

increasingly important segment of Brazilian society--the

elderly. The populations typically targeted as being at

high risk for hazardous self-medication in developing

countries are pregnant women and young children. However,









the elderly are a rapidly growing segment of many Third

World populations, including Brazil (Kinsella, 1988; Ramos

et al., 1987). The hazards associated with the use of

medications (prescribed and non-prescribed) in the elderly

have been well documented in several developed countries

(Beadsley, 1988; Chapron, 1988; Johnson and Pope, 1983;

Moore and Teal, 1985; Simonson, 1984). However, little is

known about geriatric drug use in the "aging" developing

countries.

In this investigation, medication use was modeled as a

function of various individual and community level factors

which were related to access to medical and pharmacy

services in the Municipio (county) of Rio de Janeiro,

Brazil. Self-medication was defined as the use of a

pharmaceutical or other medicinal product (including home

remedies) not prescribed or recommended by a physician for

the patient. The variables examined in the model are based

on the Andersen and Newman (1973) behavioral model for

health services utilization (HSU) and adapted to medication

use in the Brazilian context. Variables include

predisposing sociodemographic characteristics, enabling

variables reflecting aspects of access to care, and need for

care variables.

In this study, access to medical and pharmacy services

are analyzed according to their component dimensions of

perceived availability, perceived affordability, and the









sociocultural acceptability of services. Typically, access

to services is evaluated with secondary data and use

indicators such as the distribution or number of hospital

beds or physician offices as indices of the availability of

services. Similarly, the affordability of services is often

evaluated by measures such as regular source of care, income

and insurance status. However, the assumptions implicit in

these traditional measures fail to capture other dimensions

of access that may be of particular relevance to some

patient subgroups such as the elderly or patients with

particular illnesses. Given the special socioeconomic,

psychosocial, and health status considerations of the

elderly patient, an understanding of the patient's

perceptions of access to needed services may be useful in

understanding behavior. The relative importance of these

variables and their interrelationships were examined for

elderly residents in three socioeconomic areas of the

Municipio of Rio de Janeiro.

A secondary goal of this project was to begin to

describe medication use in the Brazilian elderly. Such a

description not only provides the foundation for future

evaluations of drug therapies, particularly of the extent of

inappropriateness or potential danger in self-medication,

but also allows for cross-cultural comparisons of geriatric

drug use.









Background:Medication Use in the Third World

Both the restricted access to essential medications and

the unsupervised access to legend medications in developing

countries have provoked a great deal of controversy world-

wide, at least since the 1970s (Silverman, 1976, 1977;

Melrose, 1982; Silverman et al., 1982, 1986; Landmann,

1982). Over-medication, under-medication, use of the wrong

drug, and unnecessary medication use are always important

considerations in promoting effective drug therapy anywhere,

anytime. However, these considerations acquire a greater

prominence in many developing countries, especially for the

case of self-medication.

Whereas in the more developed countries self-medication

may be considered a luxury, in many developing countries,

self-medication may be a necessity (Van de Geest and Hardon,

1990). The tendency to by-pass a physician's prescription

may be considered a necessary adaptation to a situation

characterized by an ineffective or non-functioning official

drug distribution system and the relative dearth of medical

personnel. The lack of control over the distribution and

use of medications gives multinational pharmaceutical

corporations greater latitude, especially for the marketing

of suspect medications, thereby exacerbating the already

precarious conditions for self-medication. The types of

medications made available to these populations, and the

undue expense of inappropriate treatment for impoverished









patients assigns a particularly ardent bent to the issue of

self-medication in the developing world.

A global perspective is imperative for an understanding

of the local economic-infrastructural and cultural context

of medication use. This necessarily includes an

appreciation of the role of the international pharmaceutical

industry in providing medications, and the role of retail

pharmacy in promoting pharmaceuticals as an accepted form of

therapy.

The Political and Economic-Infrastructural Context

The international pharmaceutical industry, unlike other

industries, faces a particular scrutiny because the products

involved are health products, many of which hold the balance

between life and death. Since the 1970s, industry behavior

has been severely criticized for failing to uphold the

mandate to responsibly provide pharmaceuticals, particularly

in the developing countries, with respect to questionable,

if not unethical, production and marketing practices. These

multinational corporations (MNCs) have been accused of

compromising their mandate in order to pursue the incentives

that drive any other industry "hungry for profits" (Ledogar,

1975).

The relationship between the international

pharmaceutical industry and developing countries has been

described as characterized by dependency (CEPAL, 1987;

Evans, 1979; Gereffi, 1983; Jenkins, 1984). This dependency









refers to the control by a small number of large

multinational corporations (MNCs) of the means of

production, research and development of most pharmaceuticals

throughout the world. The dependency perspective argues

that this control translates into political and economic

power which, in turn, may be used to manipulate domestic and

foreign policies of countries without a strong domestic

industry. Because they depend on MNCs to provide their

populations with needed medications, other national economic

and health interests may be compromised. On the other hand,

however, there can be no doubt that MNCs do play a vital,

positive role in meeting medication needs in situations

where no one else can do so. Many developing countries may

never be able to sustain a viable national pharmaceutical

industry and must rely on imported products, or products

produced by local MNC subsidiaries. From the industry's

perspective, the problems of providing "the right

medications at the right price" stem from public rather than

private sector inconsistencies and inadequacies (Peretz,

1983).

During the late 1950s and early 1960s, the

pharmaceutical industry world-wide experienced radical

changes in the research and development of new drugs. With

the introduction of expensive and time consuming clinical

trials and new laboratory techniques in drug development,

there was a decline in the rate of innovation, traditionally









the backbone to profits in the industry. This, together

with new regulatory restraints regarding the marketing of

pharmaceuticals (especially in the United States with the

passing of the 1962 Kefauver-Harris Amendment), encouraged

pharmaceutical firms to look to developing countries without

such rigid controls, either de facto or de jure, as

potential markets. This is particularly true for unapproved

new and old products (CEPAL, 1987:17-29).

The pharmaceutical industry typically creates a demand

for products through intensive drug promotion. Both the

real medical need and popular demand for modern medicines in

Third World countries can be easily exploited. Drug

promotion has been documented to include deceptive and

misleading practices which involve some form of

misinformation and/or error (Silverman, 1977; Silverman et

al., 1982, 1986). Errors of omission include neglecting to

mention potential adverse reactions and other warnings, and

errors of commission include listing inappropriate

indications for use and providing fictitious clinical data

on drug effectiveness and other forms of "statistical

malpractice" (Victora, 1982). Physicians, influenced by the

information presented to them, become "irrational"

prescribers (Melrose, 1982).

The capability to monitor the quality of products and

their marketing is generally beyond the means of many

developing countries. As such, government agencies must







9

rely on the good faith of the producers and distributors, at

least to maintain the standards of the countries of origin.

The dangers of relying on the industry to uphold such

standards is exemplified by the case of chloramphenicol, an

antibiotic widely dispensed in many developing countries

during the 1970s. In the United States, the indications for

chloramphenicol included only a few life-threatening

infections. Physicians were warned of the risk of inducing

aplastic anemia and other blood disorders with the use of

the drug. In Latin America, however, few warnings regarding

adverse reactions were provided, and indications included

many relatively trivial conditions, such as tonsillitis and

whooping cough (Silverman, 1976:13-150). The combination of

the dangers of the drug and the inappropriate conditions for

which it was being used was a lethal one for the populations

in Latin America.1

The high social and economic costs to many developing

countries of the production, distribution and promotional

practices of MNCs, in both the public and private sector,

prompted many countries to seek alternative means of

providing needed pharmaceuticals to their populations. In


I In 1977, after the publication of these findings,
the International Federation of Pharmaceutical Manufacturer's
Association (IFPMA) established standards for its members
regarding the provision of correct product information.
Despite concerns regarding the IFPMA's ability to enforce
itself, follow-up studies have indicated some improvement
(c.f., Silverman et al., 1982, 1986).









the 1970s, the notion of "rational drug systems" was

developed (WHO, 1975). Developing countries have been

encouraged, with the assistance of the World Health

Organization, to design national formularies that would

guide the public sector procurement of so-called "essential"

low-priced products considered appropriate for the

particular health needs of individual countries. Emphasis is

also placed on developing or expanding the role of the state

and local private pharmaceutical industries to produce these

products so as to break the cycle of dependency on MNCs (Von

Wartensleben, 1983).

The Social and Cultural Context

The relationship between the presence of a national

essential drugs formulary, physician prescribing, and self-

medication is not irrelevant. Because regulations regarding

the sale of legend medications are either very relaxed or

not well enforced in many situations, consumers can purchase

almost any medication without presenting a prescription from

a physician. Nonetheless, self-medication in many

developing countries appears to parallel the prescribing

habits of physicians, especially in the preference for brand

name products (cf., Hardon, 1987; Fergusen, 1981; Loyola,

1983; Logan, 1983). Drug merchants and consumers learn what

medications are prescribed for various conditions from

previous prescriptions (their own or others'), or drug

promotion literature and package inserts. In Brazil, for







11

example, lay individuals who make a hobby of collecting and

studying package inserts (bula) are called "bulistas".

Indeed, some researchers have suggested that, based on

existing international mortality data, there is no evidence

to date to support the claim that requiring a prescription

renders medication use any safer than self-medication

(Pelztman, 1987). Therefore, the concern regarding

irrational physician prescribing and developing national

formularies is necessarily extended to self-medication

practices.

Fergusen (1981) suggests that the medicalization of

illness, the definition and treatment of certain illnesses

as medical problems, is different in developing countries

than in the more developed countries and that this accounts

for differences in self-medication behavior. The way in

which modern pharmaceuticals are integrated into self-care

practices in these societies reveals a reliance on a type of

therapy which is based on the notion that the solution to

illness resides in the consumption of medications rather

than on the consult with a medical professional. The

"commerciogenisis" of pharmaceuticals has been described for

several developing countries (cf., Hardon, 1987; Greenhalgh,

1987; Igun, 1987; Logan, 1983), including Brazil (Tempordo,

1986).

In this schema, pharmacists often play a crucial role.

Pharmacies tend to have a less centralized distribution than









physician offices and hospitals and are, therefore,

relatively accessible (Knox, 1981). In various developing

country contexts, pharmacists and other pharmacy personnel,

whether formally trained or not, are often called upon to

play the role of a culture broker, interpreting and

mediating modern medicine and alternative or popular care

traditions (Woods, 1977; Press, 1969; Fergusen, 1983; Logan,

1983). Because of the relative accessibility of

pharmacists, in those societies where resources for medical

care compete with those for other pressing development

needs, pharmacies may represent an untapped resource by

health care planners in promoting informed self-medication.

Although the potential for pharmacists to serve as

primary providers and health care advocates in countries

like Brazil is apparently great, there are significant

barriers to overcome. Primarily, often, the vendor of

pharmaceuticals is not a pharmacist. Although the need for

a trained pharmacist in the community setting is open to

debate, some reorientation within the profession which re-

emphasizes professional responsibilities in the community

pharmacy is clearly required (Cunha, 1987). If a minimum

standard for trained, informed pharmacy assistance for

patients could be established and enforced, the abuses

arising from the precedence of commercial interests over

patient welfare may be curbed.









Theoretical Framework

Health Services Utilization and Medication Use

Medication use may be considered a subset of health

services utilization. However, there is an important

distinction between utilization of pharmaceuticals and

utilization of other health care services. Pharmaceuticals

are a market commodity, and many drugs are available to the

general public in a relatively uncontrolled environment.

Therefore, consumers are allowed greater leeway in terms of

personal decision-making about drug use than patients

seeking care in treatment facilities (Kloos et al.,

1986:670). Individuals may chose to self-medicate, to use

only prescribed medications, or to be "non-compliant" with a

physician's prescription. The latitude for action is

subject to certain constraints on access to care imposed by

various individual and local factors. These constraints may

include, for example, legal constraints, financial

limitations and other barriers to care, beliefs and

perceptions of health and illness, and access to alternative

sources for care.

A number of national and cross-national studies of

medication use have examined the bivariate relationships

between patient sociodemographic variables and medication

use in primarily Western societies in Europe and North

America (see review by Blum and Kreitman, 1981). Cross-

national medication use studies generally do not take into









account the various social, economic, and cultural

dimensions of access to care that are likely to influence

behavior differently in different places (Rabin, 1977).

In order to address some of these aspects of access to

care, some researchers have found it useful to incorporate a

multivariate approach to understanding medication behavior

in smaller populations. One such approach is based on the

health services utilization (HSU) model, originally

developed by Andersen and Newman (1973) and expanded by

colleagues (Aday and Shortell, 1988). The HSU model has

been widely used to analyze use of different kinds of

physician and hospital services by various populations,

including the elderly (Evashwick et al., 1984; Eve and

Friedsam, 1980; Wan and Soifer, 1974; Wolinsky, 1978;

Wolinsky et al., 1983; Wolinsky et al., 1989). Variations

of the health services utilization model have also been

applied to studying factors related to prescribed and non-

prescribed medication use for urban adult samples (Bush and

Osterweis, 1978; Segal and Goldstein, 1989), including the

urban elderly in particular (Stoller, 1988), and a rural

sample (Sharpe et al., 1985).

The HSU model focuses on the unique characteristics of

the population at risk, and the resources of the health care

system. The characteristics of the population at risk

include predisposing, enabling, and need variables.

Predisposing variables include social and demographic









characteristics, health care beliefs and attitudes.

Enabling variables typically encompass various measures of

access to services and are selected to identify potential

barriers to seeking care when care is needed. Need

variables describe the extent to which the individual feels

the need for a given service and is frequently measured by

actual or perceived morbidity. Resources include the

distribution, volume and organization of the health care

system. Utilization may be measured in terms of the type,

site and quantity of health services used, and the time

interval separating use or the frequency of services used.

The HSU behavioral model has become a significant

paradigm for studying the health and health care seeking

behavior, even of the elderly patient population (Wolinsky

et al., 1990). However, this is not to say that the model

is not without its limitations. In a review of the utility

of the application of the HSU model, Wolinsky and Arnold

(1988) point out that need variables are consistently the

most significant determinants of health services

utilization, and that the contribution of predisposing and

enabling characteristics are often insignificant.

Furthermore, the total amount of variance explained by the

model is usually minimal.

Often, studies employing the HSU paradigm are

constrained by the type of data available. Traditional

models that provide measures of existing services employ







16

measures of availability and cost of services as proxies for

access to care. Service characteristics (enabling

variables) typically include measures of hospital bed

supply, physician supply, and so on, for a given area.

While these are practical measures for many policy

development concerns, it has been suggested that they may

not be best suited for the elderly and that a more

psychosocial approach to conceptualizing and measuring these

constructs may be more appropriate for this population

(Wolinsky and Arnold, 1988; Wolinsky, et al., 1990). Such

an approach would acknowledge the role of other important

aspects of care seeking among the elderly, such as social

networks and other emotive aspects of illness behavior

(Stoller, 1988). Furthermore, there is an implicit

assumption of a close correspondence of "actual"

availability and cost of services with perceived

availability and cost. Such assumptions may not always be

valid, particularly under abnormal situations, as in the

case of illness and other physical and psychological

impairments. They also do not take into considerations the

availability of alternative sources of care .

Conceptualizing Access to Care

In its broadest sense, the health services utilization

model addresses the relationship between the accessibility

and use or non-use of health care services. As a general

model, it serves as a guide for the development of more







17

specific models of utilization for specific populations and

services. Indeed, access is a relative term which may be

conceptualized to acknowledge socioeconomic, cultural,

physical, psychological and organizational aspects of

access. At the very least, it incorporates the aspects of

the availability, affordability of health care, as well as

the acceptability, in terms of patient satisfaction and

trust, of care (Fosu, 1989).

Medical geographers are often concerned with access to

care in terms of physical distance. Spatial analytic

studies examine actual distance and the effects of distance

decay on service utilization. Spatially discrete

concentrations of health care services inevitably make

physical access an important issue in more rural developing

countries (Kroeger, 1983), as well as inner city areas

everywhere (Shannon et al., 1973; Kloos, 1986; Igun, 1987).

The underlying assumption in this approach is that physical

accessibility to services implies minimal time and cost

involved in travel, thereby releasing a greater proportion

of household income for expenditure on consumption and

making a greater amount of time available for other

activities.

Health care economists often operationally define

access to care to include the affordability of care in

addition to the availability of health care facilities.

Common indicators for affordability of care that have been







18

used in the United States include health insurance coverage

and family income. The assumption is that having health

insurance coverage or higher incomes enable a person to

receive services. Results have suggested that insurance

status, including public programs such as Medicaid, may have

reduced the financial barriers to care for poor patients

(Wan, 1982; Wolinsky et al., 1989).

Accessibility also implies the more qualitative aspects

of opportunity and choice in use so that physical distance

and price may not always be meaningful factors in and of

itself. The combined effect of perceived distance, the

perceived availability of transportation, costs, and

facility characteristics, has been found to affect health

care services utilization (Joseph and Reynolds, 1984; Knox,

1979). Indeed, distance may not be a relevant factor at all

for some groups of patients (von Mering et al., 1976), or it

may only be relative to all other available health care

alternatives or options (Gesler and Meade, 1988). Cross-

cultural studies confirm that greater utilization of health

care services correlates with higher socioeconomic status,

but only when such services operate on a fee-for-service

basis (Kleinman, 1980). Some studies indicate that lower

socioeconomic status patients are more likely than higher

status patients to utilize a greater number of health care

sectors (popular and professional), and a broader range of

health care practitioners so that increased income and









higher education may actually restrict rather than broaden

the patient's range of health care options (Low, 1981).

Perceived options in health care is also a reflection

of patient preference for, and expectations of, particular

services or treatment modalities. Attitudes towards medical

and pharmaceutical services, as well as alternative healing

strategies, are essentially historical in nature. They are

not only historical with respect to an individual's personal

experiences (so that elderly patients are likely to have

different views about medical care than younger patients),

but encompass a broader social and cultural experience.

The effect of the social distance between client and

professional on patient satisfaction with different forms of

health care has been researched by medical sociologists and

anthropologists for many years, in many situations in

various cultural and multicultural settings (c.f., Simmons,

1958; Koos, 1954, 1958; Clark, 1970; Low, 1983; Loyola,

1983). Patient dissatisfaction may arise from the conflict

between the social equalitarian ideology behind public

services (such as health care) and the realities of

socioeconomic inequalities and cultural conflicts regarding

the interpretation of appropriate therapies and outcomes.

The more overt examples of this interaction include the

reserved attitudes of ethnic enclaves toward "mainstream"

medical care for certain conditions and complaints, but not

others (Clark, 1970). Patients unsatisfied with a given









medical treatment may seek to supplement or substitute a

physician's treatment with the advice of another, more

"acceptable" health professional, or other alternative.

Along these lines, Loyola (1983), in her ethnography of

health care services utilization in the city of Nova Iguazu

(Rio de Janeiro), suggests that an individual's attitudes

towards health care alternatives are influenced not only by

the physical environment, but also by the social environment

in which the drama of health and illness takes place.

Through what Loyolla calls the "efeito do bairro," or,

neighborhood effect, attitudes toward services are shaped by

a kind of dialectic interaction between the relative and

absolute poverty (or wealth) of the community and the

internal and external social cohesion of the community.

Access to Care and Medication Use

Several studies have incorporated some aspects of the

HSU framework for examining different kinds of medication

use (for a review see Sharpe et al., 1985). However, few of

these have incorporated measures of perceived access to

care. Bush and Osterweis (1978) included in their model of

medication use behavior for American adults in Baltimore a

measure for perceived availability of care. Although

measured by only one item on a four point ordinal scale, the

results indicate that the more people perceived care as

available, the more likely they were to use a prescribed

medication and less likely to use a non-prescribed









medication. People were more likely to self-medicate if

care was perceived as less available. Furthermore, in this

study, perceived availability of medical care was not

related to the travel time to the site of care.

In another model developed by Sharpe et al. (1985) for

medication use among the rural elderly in Mississippi, a

measure for perceived availability of physician services and

one for perceived availability of pharmacy services were

included. These measures represented indices of the

summated scores for various items. Results showed that

perceived availability of pharmacy services exerted a

significant negative effect on both prescription and non-

prescription (OTC only) drug use, while perceived

availability of physician services was not a significant

factor in the analysis. The unexpected, counterintuitive

finding of a negative effect of the perceived availability

of pharmacy services on medication use may have been due to

the operationalization of the construct, and/or the

inclusion of the ordinal variable in a regression model.

The present study builds upon this previous research by

focussing on the relationship between perceived access to

medical and pharmacy services and medication use. It adapts

the behavioral HSU model to include three dimensions of

perceptions of access to care (acceptability, availability,

and affordability) as the enabling variables of interest.

These measures complement more traditional measures, and









offer a reasonable alternative in the absence of complete

data on actual service availability.

The current investigation adopts the perspective that

geographical area is more than a simple measure of location

and spatial discreetness. In this sense, the approach taken

in this study approximates the traditional approach of the

sociology and anthropology of community study (Stein, 1972;

Arensbery and Kimball, 1965). However, in recognition of

the limitations of the usefulness of community studies as a

source of information about broader regional or national

experiences, this study examines a larger geographic unit of

analysis (groups of communities sharing significant

characteristics) in order to enhance the representativeness

of the sample. The investigator concurs with other studies

that recognize the limitations of the distance variable in

assessing access to care (Gesler and Meade, 1988:460). In

addition, the investigator agrees with and builds upon the

work of other health services utilization studies that

acknowledge the possibility of a significant influence of

social structure on perceived access to care for various

subpopulations in a society (Wolinsky, et al., 1989).

Furthermore, she suggests that an independent examination of

smaller geographical areas within the larger areas may

reveal relationships of various predictor variables and

access to care that might otherwise be obscured in studies

of larger aggregate populations. Specifically, in this









research, predictors of medications use for the different

SES areas were examined both collectively and for each area

individually.

Research Questions

In order to address the stated goals of this study, the

following specific research questions were investigated:

1) Which variables of the hypothesized medication use

model (predisposing, enabling, and need) emphasizing

perceived access to medical and pharmacy services are most

important in explaining prescribed medication use, and which

are most important in explaining self-medication in the

sample of Brazilian urban elderly in the Municipio of Rio de

Janeiro? Do residential areas with different socioeconomic

characteristics affect these interrelationships, and if so,

in what ways?

2) How well does the conceptual model fit the

utilization of physician and non-physician prescribed

medication in the low, medium, and high socioeconomic status

areas in the municipio of Rio de Janeiro? What variables

are the best predictors of self-prescribed and physician

prescribed medication use in these areas?

3) What proportion of medications being taken are

prescribed by a physician and what proportion are self-

prescribed?









4) Which therapeutic classes of medications are most

frequently used by the elderly in the sample? How

frequently are different classes self-prescribed?

Significance

In 1985, the World Health Organization published Drucs

for the Elderly, a concise report on issues in geriatric

drug therapy. These include high rates of medication use

relative to other age groups, and the increased risks for

clinical and non-clinical drug-related problems.

Nonetheless, as a treatment modality, the cost-benefit ratio

of pharmaceuticals is often favorable relative to other

modalities for many of the conditions that typically afflict

the elderly. The timeliness of the WHO publication for

developing countries derives from by the fact that large

elderly populations are no longer confined to the developed

Western world (Kalache et al., 1987; Kinsella, 1988) and

there is relatively little known about geriatric drug use in

less developed countries.

The health care needs of the elderly have demanded the

attention of policy makers in the more developed countries

for many years. Of increasing importance is the widespread

use of both prescribed and non-prescribed medications.

Indeed, in many Western, developed nations, medication use

has been found to be more the rule than the exception among

the elderly (cf. Rabin, 1977; Simonson, 1984; Lipton and

Lee, 1987; Cartwright and Smith, 1988), and consequently,









the elderly may be identified as a high risk group for

experiencing serious drug-related problems (Strand, et al.,

1990). In the United States, for example, the elderly made

up approximately 12% of the population in 1986, but received

32% of all prescription medications (Baum et al., 1987). In

addition, it has been estimated that roughly one-third of

all medications taken by the aged are over-the-counter (OTC)

products, and as many as 75% or more of the elderly in the

United States use at least one OTC at any time (Simonson,

1984:14-15).

One of the most consistent findings in geriatric drug

use research is the increase in the number of medicines used

with increasing age. Between 1977 and 1985, prescribing for

the elderly in Great Britain increased 27% compared to a

decrease of 6% among the non-elderly population (Cartwright

and Smith, 1988:1-2). In a longitudinal study of ambulatory

elderly in Florida, the average number of medications used

increased significantly from 3.22 in 1978-9 to 3.94 in 1987-

9 (Stewart et al., 1991). The absolute number of

medications used not only increases with age, but the nature

of the medications most commonly used also changes. These

changes would appear to follow the nosological alterations

accompanying the aging process (Knoben and Wertheimer,

1976).

The elderly are more likely to suffer from chronic,

degenerative, and disabling conditions than younger adults,









and these conditions often entail long-term medication use

(Verbrugge, 1984). Many treatments involve complex drug

therapies, such that the elderly who use medications are

also likely to use more than one medication. Polypharmacy

(the use of multiple drugs) has been associated with

multiple prescribers, particularly for patients suffering

from several ailments and who are under the care of more

than one physician. Lack of coordination in drug therapy,

confusion about drug use, and non-compliance are often

associated with more complex drug regimens (German and

Burton, 1989).

With polypharmacy, the likelihood of the occurrence of

an adverse drug reaction (ADR) and drug-drug interaction, as

well as drug duplication, increases. However, many ADRs are

considered to be predictable and, therefore, preventable.

Yet, because many ADRs manifest differently in the elderly

than in younger patients, a vicious cycle may result as

medications are prescribed for treating the symptoms of the

side effects of a previous medication. Some side effects

manifest as behavioral disorders which may be misdiagnosed

as senile dementia by an untrained physician (Beardsley,

1988; Miller and Elliot, 1976). The costs of ADRs

associated with hospitalizations, prolonged

hospitalizations, and heroic life-saving measures may be

high, the preventable loss of life unmeasurable (Manasse,

1989; Grymonpre et al., 1988; Gurwitz and Avorn, 1991;









Melmon, 1971; Tinetti et al., 1988; Hallas et al., 1990;

Hepler and Strand, 1990).

There are several nonmedical drug-related problems that

elderly people may be likely to experience. The elderly are

often unemployed and typically rely on restricted incomes,

factors associated with decreased access to medical services

(Fredman and Haynes, 1985). Patients on chronic

medications, needing several different medications, or

expensive medications, may compromise their drug regimen in

order to economize.

The developing countries may anticipate similar but

more acute difficulties than the developed countries in

meeting the health needs of their elderly (Tout, 1989). It

is widely recognized that many developing countries have

overburdened, inadequate health infrastructures unable to

meet the persistent primary care needs of a younger and

poorer population. Competition for scarce resources may

result in difficult prioritization in resource allocation

(Bicknell and Parks, 1989).

Brazil has been described as a young country growing

old (Veras, 1988). In 1980, eight percent of the population

was 60 years old or more, and nearly 70% of these lived in

urban areas (IBGE, 1987). The elderly have been the fastest

growing age group in Brazil since the 1940s and it is

estimated that by 2025, Brazil will have the sixth largest

elderly population in the world. Between 1980 to 2000, the









proportion of the population over 60 years old is expected

to increase 107% in contrast to that proportion of the

population 15 years old and less, which is expected to

increase only 14%. Brazilian gerontologists are concerned

that Brazilian authorities are already facing the problem of

an aging population comparable to that experienced by the

developed countries with all its implications for the health

and social care system (Ramos et al., 1987).

Summary

Brazil shares with other developing countries the

problems regarding access to needed essential medications

and the inappropriate use of medications (Allen, 1989;

Soares, 1989). Medications, whether in the form of

vaccines, antibiotics, or analgesics, are an integral

element of public health and primary care as well as in the

management of chronic and degenerative diseases. An

understanding of the factors that influence access to and

the appropriate use of medications is of extreme relevance

for all patient/client groups, including the elderly.

The purpose of evaluating perceived access to care in

the study of health care services utilization is to identify

barriers to care, or, conversely, facilitating factors.

Access to care necessarily incorporates dimensions of

acceptability, availability, and affordability of care. In

the study of medication use, both with physician prescribed

and non-physician prescribed drugs, it is meaningful to









investigate the relative importance of perceived access to

medical and pharmacy services. In the context of

uncontrolled commercialization of medications characteristic

of many developing countries, including Brazil, where the

risks associated with self-medication are increased, this

relationship assumes particular interest. The specific case

of Brazil, including the health care system, pharmaceutical

industry, and retail pharmacy in this nation, is discussed

in Chapter 2.

The determination of the extent to which the dimensions

of perceived access influence medication use behavior in

different areas within an urban setting is also a focus of

this study. Areas may be distinguished by locational,

socioeconomic and cultural factors. Areas are not only

composed of groups of individuals, but they may also be

understood as in themselves influencing individual

attitudes, and exerting some influence on perceived access

to care.

The specific population of interest in this study is

the urban, noninstitutionalized elderly. The elderly

represent a segment of the population in developing

countries which will be commanding increased attention. The

economic, social, and political impact of the health and

illness of a growing elderly population will need to be

considered in assessing the relative value of competing

health policies. Changing demographics will force countries









like Brazil, accustomed to being concerned about the

expanding bottom of their population pyramids, to look up

and refocus.

The methodology employed for the development of a model

to describe medication use for the urban Brazilian elderly

is presented in Chapter 3, including the operational

definitions of variables and their measurement, selection of

the sample and data collection techniques. Descriptive

results are presented in Chapter 4, along with the results

of analysis modeling medication use. Conclusions and

recommendations for future research are presented in Chapter

5.













CHAPTER 2
MEDICAL AND PHARMACY SERVICES IN BRAZIL


Introduction

This chapter presents the health care context in which

medication use takes place in Brazil. The discussion begins

with an overview of the formal health care system, the

principal public and private institutions that provide

services, and how they are utilized. National formularies,

regulations that define legend and non-legend drug

categories, who may prescribe legend medications, and the

mode of distribution and commercialization of medications

are all aspects of a formal health care system.

The discussion of the informal health care system, for

the purpose of this study, is limited to the role of the

pharmacy and pharmacy personnel. Commercial pharmacies are

at once marginal to the formal health care system and an

essential element. They also represent an avenue for

recourse in self-help in general, and self-medication in

particular.

Health Care in Brazil

The character of the Brazilian health care system is

fragmented, offering disparate levels of care. The level of

technological sophistication and "completeness" of services









rivals that of the more developing countries. Indeed, the

costs of care also approximate those of some of the more

developed countries: in 1987, total public plus private

expenditures on health care in Brazil exceeded US$10 billion

per annum, more than 5% of the Gross Domestic Product, which

is approximately the same percent as the United Kingdom

(World Bank, 1988a:19). However, health care in Brazil is

marked by sharp disparities on the regional and local levels

such that the "marginal", poorer populations have limited

access to even the most basic of public health services,

including medications.

The health care system is also constantly evolving.

Health care is provided by public institutions (federal,

state, and municipal) and private institutions. These are

not totally independent, but they are not well coordinated

either. Decades of bureaucratic reforms gave rise to a

large centralized public sector which became notorious for

its inefficiencies in service delivery at all levels. More

recent reforms, however, call for the decentralization of

the system.

The Public Sector

The Brazilian public health care sector consists of two

major agencies: the Ministry of Health and INAMPS (Instituto

Nacional de Assistdncia Medica), the social security

institution. The Ministry of Health, which is financed

through general government revenues, is responsible for the








33

national public health programs, such as maternal and child

health and nutrition programs as well as vaccinations.

Financed through federal payroll tax revenues, INAMPS, until

recently, has been primarily responsible for providing

curative, hospital-based services to its beneficiaries.

Since the 1940s, and until 1975, the public health and

social security curative care subsystems had little to do

with each other. The Ministry of Health held low political

priority and struggled with limited budget resources to deal

with the major public health problems, whereas social

security programs were politically far more important to a

rapidly industrializing country. As social security

benefits were extended to more individuals, revenues

increased. The curative hospital-based system of the social

security medical benefits program grew at a cumulative

average annual rate of almost 20 percent for more than a

quarter of a century, while public health programs

floundered (Braga and Paula, 1980: 101).

The growth in social security medical care was directed

primarily to very costly medical treatments that were so

concentrated that they benefitted only a relatively few

patients. This style of health care delivery, which began

as a deliberate strategy of the populist political figures

to woo the emerging urban working and middle classes,

ultimately evolved to reflect the tastes of the military

technocrats for modern science and large, centralized









bureaucracies (Horn, 1985; Luz, 1986). By 1974, however,

pressure was put on political leaders to address the dearth

of public health services and the rising costs of health

care to specific needy populations not covered by social

security, such as nonsalaried urban workers and rural

workers (Malloy, 1977; Mesa-Lago, 1978).

In 1975, the Sistema Nacional de Saude (SNS) was

created as the first attempt at a unified, coordinated

national health care system. The new system

administratively linked the three ministries already

involved in some aspect of health care: the Ministry of

Labor was to oversee occupational health and safety

programs; the Ministry of Health was to be responsible for

health planning and for environmental and collective

preventative health care; the Ministry of Social Security

and Social Assistance (MPAS) was to be responsible for the

provision of personal health services. The newly created

INAMPS was to be directly responsible for the reorganization

and expansion to the poor of certain services previously

reserved for beneficiaries.

The role of the social security program in providing

medical services increased with the growing pool of social

security beneficiaries. Between 1970 and 1980, the

proportion of all workers covered by Social Security in

Brazil increased from 27 percent to 47 percent (Isuani,

1984:195). In the urban areas, 86.3 percent of all









employees and 50.4 of all self-employed individuals were

covered to some extent by 1980, with the highest proportion

residing in the more industrialized southern regions (IBGE,

1980).

There has been a direct cost associated with this trend

which has become the nemesis of the system. As mentioned

previously, the curative, hospital-based care INAMPS

provides is expensive. However, INAMPS also pays for

services rendered in non-INAMPS facilities on a fee-for-

service basis. Patients with a choice of facilities tended

to select the higher cost private care, invoking a version

of the "moral hazard" associated with certain health

insurance schemes. Since insurance lowers the price of care

to individuals, they will consume more care than if they had

to pay the entire price themselves, and "too much" medical

care is consumed (Feldstein, 1988:128-129).

The physicians also had a direct role in promoting this

behavior by means of what Brazilians call "duDla

militancia", referring to a conflict of interest that arises

when physicians work as part-time employees at several jobs,

as many do, in both public and private facilities. Under

dupla militancia, physicians recruit patients from the

public facility, where they are salaried and work with

patient quotas, into the private facility where (it is

assumed) the physician believes s/he can offer better

quality services. This is also a lucrative business move








36

for the physician because s/he can then charge on a fee-for-

service basis, even when INAMPS reimburses (Cordeiro, 1984;

World Bank, 1988:44-45).

This unanticipated abuse of the system was not the only

problem with the SNS. There were serious problems with

meeting some of the other reform mandates to provide care to

the needy. Although the SNS promised to give a boost to

traditional public health programs, there was no

administrative mechanism that permitted coordination to take

place between the various agencies, especially the Ministry

of Health and INAMPS. The Ministry of Health actually did

experience a 35.7% budget increase between 1974 and 1975,

but the positive impact of the new reform on the Ministry of

Health was short-lived. New programs were forced to operate

under severe limitations as promised resources never fully

materialized (Braga and Paula, 1980: 97-98). Since the

ministries could not resolve their ideological differences

about health care priorities and coordinate activities, an

informal geographical division grew up between them, with

the Ministry of Health focusing on the Northern regions and

rural hinterlands, and INAMPS on the Southern regions and

industrialized centers. In 1977, a reform within SNS aimed

to resolve the administrative barriers between the

ministries. However, despite these reforms and the

expansion of free-to-patient INAMPS emergency medical









services, private health care expenditure did not decrease

(Musgrove, 1983).

The mid-1980s marked the beginning of the return of

democracy to Brazil. With it came a flood of proposals for

a more democratic health care system which resulted in the

creation of the new Unified System for Services (Sistema

Unificado de Saude, or SUS). In sharp contrast to previous

efforts, SUS aims to improve the efficiency of the public

sector by decentralizing its administration and allowing

states and local municipalities to take on a larger role in

administrating and coordinating local health care services.

It is too soon to evaluate the impact of SUS on health

care, but the heritage of the system that developed in the

decades prior to SUS is not likely to be easily shaken. The

inefficiencies of the bureaucracy which proliferated with

each successive administrative reform have been harshly

revealed in the face of the recent national economic crisis.

In August, 1990, INAMPS announced that it would be

"trimming" some of its more redundant, dispensable personnel

(50% of which worked in Rio de Janeiro), including some

physicians ("INAMPS afasta...", 1990). While apparently a

sensible motion, it was disconcerting to the public for two

reasons: firstly, public servants (traditionally a very

secure type of position in Brazil) do not typically lose

their jobs, and, secondly, despite assurances to the

contrary by officials, the public feared the further









discontinuation of badly needed services. Indeed, two

thousand health posts and several public hospitals

throughout the nation were not providing services due to

lack of funds to pay personnel and purchase supplies

("Atraso na verba....", 1990).

The Private Sector

The private health care sector in Brazil includes

services provided by health care corporations for large

companies and institutions (such as banks, and labor

unions), religious and other charitable institutions, as

well as large and small private practices. The delivery

style in the private sector mirrors that of the public

sector and is heavily hospital-oriented. Indeed, the

character of the medical-industrial complex in Brazil is the

result of a symbiotic relationship between private medical

businesses and public funds.

Prior to 1965, there were several health-related

programs, each designed for a separate workers group (i.e.,

railroad workers, steel workers, etc.). When these various

programs were unified, Social Security began to contract

with health care organizations to provide medical services

to some of these groups. Health care corporations and group

practices, generally affiliated with private hospitals,

could be certified by Social Security and negotiate with

businesses and workers groups, and then be reimbursed by

social security. Private, subsidized services were made







39

available to salaried industry workers and various tertiary

sector (mostly commerical and services) workers. The

extension of services by the private sector to non-Social

Security beneficiaries occurred in 1974. At this time, the

right to emergency care was extended to all citizens.

Most of the empresas medical (medical corporations) are

non-profit organizations. Many offer pre-paid health plans

to members in a kind of HMO structure. Parallel to the

development of these group practices, physician cooperatives

also began to compete for patients. The cooperatives are

ideologically opposed to the closed-group, pre-payment

structure of group practices, and may be likened to the

preferred patient programs in the United States.

As Social Security grew in Brazil, extending coverage

to include more benefits to a broader population base, the

subsidized business for the private medical sector also

grew. Cordeiro (1984) argues that the increase in contracts

between Social Security and private health care

organizations indicated dissatisfaction on the part of

beneficiaries with the services provided directly by Social

Security physicians and hospitals, and that demand for these

services exceeded supply. The preference by certain

industries and businesses to contract with the health care

organizations was also a politically safe and economical

means of satisfying worker's demands (Cordiero, 1984:64-86).









As with many other businesses, these corporations are

having difficulties in dealing with the vagaries of the

contemporary Brazilian economy. Within the last few years,

the tension between the actual health care providers and the

contractors for their services has run high. Conflicts

revolve around the inadequacies of the payment structure,

(primarily reimbursement schedules), in the wake of the

prevailing inflation rates. With run-away inflation, the

more time that elapses between charging for a service and

receiving payment, the greater the devaluation of the

remuneration.

Similarly, salaries had to be constantly reajusted for

inflation. In June, 1990, the national organization for

health care corporations presented a new payment scheme for

their physicians in response to the new rates previously set

by the Brazilian Medical Association (BMA). The medical

corporations argued that they could not afford to pay their

physicians according to the BMA rates because the

corporations were not permitted to adjust the fees they

charged their clients. Unsatisfied physicians went on

strike (crippling both public and private health care

services) and began to charge for private services using the

BMA rates. It was not until nearly three months later, in

September, that a judge ruled against using the BMAs rates

as mandatory rates, and sent all parties to the negotiating

table.







41

The health care organizations were also recently faced

with other changes that directly affected their clientele.

In January, 1991, new federal regulations gave health care

organizations the option of either formally becoming health

insurance corporations, or of maintaining their health

programs as they were, but managing them as if they were

insurance policies. Previously, health plans offered

services similar to health insurance policies, but were not

subject to the price and other quality controls imposed on

insurance policies.1 Golden Cross, with over 700 thousand

clients in its health plan nation-wide, was one of the first

to switch to a formal insurance entity, Golden Cross

Insurance. Although there were no changes in service, the

monthly fees to clients did increase enough to make many

clients very concerned: in Rio de Janeiro, for example,

where more than half of Golden Cross' clients reside, rates

increased by over 150% (Susep elabora..., 1991).

Health Services Utilization in Rio de Janeiro

In 1986, a national household survey examined health

services utilization in Brazil. The study revealed that 67%

of all Brazilians who had a health problem sought medical

attention. Ninety-seven percent of all urban residents, and

53% of all rural residents with a health problem sought

1 In addition, if the corporations changed their non-
profit status to become a private insurance company, the
government could reap an estimated US$80 million per annum in
new tax revenue (Dantas, 1991).









medical attention. Of the urban residents who sought care,

10.5% were persons 60 years old or more. Of the rural

areas, 8.5% of health services users were elderly (IBGE,

1989:4).

The State of Rio de Janeiro is one of the wealthiest

states in Brazil, and boasts one of the largest metropolitan

area in the country. With 68 municipios (counties), and an

estimated population of 14 million, Rio de Janeiro has both

extensive urban and rural areas. In the urban areas of Rio

de Janeiro, 79.5% of the persons who reported having had a

health problem sought medical attention, and 14.4% of all

urban patients were elderly. In the rural areas, 77.5% of

those who reported having had a health problem sought care,

and 11% of these were elderly (IBGE, 1989:322). These

figures suggest roughly equivalent access to care on the

basis of perceived need (ie., having a health problem). The

higher percentage of elderly patients in the urban areas

reflects the relatively greater proportion of elderly in the

urban population than in the rural areas.

Reasons for not seeking care are presented in Table

2.1. Transportation and financial barriers to care were

reported less frequently in urban areas of Rio de Janeiro

than rural areas. On the other hand, scheduling and other

time barriers, probably related to the busy urban working

class lifestyle, were more likely to keep people from

seeking medical attention in urban areas.











Table 2.1 Reasons why people did not seek medical
attention but had a health problem in Brazil
and the State of Rio de Janeiro, 1986.

Reason Brazil Rio de Janeiro

Urban Rural
0 6 '6a

Transportation
problem/distance 10.1 4.4 13.7

Scheduling problem 3.4 6.7 6.4

Long wait time 4.3 5.5 1.5

No need 63.8 62.4 60.0

Financial problem 10.9 5.2 7.3

Other 7.4 15.8 11.1

Total 100.0 100.0 100.0


Source: IBGE (1989), table 7, p. 9 and p. 327.









In the municipio (with approximately 6 million

inhabitants), there are 16 municipal hospitals, two major

university hospitals, other state and federal hospitals, and

several private and philanthropic hospitals offering

distinct, specialized services. In addition, there are 70

public health posts and health centers and over 40 INAMPS

facilities. The more urban, metropolitan area also has a

relatively high concentration of private clinics and

physicians. The hospital utilization rates in both the

urban and rural areas do not differ greatly from the

national rate (see Table 2.2). This reflects the high

reliance on the curative, hospital-based health care system,

even though the public system has been struggling to keep

hospitals functioning ("Cremerj vai a Justica...", 1990).

The decreased reliance on public health posts and centers

and the greater utilization of clinics and physicians'

offices in the urban areas demonstrates the relative

abundance of health care plans/policies available in the

urban areas that are not widely available in the more rural

areas, and, indeed, throughout the rest of the country.

Where one seeks medical attention is related to income

(Table 2.3). Unfortunately, the data do not distinguish

between public and private facilities. Nonetheless, given

our understanding of the health care system, it is not

surprising to find that, in both urban and rural areas,










Table 2.2


Types of health services
Rio de Janeiro, 1986.


used in Brazil and


Type of Service Brazil Rio de Janeiro

Urban Rural
6* 6

Public health post or
health center 20.8 12.2 16.9

Hospital 36.9 34.5 35.6

Clinic, Polyclinic,
or physician's office 36.2 49.2 39.3

Union or employer's
infirmary 4.1 2.9 6.9


Other 2.0 1.2 1.3

Total 100.0 100.0 100.0

Source: IBGE (1989), table 9, p. 11 and p. 329.


Table 2.3 Utilization of health care serivces in Rio de
Janeiro by household income per capital, 1986.

Income Group Typve of Service
(Minimum salary) Public health Hospital Clinic, Other
post/center MD office
% (1) (2) (3) (4)


Urban
No income
<= 1/4
1/4 to 1/2
1/2 to 1
1 to 2
+ 2

Rural
No income
<= 1/4
1/4 to 1/2
1/2 to 1
1 to 2
+2


100.0
100.0
100.0
100.0
100.0
100.0


100.0
100.0
100.0
100.0
100.0
100.0


17.7
14.9
21.2
17.7
10.8
5.3


100.0
28.3
22.4
12.2
8.3


50.6
41.0
38.4
41.5
36.0
26.7



45.3
35.0
38.4
16.6
37.2


28.0
42.6
34.4
37.1
49.7
64.2


3.7
1.5
6.0
3.7
3.5
3.8


14.7
33.0
39.7
75.1
62.8


11.7
9.6
9.7


(1989), table 11, p. 331.


Source: IBGE











higher income groups rely more on clinics and physician

offices than do the lower income groups.

The Pharmaceutical Industry In Brazil

The role of medications in the Brazilian health care

system is not insignificant. In 1989, Brazil was the eighth

largest market in the world for pharmaceuticals. It was

estimated that there were approximately 20,000 products on

the market, utilizing some 2,100 different active

ingredients (Soares, 1989:43). In 1990, this was a US$2.9

billion dollar market, with room to expand. Currently,

multinational corporations control 73% of the market

("Remedios congelados",...1990). Eighty percent of all

physician visits result in a prescription (IBGE, 1989:29),

although complaints of shortages of essential medications,

even in the urban areas, are a constant (Allen, 1989). This

section explores the Brazilian pharmaceutical industry, both

private and public, and industry's recent impact on the

economic and social aspects of medication use.

The Private Sector

By the 1940s, Brazil had an established, if modest,

domestic pharmaceutical industry, including infrastructure

and trained personnel. This was due in part to the

contributions of chemists and pharamcists who immigrated

from a war-torn Europe. Brazil also had by this time an

established medical care system heavily biased in favor of







47

an individual-curative model of medicine. All thses factors

contributed to make Brazil particularly attractive for

investment by foreign pharmaceutical firms in the 1950s.

A major transformation in the make-up of the

pharmaceutical industry occurred in the early 1960s. An

extended period of political crisis triggered economic

stagnation that lasted until 1967 (Baer, 1983:93-97). The

impact was hardest on national firms: between 1960 and 1962,

75 national pharmaceutical firms disappeared from the

industry. After the military coup of 1964, strict

stabilization reforms were introduced which favored foreign

investment, and between 1966 and 1969, five of the largest

remaining Brazilian pharmaceutical firms were bought out by

international companies (Evans, 1979:125).

The local Brazilian firms that survived the waves of

denationalization seemed to have done so on the basis of

their successful commercial and marketing capacities rather

than competiveness in research and development (CEPAL,

1987). The top firms concentrated on specific therapeutic

classes and market power was gained from brand preferences.

However, each firm's power was limited by the presence of a

large number of close substitutes, indicating a market

characterized by an undifferentiated oligopoly.

Furthermore, although there was a large diversity of

different products, the required technology was relatively

simple and unconcentrated so that the market for the









introduction of new products was fragile. The basis of

competition for control of the pharmaceutical market in

Brazil, therefore, was in the area of production of

pharmaceutical specialties, including new combination drugs,

and new dosage formulations, not the development of new

drugs per se. Indeed, since Brazil has not recognized

patent protections since 1969, any laboratory could submit

registrations for any product. The small national firms

took advantage of this by registering copies of all the most

commercially important products, the vast majority of which

were MNC products. For example, in 1982, apart from

Beecham's brand of amoxycillin, under patent protection in

the United States, and that of their licensed subsidiary,

there were 17 other brands available on the market, with

many more registered (Adler, 1982:627).

The Public Sector

In 1971, CEME (Central de Medicamentos) was established

as a crucial element of the Brazilian government's answer to

the ever increasing costs of medical care in general, and

medications in particular. The stated purpose for the

creation of CEME was to provide essential medications, as

listed on the national formulary (Relat6rio Nacional de

Medicamentos), free of charge or at a reduced rate to that

segment of the population determined unable to afford them

on the open market, which at the time of CEME's inception

was estimated at 90 million people (Cordeiro, 1985). CEME









was to develop and produce medications as well as contract

out to private firms to make up for production

difficiencies.

Ideally, the merits of adopting essential drug policies

may be phrased in terms of health benefits and potential

savings, not only on the national level (Lilja, 1983;

Wang'ombe and Mwabu, 1987), but on the individual consumer

level as well (Patel, 1983). However, the promises of the

essential drugs program in Brazil were never to be

fulfilled. In 1974, over half (57%) of household health

budgets in Brazil was spent on medications (Musgrove,

1983:252), compared to 34% in the more prosperous urban Rio

de Janeiro (Cordeiro, 1985:181). Similarly, a comparison of

four communities in Sdo Paulo demonstrated that the

proportion of health care expenditures related to medication

use was greatest for the poorest socio-economic strata

(Giovanni, 1980:129). In 1990 CEME revealed that as much as

55% of the targeted population was not being served.

CEME never became the national industrial contender

some would have had it become. In 1975, CEME was

dismembered: distribution services were allocated to the

Ministry of Welfare, while research, development, and

production were incorporated into the Ministry of Trade and

Commerce. As of 1985, CEME administratively resides under

the auspices of the Ministry of Health, but remains









operating suboptimally, especially in the production of

medications.

The failure of the program has been a great

disappointment politically, economically and socially

(Evans, 1979, Landmann, 1982; Cordeiro, 1985; Cunha, 1987;

Soares, 1989). The negative implications of its failures

have been ballooning during the last few years. A recent

study by the Health Commission of the Legislative Assembly

in Rio de Janeiro reported that CEME spent 95% of its budget

on the acquisition and distribution of medications and that

contracts with private firms accounted for nearly 55% of

this amount, approximately CR$10 billion, in 1990 ("Deputado

diz...", 1991; "CEME nega...", 1991). The dependence on

private firms became a problem when government price-fixing

of medications was terminated, beginning in August, 1990,

and prices began to rise at unprecedented rates. The cost

of doing business with private firms became untenable and,

in the face of dire shortages for many drugs, CEME was

forced to look elsewhere for the medications it required.

In January, 1991, the president of CEME, Antonio Carlos

Alves dos Santos, asked that 16 state laboratories expand

production as a means to alleviate the shortages ("Verba

para os laboratorios...", 1991). Whether or not this was a

"reasonable" request, whether production capacity could be

expanded, and so on, is questionable.

Economic and Social Aspects of Drug Use







51

Although the price of medications in general has been a

matter of public concern, at least since the early 1970s,

the current economic crisis, marked by both hyper-inflation

and recession, has brought the issue back in full force. In

a 17 month interval, from January 1987 to May of 1988, the

price of medications increased on the average 5,297%,

although the rate of inflation during this period was

943.7%. Among the medications experiencing the greatest

increase were those commonly used for chronic diseases like

Higroton and Atenol, both antihypertensives (medications

frequently used by elderly patients), which increased 1,952%

and 2,969% respectively during this period (Caldas, 1988).

After the steps were taken to deregulate the economy in

1990, further price increases were the result of hikes in

the commercial dollar exchange rates for imports and

exports. Since 42% of the value of the primary materials

used in production is imported, this increase (approximately

30% between October and November, 1990) was transferred to

the price of medications. Although the industry argued that

price increases reflected the increases in cost of

production, as well as mark-ups to cover the cost of

producing products whose prices were still controlled, new

prices generally outstripped these increased costs and

general inflation ("A inddstria farmaceutica...", 1990;

"Remedios terdo...", 1990).









Those hardest hit by the impact of these events were

the consumers, particularly chronic medication users. The

following testimonies from letters to the editor of the

major newspaper in Rio de Janeiro, Jornal do Brasil, are

examples of the experiences consumers encountered:

(...) I went to the Drogaria Popular on Rosario
Street, downtown, to buy a box of Antak, which I
take regularly for ulcer problems. Upon arriving
home I compared the price with the last one I
bought and almost flipped. On December 5, I paid
Cr$689, and on December 14, only nine days later.
they charged me Cr$l,886, a 173.68% increase
(...). -- Paulo Sergio Pereira (RJ) (Dec. 28,
1990).

(...) On January 8, 1991, I had to buy a box of
Frontal, that was purchased by a third party, at
the Drogaria Mexico, Ltda., on Mexico Street,
downtown, upon receiving the medication I was
surprised by the price of Cr$l,375, because not
long before I bought the same medication at the
same pharmacy for a much lower price. Upon
examining the package, I noticed that the price
sticker was placed on top of others. I took it
upon myself to lift off, one by one, the old
stickers and verified that the original price,
according to the first sticker, was Cr$612, on the
second it was Cr$642, on the third Cr$919, and,
finally, on the last one, it had been changed to
Cr$1,375 a 124% increase in a month and half!
(...). Theo de Castro Drummond (RJ) (Jan. 1,
1991).

(...) I am a heart patient, having survived a
triple by-pass surgery. I am required to take the
prescription drug Ancoron. There are 20 pills per
package. For me, a package lasts 40 days, and 40
days ago I paid Cr$505 for one box. On January 5,
I went to buy the medication at the same pharmacy
and I paid Cr$960, or, an increase of 90% in 40
days. This is scandalous (...) -- Leno Cunha
(Petr6polis, RJ) (Jan. 19, 1991).

(...) I am nearly 80 years old and have had two
by-pass surgeries (...). Early December, 1990,
among the many medications that I am obliged to
purchase, I bought at the Drogaria Popular, on









Sen. Dantas Street, a package of Venalot for
Cr$471.50. One week later, at the same pharmacy,
the drug cost me Cr$l,374, which took into account
the 15% discount [for seniors] (...). Within a
week there was an increase of 342.9%. (...) -
Fritz Berg (RJ) (Jan. 19, 1991).

The beginning of 1991 was marked by a series of

hearings by the National Secretary of Economic Rights (SNDE)

in which 17 major pharmaceutical firms were summoned to

formally justify their price increases. Only one firm,

Fontoura Wyeth, refused to lower its prices and was found

guilty of violating the antitrust law ("Governo

encerra....", 1991). These actions provoked a heated

exchange between the producers, wholesalers, and retailers,

each accusing the other of illegally increasing prices

(Lapa, 1991). By February, the Secretary of the Economy was

forced to announce the return of price-fixing for

pharmaceuticals ("Governo tabela...", 1991).

The price scandals in early 1991 resulted in some

remarkable, if not positive, changes in industry behavior.

Industry, rather ironically, responded by terminating the

production of certain product lines, or certain dosage

forms, that, in reality, may be considered irrational from a

therapeutic perspective to begin with. For example, when

the price for the 30 dose package of Vibramicina, a wide

spectrum antibiotic was fixed with a ceiling very close to

that for the 15 dose package, Pfizer stopped marketing the

unnecessary 30 dose package (Rangel, 1991).









Brazil has not had a tradition of consumer interest

groups. Therefore, it is worth noting that the health care

professionals and consumers also responded, in organized

fashion, to the situation that appeared to be getting out of

(the government's) hand. In February, 1991, SOBRAVIME

(Sociedade Brasileira de Vigilancia de Medicamentos), was

created as the first civilian organization to be concerned

with pharmaceutical quality control. Its self-purported

role is to denounce irregularities in the production,

licensing, propaganda, and sale or use of pharmaceuticals.

SOBRAVIME, while comprised principally of physicians and

pharmacists, is guided by the principals of the recently

published Consumer Defense Code (C6dico de Defesa do

Consumidor) which represented the efforts of an incipient,

broad-based consumer movement.

These organizations are interested in monitoring not

only the price of medications, but also the medications that

are marketed. Some experts estimate that more than 50% of

the medications sold in Brazil have no proven therapeutic

value, and the number of products on the Brazilian market

that are known to be dangerous or inappropriate is large.

In 1990, Health Action International, the Berne Declaration

Group, and BUKO-Pharmakampagne denounced the sale of

products in the Third World, including combination drugs

which nave no pharmacologic justification, products with an

inappropriate dosage or with "inadequate" (subtherapeutic)







55

amounts of the active ingredient (Autran, 1990). The study

revealed that 32% (142) of the German products sold in

Brazil in 1984/1985, and 37% (127) of those distributed in

1988, were considered to be inadequate. Of the Swiss

products put on the Brazilian market, 44% were inadequate.

Dipirone, a very controversial analgesic that is prohibited

in Germany, the United States, and other nations, was among

the products listed as inadequate yet currently available in

at least 99 different products in Brazil (Autran, 1991).

Pharmacies and Drugstores

Up to this point, the discussion has focused on the

production and consumption of medications. In between these

two polar ends of the path to medication use, there remains

the point of interface between the medication and the

consumer, namely, the pharmacy. According to Brazilian law

(Lei No. 5.991, 17/12/73; Decreto No. 74.170, 10/6/74),

medications may only be dispensed from four different

places: a pharmacy (farmacia), a drug store (drogaria)2, a

health/medication post (including mobile posts), and

hospital dispensaries. Medicinal plants are also restricted

to sale in pharmacies and herbal stores. Although


2 Technically, pharmacies are distinct from drug
stores in that pharmacies are allowed to formulate
medications, and drug store are strictly retail outlets for
prepackaged medications. This distinction is of little
practical significance in contemporary Brazil because tha vast
majority of pharmacies no longer formulate medications.
Hence, the term pharmacy will be used interchangeably for
both.









supermarket chains are trying to gain the right to sell

pharmaceuticals, only establishments such as hotels or non-

profit, philanthropic organizations are currently permitted

to sell or otherwise dispense non-legend (OTC) medications,

and these only to their clients (CRF-8, 1983:120-121;136-

141), although the illegal sale of medications outside of

pharmacies has been documented (Costa et al., 1988).

Pharmacists are responsible for the direct sale to

consumers of medications and other pharmaceutical

specialties, but Brazilian law also stipulates that others

may also have this responsibility (Decreto No. 20.377,

8/9/31). This includes individuals who may have some

limited formal training or apprenticeship, but are not

registered pharmacists, known as "praticos" and "oficiales".

In 1960, these practitioners were permitted to register with

the regional boards of pharmacy to qualify as a technician,

capacitated with all the rights of a pharmacist except in

the formulation of medications. This includes the right to

own and register a pharmacy and to give injections. Law No.

5,991 (17/12/73) and Decree No. 74,170 (10/6/74) stipulate

that the presence of the responsible technician (either

pharmacist or other technician) is obligatory during all

commercial hours, but a pharmacist is not required to be

present at all times.

The concern for ensuring access to medications to all

communities is also cited as the rationale for legislation









regarding the number and distribution of pharmacies

permitted in any area. New pharmacies must demonstrate a

need for services, based on a population-to-service ratio,

in order to be licensed. If no pharmacists are available in

a given area, other qualified technicians can be designated

as the responsible party. Furthermore, pharmacies are

required to participate in a rotation system with other

pharmacies to ensure the uninterrupted provision of pharmacy

services in a given area. In the event that there is a

demonstrated need but neither qualified technicians nor

pharmacies are available, there are provisions for the

licensing of postos de medicamentos, which are simply

medication outlets of limited capacity that carry only the

most basic supplies (CRS-8, 1983:117-159).

In 1991, there were 2,851 pharmacies and drugstores

(excluding hospital pharmacies and dispensaries) registered

in the state of Rio de Janeiro. Forty-four percent of these

(1,241) were in the metropolitan area so that the

population-to-pharmacy ratio was approximately 4,100:1.

There were 3,870 pharmacists (including 300 oficiales and

praticos) registered with the state, and 63% (2,439) were

registered in the municipal area. Although the data are not

broken down into smaller geographical units, the

distribution of pharamcies in the city is not uniform.

Regulation regarding distribution did not affect established

pharmacies, so older sections of the city have a relatively









high concentration of pharmacies, as much as two or three

per city block, and sometimes even more, as in the

commercial district of Copacabana. The vast majority of

registered pharmacists are employed in industry (personal

communication, CRF), although there is a small and lucrative

business in specialty pharmaceuticals, primarily

dermatological products, as well as several homeopathic

pharmacies that compound their own products.

Pharmacy Practice and Self-Medication

A significant proportion of private health care

spending in Brazil represents drug purchases occurring

outside the direct control of the formal medical care system

(McGreevey, 1988:158). The frequency of self-medication in

Brazil has been estimated to be approximately 50% to 60% of

all medication use (Giovanni, 1980:132; Haak, 1988:1420;

Cordeiro, 1985:190). However, because commercial pharmacies

do not typically keep records of prescriptions, and due to

the lack of other systematic record keeping, there is

relatively little known about both self-medication and

prescription medication use.

Today, pharmacists, or otherwise qualified technicians,

are hard to come by in the community setting. A consumer is

more likely to interact only with salespersons (balconistas)

with no formal training in pharmacy at all. According to

Giovanni (1980), the disappearance of the community

pharmacist was inevitable. Giovanni argues that there is no







59

data to justify the claim of a pharmacist shortage and that

the laws mentioned above were based on questionable, if not

false, premises (1980:104-105). These laws served to

conspire with the pharmaceutical industry to promote

drugstores as efficient commercial outlets for their

products. The traditional pharmacy that formulated its own

drugs could not compete with the industries that operated

with large economies of scale. As pharmacists no longer

held exclusive rights to operate establishments for the sale

of pharmaceuticals, this represented a virtually untapped

market for the entrepreneur. By the end of World War II,

the drugstore boom had begun and pharmacists left the

community setting and headed for industry.

The impact of these changes on pharmacies and practice

has not been uniform. In some areas, especially where

medical care is scarce, the pharmacy still represents an

important health care resource. In an ethnography of two

neighborhoods in the Rio de Janeiro suburb of Nova Iguazu,

Loyola (1983) describes two general types of practicing

community "pharmacists": practitioners who provide

therapeutic assistance ("farmacduticos-praticantes" or

"farmacduticos-terapeutas") and commercial or business

"pharmacists" ("farmaceuticos-comerciantes"). These two









types of pharmacists3 differ in social origin, location of

practice, and practice style and philosophy.

In this typology, therapist-pharmacists are community-

oriented, are familiar with their clients and their families

and lifestyle. These represent the fading "farmacia do

bairro", the neighborhood pharmacy, run by an involved,

active member of the community. This kind of pharmacist

assumes the role of a health care professional, and may even

provide a diagnosis and recommend drug treatment in "banal"

cases. As a professional, he is expected to refer the

client to a trusted physician if deemed necessary.

The second type of pharmacist may be considered the

antithesis of the first. The practice location is generally

in the central business areas, near medical laboratories,

physician offices and clinics. Their identification is with

the medical profession yet their focus is on the commercial

aspects of pharmacy practice. The clientele reflect this:

they too are more closely articulated with the formal health

care system, and tend to be of the more privileged socio-

economic groups that utilize the medical services in the

area. As the pharmacist's primary job is generally in

industry, s/he visits the pharmacy for only a few hours a

week, and then only to check the books for the sale of


3 In this discussion, references to pharmacists,
unless otherwise stated, describe the person who works in the
pharmacy/drugstore, regardless of training.







61

controlled substances, such as potent narcotics. The volume

of drugs dispensed is large in these establishments and

there is little opportunity and no expectation for any

professional-client relationships to develop. A similar

characterization of pharmacy practice has been described for

urban pharmacy practice in Cost Rica (Low, 1981).

Given their "strictly business" orientation, commercial

pharmacies are more likely to engage in illegal

"empurroterapia" (push therapy). This practice, which

involves pushing products onto gullible clients with little

regard for therapeutic usefullness, evolved from the custom

of paying pharmacy salepersons (balconistas) on a commission

basis. Enforcement of regulations regarding the sale of

medications was and continues to be beyond the capacity of

enforcement agencies. Therefore, if the intent of the law

that encouraged the evolution of drugstores was to make

medications more accessible to the public the secondary

effect was the loss of control over their appropriate

commercialization and use.

Some of the concerns regarding the recommendations lay

salespeople might offer to clients for the purposes of self-

medicating is exemplified by the following recent example

that involved an ulcer medication, Cytotec (a prostaglandin)

that was being pushed as an abortifacient. A study

conducted by the Federal University of Ceara (UFC) in 1990

used a "shopper" technique to determine the extent to which







62

medications were recommended by the pharmacy for the purpose

of provoking an abortion. The study found that 83% of the

pharmacies studied (N=102) recommended a medication for this

purpose. Cytotec was recommended in 67% of the pharmacies.

The study suggested that salespersons who recommended

Cytotec were "informed" by the product package insert, which

listed pregnancy as a contra-indication for use ("Remedio

para ulcera...", 1991).

There is an increasing awareness on the part of the

pharmacy profession in Brazil of the need to return to the

community pharmacy. In January, 1990, the National Board of

Pharmacy (Conselho Federal de Farmacia--CFF) announced that

it was presenting to Congress a plan, the "Project for

Assistance to the Pharmacy", that called for the mandatory

presence of a professional pharmacist in all pharmacies.

The principal objective of this plan is to curb self-

medication. On Februrary 21, 1991, the National Assembly of

the CFF met in Brasilia to address this issue, to identify

barriers, and to set goals and objectives for the future of

the profession which would include a return to community

practice. There are decades of resignation to shake off,

and little economic incentive to leave the harbor of

industry employment, but it appears that the public

continues to value the pharmacist and is likely to welcome a

return to the pharmacy, if it doesn't cost too much!









Summary

This chapter outlined the context of health services

utilization in Brazil. Brazil's health care system includes

an expansive, yet chronically troubled, public sector. The

difficulties it faces have risen from conflicts between

promises to provide first-rate medical attention to certain

segments of the population while neglecting basic primary

care needs of other segments, and the constraints placed on

a Third World nation suffering an economic crisis. A

private sector dominated by large health care corporations

was able to flourish on the promises of the public sector

(through subsidies) and the expectations of their clients.

In addition, the private sector promised less bureaucracy, no

endless lines and waiting, and a diminished threat of

shortages in manpower and supplies; in short, it promised

that "private is better than public". Public facilities

became the principal source for medical care for the poor

and otherwise marginal or disenfranchised, and for a few

beneficiaries, a source for otherwise expensive, high

technology procedures free of charge.

The availability of medications has been a concern in

health care politics in Brazil since the 1930s and 1940s,

especially following the development of new antibiotics and

vaccines, and the advent of the industrialization of

pharmaceuticals. Prepackaged medications could be sold in

drugstores, where the presence of a professional was no









longer mandatory. As pharmaceuticals became more

accessible, the professional pharmacist abandoned community

practice to commercial interests, and a new dimension was

added to the potential hazards of self-medication, relative

to other countries with more controlled environments.

The relationship between the health care system and

care-seeking behaviors in Brazil reflects an historical

process that is deeply rooted in the culture and politics of

the country. Health care services have not been universal

nor uniform for all: some groups have had quite different

experiences and individuals' expectations regarding services

are bound to be related to their experiences and needs.

With this understanding of the context in which health

services are utilized in Brazil, the question of the

relationship between perceived access to medical care,

perceived access to pharmacy services, and medication use

may be addressed. The following chapter discusses the

methodology that will be employed to examine this question

for elderly residents in three different socio-economic

areas in Municipio of Rio de Janeiro.













CHAPTER 3
METHODOLOGY

Introduction

This project required the development of a survey

instrument that would measure the access dimensions of

interest since there was no instrument available for the

Brazilian context. This entailed a process that began with

a general model of medication use that included variables

believed to be relevant based on previous studies in Brazil

and elsewhere. Item selection for the access variables

involved the adaptation of items used in the United States,

the participation of experts in the field in the translation

and formulation of new items, revision as a part of the

interviewer training, and field testing of the instrument,

which resulted in further revisions of the instrument. This

chapter discusses each step of the instrument development,

the selection of the sample, the research procedures and the

analysis strategy.

Building a Medication Use Model for Brazil

The theoretical framework that was used to analyze

medication use behavior among the noninstitutionalized

elderly in Brazil was based on the health care utilization

model developed by Andersen and Newman (1973), discussed in

Chapter 1, and builds upons previous studies of medication

65










use. The unique aspect of the model presented is the

emphasis on subjective measures of access to both medical

and pharmacy services in relation to prescribed and

nonprescribed medication use. Each variable to be examined

and its measurement is listed in Table 3.1, and will be

discussed in this section.

Predisposing Variables

The predisposing variables examined in this model

include the patient's age, gender, education, household

size, income, as well as attitudes toward formal medical

care, and attitudes toward accepting lay advice about

pharmaceuticals.

Age: The elderly are defined as 60 years old or more,

which is the definition currently accepted for many

developing countries. Age, in this study, is measured as a

continuous variable.

An increase in prescription drug use has been found to

correspond with an increase in the age of the patient in

studies in Western countries (see review in Stewart, 1988;

Dunnell and Cartwright, 1972). This trend probably reflects

normal physiological changes in health status over time.

However, the rate of nonprescription drug use appears to

stabilize and in some reports it has been found to drop with

increasing age (cf. Simonson, 1984; Johnson and Pope, 1983).

The reasons for this phenomenon are not well understood,

although similar patterns have been noted for other forms of








Table 3.1 Variable

Variable name

Predisposing variables:


s and their measurement

Measurement


Age

Gender

Household size

Education

Income


Attitudes toward medical care
(AttMedCare)

Attitudes toward lay advice about
drugs (Att_Lay_Advice)

Enabling variables:

Perc'd acceptability of medical services
(Accept_Med_Serv)

Perc'd availability of medical services
(Avail_Med_Serv)

Perc'd affordability of medical services
(AffordMedServ)


Number of years of age

0=male, l=female

No. persons living in the home

No. of years of schooling completed

Estimated personal monthly income,
adjusted for monthly inflation

Summated score of 7 items
(ordinal measures)

Summated score of 3 items
(ordinal measures)



Summated score of 15 items
(ordinal measure)

Summated score of 11 items
(ordinal measures)

Summated score of 2 items
(ordinal measures)








Table 3.1--continued


Variable name


Measurement


Perc'd acceptability of pharmacy services
(Accept_PharmServ)

Perc'd availability of pharmacy services
(Avail_Pharm_Serv)

Perc'd affordability of Drugs
(Afford Drugs)


Need variables:


Perc'd health status


Symptom experience


Summated score of 15 items
(ordinal measures)

Summated score of 13 items
(ordinal measures)

Summated score of 2 items
(ordinal measures)



Summated score of 2 items
(ordinal measures)

No. of reported symptoms
experienced with frequency


Use variables:


Physician prescribed (PP) medication use


Non-physician prescribed (NPP) medication use


No. of medications used prescribed
(or recommended) by a physician

No. of medications (incl. home
remedies) used recommended by
a lay friend or family member,
pharmacist, nurse, self, or other
lay individual.









self-care as well (Segall and Goldstein, 1989). Indirect

relationships with both prescription and non prescription

drug use in old age have been found through enabling

such as the availability of transportation (Sharpe et al.,

1985) and need variables, such as perceived morbidity, in

studies using path analytic techniques (Bush and Osterweis,

1978).

Gender: Gender has been found to have consistent

relationships with drug use. Women are more likely to use

medicines than men, both prescribed and nonprescribed. In

addition there are differences based on gender in use of

drugs of different therapeutic classes, although the reasons

for this are not always clear (Johnson and Pope, 1983;

Verbrugge, 1982; Verbrugge and Steiner, 1985; Svarstaad et

al., 1987). Furthermore, the effect of gender in old age

appears to be even more dramatic. This is especially true

for the use of prescribed psychotropic drugs, although their

use is less chronic in females than in males. It has been

suggested that the role of gender and age in provoking

agismm" in physician prescribing behavior may be a

contributing factor (Arluke and Peterson, 1981). There is

no apparent reason to suspect major departures from this

pattern for the Brazilian urban elderly.

Household size: In Western countries, studies indicate

that individual medicine use rates, as measured by the

number of medications obtained per individual, for both







70

prescribed and nonprescribed medicine use, has been found to

decrease as household size increases. This is generally

considered a function of income (Rabin, 1977). However, a

larger household increases the opportunity for and may thus

increase the likelihood of the sharing and lay prescribing

of medications among household members. Therefore, a

positive association may be expected between increase in

household size and number of nonprescribed medicines

actually used.

Education: The influence of formal education on

medication use in Western societies is not clear. One

difficulty in assessing it is that, together with income and

occupation, education is one of the indicators of social

class, a variable frequently used in many medication use

studies in lieu of education. Education is associated with

a greater ability to manipulate the socio-political system,

to excert control over one's environment and to mobilize

resources needed for health-related needs (Wood and

Carvalho, 1988:90). Generally, educational achievement and,

hence, social class, is thought to imply greater health

knowledge. According to Blum and Kreitman,

"health knowledge, including information about
medicines, is but one instance of that general
sophistication which is predictable on the basis
of economic, social, political and personal
factors which affect the availability of, access
to, interest in, and capacity to utilize knowledge
sources" (1981:134-135).







71

The relationship between education and health services

utilization and other care seeking behavior is a relevant

issue in Brazil (Singer et al., 1981) and other countries

with high levels of illiteracy. In particular, there is a

well known inverse association of female (and to a lesser

extent, male) education with infant and child mortality and

fertility, through a variety of intervening factors,

including greater use of health care services (Wood and

Carvalho, 1988:170-2).

In 1990, a significant proportion of the urban

Brazilian elderly (41%) were considered illiterate (IBGE,

1987). There is no reason to suspect that the relationship

between education with health services utilization among the

elderly would differ from that for the general population.

With respect to medication use in particular, the

relationship between education and prescribed medication use

may be considered a proxy for use of medical services.

Conversely, lower levels of educational achievement may be

associated with increased self-care behaviors, including

self-medication.

Income: For the purposes of this study, education and

income will be included as separate variables, while

recognizing their close relationship. Generally, household

income is considered a more reliable indicator in health

services utilization, however, it is a more difficult

measure to obtain because it requires that the respondent be









informed about the income contributions of other household

members. In this study, because the number of individuals

who were not able to report an estimated household income

was relatively large, severely affecting the sample size,

personal income was used. Personal income was adjusted for

inflation on a monthly basis using FIPE/IPC (Fundacgo de

Investigacgo e Pesquisa Econ6mica/Indice de Pregos ao

Consumo) estimates, and standardized to March, 1991 values.

Attitudes toward Medical Care (Att Med Care): The

indicators for measuring attitudes towards medical care are

adapted from Stoller (1988). Items included in a summated

ratings include skepticism regarding the efficacy of medical

care, reluctance to accept professional recommendations, and

belief that a person understands his or her own health

better than a physician. High scores indicate positive

attitudes toward modern medicine.

Attitudes toward Lay Advice about Drugs

(AttLay Advice): The items for this measure tap the

willingness to accept non-professional advice about

medications. The measures are derived from the summated

scores of responses to each item. High scores indicate a

greater willingness to accept non-professional (lay) advice

about medications.

Enabling Variables

Enabling variables address various aspects of access

to care. Ware and Snyder (1975) have identified several







73

indicators related to patient satisfaction with medical care

in the United States which address issues of perceived

access to medical care. Similarly, McKeigan and Larson

(1989) developed a list of items for pharmacy services.

These indicators served as a guide to identify or formulate

revised items that were relevant to the Brazilian context or

could be appropriately adapted. Responses to items were

scaled in Likert fashion and indicators for all enabling

variables are derived from the summated scores of responses

to each item so that high scores reflect greater perceived

access to care. The items selected for the final analysis

are presented in Chapter Four.

Perceived Acceptability of Medical Services

(Accept Med Serv) and Perceived Acceptability of Pharmacy

Services (Accept Pharm Serv): The first dimension of access

considered is acceptability. Acceptability of services

refers to the extent to which a patient or client is

satisfied with the quality of care received. Traditionally,

in the developed countries, quality of care has been

associated with increased sophistication in medical

technology. More recently, however, the development of a

socially amenable and operational definition for quality of

care that includes aspects of patient-provider dynamics has

become a central concern for health policy analysts:

patients who are unsatisfied with the care they receive are

less likely to continue treatment, and are more likely to









seek alternative care than satisfied patients (Donabedian,

1982).

Perceived Availability of Medical Services

(Avail Med Serv) and Perceived Availability of Pharmacy

Services (Avail Pharm Serv): Availability suggests not only

locational dimensions, but also convenience in terms of

operating hours, and assurance of regularity of services.

In rural areas, for example, where distances are greater

than in urban areas, transportation appears to be a

significant factor affecting medication use patterns among

the elderly (Sharpe et al., 1985). Bush and Osterweis

(1978), interested in perceived access to services, found

that although there was a positive association with

prescription medicine use, there was an inverse association

with OTC use. The authors suggest that OTC use may be a

substitute for physician visits when access to medical care

is perceived as inconvenient. Sharpe et al. (1985) also

suggest a substitution effect when perceived access to

pharmacy services was found to be inversely related to

prescription medication use in their rural sample. Some

elderly may be particularly handicapped by disability or

disease such that the perceived availability of services is

of particular importance.

Perceived Affordability of Medical Services

(Afford Med Serv) and Perceived Affordability of Drugs

(Afford Drugs): Affordability, the third dimension of









access considered, is often assumed given certain

conditions. These conditions may be measured in terms of

direct and indirect costs. Typically, direct costs are

related to insurance status, income, out-of-pocket

expenditures and other financial barriers. Indirect costs

include time needed to get to the services, time waiting for

services to be rendered, and related expenses. In many

countries like Brazil, however, organizational mechanisms

may exist for the provision of medical care as well as

needed medications to targeted groups, such as CEME for

generic drugs in Brazil, but these mechanisms often do not,

in fact, function as indicated. Therefore, although the

potential barriers are seemingly minimized, the reality is

another case and enrollment in a public program may not

correspond to availability nor increased perceived

affordability of care. Therefore, the extent to which the

cost of receiving care is perceived as a burden remains a

relevant political and social issue. Items included the

frequency of skipped or reduced doses of a medication for

the purpose of economizing, delaying the purchase of a

medication and delaying medical care due to lack of funds.

Need Variables

The need variables that will be used in the analysis

include perceived health status and number of symptoms.

Ideally, these measures would include clinical diagnosis of

disease states, but usually this information is not









available for HSU studies, and, hence, perceived health

status and symptom experience are the most commonly used

indicators. Measures of health status typically are the

strongest predictors of health services utilization

(Wolinsky and Arnold, 1988), and, by extension, of

prescription drug use (Bush and Osterweis, 1978; Sharpe et

al., 1985, Stoller, 1988). The relationship between

perceived health status and self-medication, or use of OTC

medications, has not been found to be as significant. These

findings suggest that prescription medications are used for

more serious health problems among the elderly, whereas OTC

medicines are used for less serious conditions.

The measure of health status used in this study results

from the summated scores for two items: perceived current

health status, and perceived health status relative to

others of the same age. By including an item of relative

health status, one may control for possible confounding of

perceived morbidity and what might be perceived as the

effects of normal aging.

Number of symptoms experienced by an individual is also

used in this study as a need variable. Although a very

crude measure which does not take into account severity of

symptoms experienced, when analysed together with perceived

health status, it may provide some insight to use of

medications in the presence of a few or many symptoms, given









perceived health status, as in the case of self-medication

for relatively banal health problems.

These measures are not without shortcomings in health

services research, and they bear mentioning. Often, in

research using the HSU model, the researcher presumes an

implicit causal relationship between the patient population

characteristics. For example, the relationship between

symptoms (and health status in general) is assumed to be a

precursor to health services utilization. However, it is

conceivable that the relationship is actually in the

opposite direction and is not discovered given the cross-

sectional nature of the study design. That is to say that a

patient may experience poor health as a result of a

treatment being received. This may be the case with number

of symptoms and side effects in medication use. In the

absence of longitudinal data, inferences should be made

cautiously about relationships that emerge from cross-

sectional data.

Use Variables

The dependent variables examined are number of

physician prescribed (PP) and non-physician prescribed (NPP)

medications used by the participant. The reference period

selected for this study is two weeks prior to the interview.

Participants were asked to recall all medications used

during this period, and to identify who recommended the

medication for them, and for what purpose. Prior to the







78

inquiry, participants were asked to retrieve their medicine

containers, if available. Included in this analysis are

home remedies. This served to enhance the respondent's

recall and to assist the interviewer to correctly identify

the medicines.

Area

The sample was drawn from three socio-economic areas in

the Municipio (county) of Rio de Janeiro. The basis for the

selection of these areas and a description of their salient

characteristics are discussed in a following section on

sampling.

Instrument Development

Instrument development and interviewer training in this

cross-sectional survey were very much intertwined and are

best characterized as a single process. A participatory

approach afforded unique instrument development

opportunities and, in addition, allowed the interviewer to

apply an instrument with which s/he was intimately familiar.

This section will discuss the research procedures, the

survey instrument development, and interviewer training

employed in this study.

Item Selection

Studies of patient satisfaction with medical care

services (Ware and Snyder, 1975) and pharmacy services

(McKeigan and Larson, 1989) provided the basis for item

selection for the instrument in this study. Aspects of









these services relevant to the issues of accessibility,

availability, and affordability were identified and modified

for the Brazilian context. These items (see Appendix A),

together with new items developed for the purpose of model

building and medication use, were reviewed by Brazilian

health care professionals and social scientists, including

two sociologists, two physicians, a dentist, a pharmacist, a

social worker, a psychologist, and a nurse.

Preliminary "test runs" on a small independent sample

of individuals, elderly and not, indicated that response

sets which required responses to items on a five point

"strongly disagree" to "strongly agree" scale, used in the

above mentioned studies, were not successful. It was noted

that these tended to result in monotonic response sets with

little to no variation, and increasingly so as the interview

progressed. This may have been due to the fact that, unlike

the previous studies, items were stated verbally by the

interviewer and subjects were not permitted to read their

alternatives. The use of an interview format rather than

the written questionnaire used in previous studies was

thought necessary to increase response rates and to control

for the effects of high rates of illiteracy. Because of the

problems with five point response scales, the statement

format of the items was changed to a question format

requiring responses which were more concrete, making

reference to actual experiences, and had a more limited







80

number of alternatives. For example, rather than requiring

a respondent to "agree" or "disagree" with the statement,

"The pharmacy is always open when I need", the question was

posed as, "Is the pharmacy always open when you need?" and

possible responses included "Always", "Sometimes", and

"Never". The format also encouraged the respondent to

clarify or expound on their responses and recount specific

relevant experiences. Interviewers were instructed to make

note of these experiences in the questionnaire. The

instrument is included as Appendix B.

Interviewer Training and Instrument Pilot

Interviews were conducted by a team of twelve

individuals in addition to the principal investigator,

selected on the basis of personal or professional interest

in the subject matter. Interviewers were identified by the

field coordinator of the BOAS project. The interview team

included a social worker, a pharmacist, a medical student, a

physical therapist, a sociologist, a journalist, and five

senior university students from the School of Social

Sciences at the State University of Rio de Janeiro (UERJ).

Three training sessions were held. The first session

briefed 15 potential interviewers on the nature of the

project. Printed background material on aging in Brazil and

related health care concerns distributed prior to the first

meeting were reviewed in conjunction with the specific

objectives of the project. Basic survey logistics and the









chronogram were presented at the first session. This

allowed potential interviewers to decide whether or not they

could commit their time for the project, and three did drop

out at this point.

The interviewers reviewed the questionnaire for

content, readability, and clarity in a second meeting. Each

interviewer was asked to complete three questionnaires for

elders not included in the study sample. Results were

discussed in a third training session after which the

questionnaire was again modified to accommodate the

observations and comments offered by the team.

Approximately four weeks after the pilot, interviewers were

asked to re-interview one of the three subjects previously

interviewed. This allowed for the evaluation of the changes

made in the instrument as well as to establish a test-retest

reliability (stability) coefficient for unchanged items.

For unchanged items, those which had coefficients of .70 or

higher were maintained, and others were eliminated or

revised.

The survey was conducted between October 1990 and March

1991. Each interviewer was assigned a quota of interviews

for selected clusters and areas.' Interviewers were

provided with the names, addresses, and if available,

1 Three of the original interviewers resigned from the
team during the course of the survey, and replacements were
trained. Two other interviewers were dismissed during the
survey due to research fraud.









telephone numbers of subjects. The interviewers were

provided with letters of introduction (Appendix C) which

could either be presented personally to the subject or sent

in the mail. These letters advised the subject that they

would be contacted by someone from the research team in

order to make an appointment for an interview.

Each interviewer was accompanied by the principal

investigator for the evaluation of at least one interview

prior to the completion of the interviewer's fifth

interview. The principal investigator observed the

interview and filled in a questionnaire as the interviewer

proceeded with the interview in order to determine the

inter-rater reliability of the instrument. In all cases,

there were no discrepancies between scores. This was

probably due to the closed nature of the response sets which

left little room for interpretation. However, interviewers

had been instructed to note in the questionnaire any

pertinent observations or comments on the survey form,

including responses that did not correspond to any of the

options provided. The principal investigator was then able

to return to the subject at a future date for further

clarification of responses or to re-address a question if

needed.

Quality control mechanisms were in place throughout the

survey, and several cases of fraud in the data collection







83

were discovered.2 Although interviewers were forewarned of

a reinterview schedule for the purpose of quality control,

they were not informed of the actual schedule. Every third

questionnaire completed and returned by each interviewer was

selected for review. A follow-up call or visit with the

subjects who had been interviewed included an explanation to

the subject of the purpose of the reinterview. A selected

subset of questions with high stability coefficients was

repeated to the subject to verify the answers obtained in

the interview. This also afforded the principal

investigator an opportunity to ask other questions of the

subject that would help to clarify responses, as well as to

collect any missing data.

The Sample

The sample for this study consisted of a randomly

selected subsample of all surviving and consenting

participants of the 1989/90 Brazilian Old Age Survey (BOAS).

The BOAS survey was developed and conducted by the Institute

of Social Medicine of the State University of Rio de Janeiro

(IMS/UERJ). The sample consisted of 738 respondents aged

60 years or more, selected to be representative of municipio

of Rio de Janeiro.


2 Two interviewers turned in completed questionnaires
without having actually conducted the interviews. All of the
questionnaires provided by these interviewers were
disqualified, and their behavior reported to relevant
authorities. The respondents were later interviewed in order
to recuperate the sample.









In order to capture the heterogeneity of the

residential zones in the municipio, the BOAS sample was

drawn from three residential areas representing different

socio-economic strata. Five indicators were used to

identify the census districts to represent these strata. The

indicators included mean household income, availability of

piped water and sewage, the average number of children for

women 15 to 49 years of age, the proportion of elderly in

each district, and the number of banking establishments.

Each of these indicators had been shown to be valid and

reliable markers of community socio-economic status in

Brazil (Veras et al., 1989:3-7).

The original targeted BOAS sample size was to be 780

persons aged 60 years or more, with 260 from each designated

SES area. However, the final BOAS sample consisted of only

738 respondents (see Table 3.2). Moreover, 28 participants

who had served as the pilot sample for the BOAS were not

included in this study because their identity was not

available from the BOAS project staff. Therefore, the base

sample from which this study selected its sample included

only 710 elderly.

In selecting a sample for the BOAS project, twenty-four

census districts were ranked according to scores received on

an index composed of the above listed indicators. The three

districts selected as representative of high, middle, and

low socio-economic status communities were, respectively,







85

Copacabana (including the neighborhoods of Copacabana, Leme,

part of Ipanema and Botafogo), Meier (including Meier, Maria

da Graca, Cachambi, Pilares, del Castilho, Todos os Santos,

Abolicao, Cavalcante, Inhauima, Engenho N6vo, Engenho da

Rainha, Tomas Coelho and Piedade), and Santa Cruz, including

the communities of Santa Cruz, Pacidncia, Cosmos, and

Sepetiba (Veras et al., 1989:10-11).


Table 3.2 Summary Statistics of BOAS Study Participants

Copacabana Meier Sta. Cruz

Gender
Female (%) 63.5 60.7 60.3
Male (%) 36.5 39.3 39.7

Mean Age (years) 71.65 71.39 69.37
(SD) (7.57) (7.59) (6.65)

n= 252 244 242





For the present study the targeted sample size was 150

elderly for each district selected from the BOAS

enumeration, for a total of 450. This would allow a power

on the ability to detect a difference between the three

strata on medication use of .97, with f=.25, which is a

medium effect size, and alpha=.05 (Cohen, 1977). This was

considered to be both an attainable figure and one that

would allow for analysis with multivariate techniques. The

sample was selected by using a random numbers table and BOAS

questionnaire numbers as proxies for subject identification







86

until the target sample size for each area was obtained. In

anticipation of attrition due to mortality and change in

residence, as well as refusal to participate, the remaining

subjects were retained as alternates.

Study Areas

Rio de Janeiro is the capital city of the State of Rio

de Janeiro. Rio de Janeiro, together with its neighbors to

the south (S&o Paulo) and east (Belo Horizonte) make up the

core cities of the Southeast region of Brazil, the

wealthiest and most diversified region of the country. Rio

de Janeiro, in addition to being a major tourist center, is

one of the most important commerical, financial, and

industrial centers in the country. It also harbors the

largest slum (Roginha) in Latin America. The Municipio

(county) of Rio de Janeiro, with a population of more than

5.5 million, encompasses a part of a vast metropolitan area,

several suburban and rural areas. The three study areas

selected for this study are representative of this

diversity. A map of the study areas is presented in Figure

3.1.

Copacabana

Copacabana is the most metropolitan of the areas

studied. International known for its beaches, night-life

and social clubs, became a haven for the affluent in the

1940s and 1950s, after the construction of tunnels that made

the area more accessible by automobile and increased the









..-"SAO JOAO DE MERITI
......... .
.................................
..... .o...
S.. NILO-.-
'POLIS.-'


RIO DE JANEIRO


municipio boundaries
municipal railroad
areas represent study areas


Study areas in the Municipio of Rio de Janeiro, Rio de Janeiro, Brazil.


MESQUITA


Legend:


I IShaded I
Shaded


Figure 3.1


4 .... -


12w









value of the property. Previously, it was dotted by beach

houses used by vacationing middle class families from the

older, more established parts of the city (Velho, 1973).

Now, apartment buildings are the modal dwelling

structure and the principal streets are bordered by busy

groundlevel shops and boutiques (i.e., a horizontal

distinction between residential and business and commerical

areas). Mass transportation in the form of buses are

plentiful, their routes criss-cross major avenues, and lead

directly to important points in the city. Most of the

residents in this area are white collar workers and

professionals. Although no longer the most wealthy part of

the city (the money has since moved south to Barra de

Tijuca), the level of infrastructural completeness and

wealth of Copacabana relative to other areas remains high.

There is a INAMPS hospital in Ipanema, known for being

one of the best, and numerous physician offices and clinics

as well as smaller private hospitals. In addition, compared

to the other two study areas, this area is the closest in

proximity to larger facilities in the center of the city.

Pharmacies of various types of pharmacies (homeopathic,

herbal, specialty), are plentiful, with as many as two or

more to a block. The BOAS project estimated that 45,775

elders lived in this area in 1988.









Meier

Meier and surrounding neighborhoods constitute what

once was the growing suburban residential area before

interest turned to the beachfront. Meier was traditionally

considered to be an upwardly mobile, middle class area. The

suburban train routes and the subway also reach out to most

of the neighborhoods in this area. There is an old,

established commerical area that embraces these points of

mass transit.

Single family houses still predominate although some

areas are "building up". In some neighborhoods, such as

Cachambi, there are apartment complexes more than thirty

years old, developed by institutions like the Bank of Brazil

(Branco do Brasil) for its employees with grants obtained

from the federal government (elders living in these

apartments today were among the first tenants).

There are several hospitals throughout the area

(university, public and private), but fewer physician

offices and more public health posts are visible than in the

Copacabana area. The distribution of pharmacies is less

concentrated as well. Approximately 11,249 elders lived in

this area in 1988.

Santa Cruz

Santa Cruz is literally the end of the line: it is the

last stop of the suburban train route after an hour and

forty-five minute ride from downtown. Although there are









bus lines that go into the downtown area from Santa Cruz,

they are relatively expensive and not practical unless one

can afford to go by fresco&o, an air-conditioned express

bus that goes straight to downtown Rio de Janeiro.

Santa Cruz is a rapidly developing suburban area, yet

it still has a rural flavor. Only the principal streets are

paved, and construction is relatively simple, and there are

still many open spaces. The population density in the area

is relatively low compared to the other two study areas.

The estimated number of elders living in this area in 1988

was 11,249.

In Santa Cruz, there is a public hospital, some clinics

scattered about, and various small pharmacies, three of

which are within walking distance of the train station.

There is a large military base and a new industrial complex

near Santa Cruz that provide employment for some residents,

but many residents must commute into the city for their

jobs.

Although there are obvious signs of prosperity in some

of the houses in Santa Cruz proper and neighboring Sepetiba

(approaching the coast), this is less so for the adjacent

neighborhoods of Pacidncia and Cosmos. In these

neighborhoods there are more dwellings in various stages of

a slow construction, or, as the case may be, deconstruction.

A local public elementary school lies in half completion,

and the sewer drainage is open. There is minimal




Full Text
care variables. Access to care was analyzed according to
the dimensions of perceived availability, affordability, and
acceptability of medical and pharmacy services. The
importance of these variables and their interrelationships
were examined for elderly residents in three socioeconomic
areas of Rio de Janeiro (N=436).
The rate of prescribed medication use in the sample was
found to approximate that of elderly populations in the
developing world, but self-medication was not as prevalent
as expected. Need variables were the most important
predictors of use in all areas. Age, gender, and income
were the most important predisposing variables in predicting
prescribed drug use. Household size and attitudes towards
lay advice about drugs were significant predictors of self-
medication.
Access to pharmacy services was not a significant
factor in predicting medication use. Although access to
medical care was not significant in predicting self-
medication, acceptability of medical services was the most
important access variable explaining prescribed drug use.
However, separate area analysis revealed that access to care
was not relevant for either prescribed or nonprescribed
medication use in the high SES area, and different
dimensions were important for each area. The value of
smaller area studies in understanding medication use is
borne out. Directions for further research and the role of
the pharmacy practice in Brazil are discussed.
x


11.
0(a) Sr(a). se considera de que raga ou cor?
Entrevistador: deixa o entrevistado dar a informago livremente.
201
1.
Branco
2. Pardo
3. Amare lo
4.
Moreno
5. Moreno claro
6.
Negro
8.
NS
9. NR
7. Outro
0(a)
Sr(a). tem
alguma religo ou filosofa
de vida?
1.
Sim
0. Nao (Entrevistador:
se Nao, v
para 012)
Qual?
12b. 0(a) Sr(a). practica essa religo? 0. Nao 1. Sim
13. Quando o(a) Sr(a). est doente ou precisa de atendimento mdico, onde ou a quem o(a) Sr(a).
normalmente procura primeiro?
00. o entrevistado nao procura ningum
01. o mdico da instituigo pblica que o entrevistado tem direito de utilizar
02. mdico particular
03. mdico de instituigo privada
04. mdico em urna instituigao de caridade
05. enferme ira
06. farmacutico ou balconista de farmacia
07. conselho de um le i go
08. outros (especificar)
98. NS 99. NR
14a. Quantos mdicos e/ou pessoas nao mdicas o(a) Sr(a). consulta?
Entrevistador: especifique quais sao: (ex: cardiologista, neurologista, homepata...) .
(nmero) Total Favor escrever no outro lado da pgina se faltar espago
14b. Quantos destes tem receitado algum remdio, de qualquer tipo, para o(a) Sr(a).?
Entrevistador: marque com "X" os que tem receitado remdios.
(nmero)


189
b. It is possible that my doctor might recommend
surgery (an operation) when another treatment
would be better.
c. My doctor has continued to treat some of his
patients even when he/she was unsure about what
was wrong with them.
6. MODERNITY
a. In general, the medical care in my area is
somewhat out-of-date.
b. My doctor keeps up on all of the latest medical
discoveries.
7. THOROUGHNESS (INFORMATION TAKING)
a. I think that my doctor forgets to ask about the
problems I've had in the past.
b. Sometimes my doctor misses important information
when I talk to him/her.
c. My doctor will examine his patients carefully
before deciding what is wrong.
d. My doctor lets his/her patients tell him/her
everything that is important.
8. CONSIDERATION
a. My doctor does not seem to care if he hurts me
during an examination.
b. My doctor never keeps his patients waiting very
long.
c. My doctor takes the feelings of his/her patients
into consideration.
d. My doctor does his best to keep his patients from
worrying.
9. COURTESY/RESPECT
a. The people who work in my doctor's office are
always courteous and friendly.
b. My doctor always treats his/her patients with
respect.


75
access considered, is often assumed given certain
conditions. These conditions may be measured in terms of
direct and indirect costs. Typically, direct costs are
related to insurance status, income, out-of-pocket
expenditures and other financial barriers. Indirect costs
include time needed to get to the services, time waiting for
services to be rendered, and related expenses. In many
countries like Brazil, however, organizational mechanisms
may exist for the provision of medical care as well as
needed medications to targeted groups, such as CEME for
generic drugs in Brazil, but these mechanisms often do not,
in fact, function as indicated. Therefore, although the
potential barriers are seemingly minimized, the reality is
another case and enrollment in a public program may not
correspond to availability nor increased perceived
affordability of care. Therefore, the extent to which the
cost of receiving care is perceived as a burden remains a
relevant political and social issue. Items included the
frequency of skipped or reduced doses of a medication for
the purpose of economizing, delaying the purchase of a
medication and delaying medical care due to lack of funds.
Need Variables
The need variables that will be used in the analysis
include perceived health status and number of symptoms.
Ideally, these measures would include clinical diagnosis of
disease states, but usually this information is not


85
Copacabana (including the neighborhoods of Copacabana, Leme,
part of Ipanema and Botafogo), Meier (including Meier, Maria
da Graga, Cachambi, Pilares, del Castilho, Todos os Santos,
Aboligo, Cavalcante, Inhama, Engenho Novo, Engenho da
Rainha, Toms Coelho and Piedade), and Santa Cruz, including
the communities of Santa Cruz, Paciencia, Cosmos, and
Sepetiba (Veras et al., 1989:10-11).
Table 3.2 Summary Statistics of BOAS Study Participants
Copacabana Mier Sta. Cruz
Gender
Female (%) 63.5 60.7 60.3
Male (%) 36.5 39.3 39.7
Mean Age (years)
71.65
(SD) ( 7.57)
71.39 69.37
( 7.59) ( 6.65)
n=
252
244 242
For the present study the targeted sample size was 150
elderly for each district selected from the BOAS
enumeration, for a total of 450. This would allow a power
on the ability to detect a difference between the three
strata on medication use of .97, with f=.25, which is a
medium effect size, and alpha=.05 (Cohen, 1977). This was
considered to be both an attainable figure and one that
would allow for analysis with multivariate techniques. The
sample was selected by using a random numbers table and BOAS
questionnaire numbers as proxies for subject identification


116
Table 4.16 When you have a question about your
medications, whom do you usually consult first?
Copacabana
(n=138)
%
Mier
(n=147)
%
Sta. Cruz
(n=151)
%
No one
16.7
11.6
4.0
Physician
74.6
60.5
63.6
Nurse
0.0
1.4
6.0
Pharmacist
0.7
8.2
11.3
Lay person
4.4
15.0
11.3
Other
3.6
3.4
4.0
When asked if qualified pharmacists can explain to
clients the effects of medications better, the same, or
worse than physicians, 47.6% of the respondents answered
that pharmacists explain worse than physicians, 39.3%
believed that pharmacists explain the effects of medicines
about the same as physicians, and only 13.2% believed that
the pharamcist is better than the physician. There was no
statistical association with area (X2=4.74, df=4,p=.31).
However, when asked if the pharmacists should explain the
effects of medications, the elders in Copacabana are much
more skeptical than in the other two areas (see Table 4.17)
Table 4.17 Should the pharmacist explain the effects of
medications to their clients?
Copacabana
(n=138)
%
Mier Sta. Cruz
(n=147) (n=151)
% %
38.4 66.2 68.2
18.8 10.3 18.5
42.8 23.5 13.3
Xz=42.42, df=4, p<.000
Always
Not always
Never


89
Mier
Mier and surrounding neighborhoods constitute what
once was the growing suburban residential area before
interest turned to the beachfront. Mier was traditionally
considered to be an upwardly mobile, middle class area. The
suburban train routes and the subway also reach out to most
of the neighborhoods in this area. There is an old,
established commerical area that embraces these points of
mass transit.
Single family houses still predominate although some
areas are "building up". In some neighborhoods, such as
Cachambi, there are apartment complexes more than thirty
years old, developed by institutions like the Bank of Brazil
(Branco do Brasil) for its employees with grants obtained
from the federal government (elders living in these
apartments today were among the first tenants).
There are several hospitals throughout the area
(university, public and private), but fewer physician
offices and more public health posts are visible than in the
Copacabana area. The distribution of pharmacies is less
concentrated as well. Approximately 11,249 elders lived in
this area in 1988.
Santa Cruz
Santa Cruz is literally the end of the line: it is the
last stop of the surburban train route after an hour and
forty-five minute ride from downtown. Although there are


CHAPTER 2
MEDICAL AND PHARMACY SERVICES IN BRAZIL
Introduction
This chapter presents the health care context in which
medication use takes place in Brazil. The discussion begins
with an overview of the formal health care system, the
principal public and private institutions that provide
services, and how they are utilized. National formularies,
regulations that define legend and non-legend drug
categories, who may prescribe legend medications, and the
mode of distribution and commercialization of medications
are all aspects of a formal health care system.
The discussion of the informal health care system, for
the purpose of this study, is limited to the role of the
pharmacy and pharmacy personnel. Commercial pharmacies are
at once marginal to the formal health care system and an
essential element. They also represent an avenue for
recourse in self-help in general, and self-medication in
particular.
Health Care in Brazil
The character of the Brazilian health care system is
fragmented, offering disparate levels of care. The level of
technological sophistication and "completeness" of services
31


62
medications were recommended by the pharmacy for the purpose
of provoking an abortion. The study found that 83% of the
pharmacies studied (N=102) recommended a medication for this
purpose. Cytotec was recommended in 67% of the pharmacies.
The study suggested that salespersons who recommended
Cytotec were "informed" by the product package insert, which
listed pregnancy as a contra-indication for use ("Remdio
para lcera...", 1991).
There is an increasing awareness on the part of the
pharmacy profession in Brazil of the need to return to the
community pharmacy. In January, 1990, the National Board of
Pharmacy (Conselho Federal de FarmciaCFF) announced that
it was presenting to Congress a plan, the "Project for
Assistance to the Pharmacy", that called for the mandatory
presence of a professional pharmacist in all pharmacies.
The principal objective of this plan is to curb self-
medication. On Februrary 21, 1991, the National Assembly of
the CFF met in Brasilia to address this issue, to identify
barriers, and to set goals and objectives for the future of
the profession which would include a return to community
practice. There are decades of resignation to shake off,
and little economic incentive to leave the harbor of
industry employment, but it appears that the public
continues to value the pharmacist and is likely to welcome a
return to the pharmacy, if it doesn't cost too much!


34
bureaucracies (Horn, 1985; Luz, 1986). By 1974, however,
pressure was put on political leaders to address the dearth
of public health services and the rising costs of health
care to specific needy populations not covered by social
security, such as nonsalaried urban workers and rural
workers (Malloy, 1977; Mesa-Lago, 1978).
In 1975, the Sistema Nacional de Sade (SNS) was
created as the first attempt at a unified, coordinated
national health care system. The new system
administratively linked the three ministries already
involved in some aspect of health care: the Ministry of
Labor was to oversee occupational health and safety
programs; the Ministry of Health was to be responsible for
health planning and for environmental and collective
preventative health care; the Ministry of Social Security
and Social Assistance (MPAS) was to be responsible for the
provision of personal health services. The newly created
INAMPS was to be directly reponsible for the reorganization
and expansion to the poor of certain services previously
reserved for beneficiaries.
The role of the social security program in providing
medical services increased with the growing pool of social
security beneficiaries. Between 1970 and 1980, the
proportion of all workers covered by Social Security in
Brazil increased from 27 percent to 47 percent (Isuani,
1984:195). In the urban areas, 86.3 percent of all


ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL
By
MARIA ANDREA MIRALLES
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1992


98
Half of all respondents from Copacabana (50.7%)
reported their health to be good to very good, 35.4% of
those from Mier and 40.7% from Santa Cruz reported their
health to be good to very good. The differences between the
strata on this item, however, are not statistically
significant. When asked to evaluate their health relative
to others of the same age, 94% of those from Copacabana, 90%
of those from Mier, and 86% of those from Santa Cruz
believed that their health was the same as or better than
their age cohorts, but, again, differences are not
statistically significant.
Health status was also evaluated by the presence of
certain symptoms. The participants were asked whether or
not they were experiencing any of the symptoms listed in the
questionnaire, or any other not listed. Summary information
on the frequency of symptoms reported for the the entire
sample and for the three areas is given in Table 4.4. The
three most commonly reported symptoms for both Santa Cruz
and Copacabana are backaches and other pains in joints and
extremities, vision problems, and nervousness. In Mier,
the most frequently reported symptoms were vision related
problems, follwed by backaches and other aches in the
extremeties, and forgetfulness. The average number of
symptoms reported for the entire sample was 6.3. On this


109
Table 4.12 Usual source of medications.
Copacabana
(n=138)
%
Mier
(n=147)
%
Sta. Cruz
(n=151)
%
Physician
0.0
2.0
0.0
Health post
0.0
3.4
1.3
Hospital dispensary
Retail pharmacy
0.0
1.4
7.9
(allopathic)
Retail pharmacy
94.2
85.7
83.4
(homeopathic)
2.9
3.4
3.3
Other, pharmacy
2.2
1.4
1.3
Other, non-pharmacy
0.0
1.4
2.7
Never uses medications
0.7
1.4
0.0
On average, the elders in the sample reported having
visited a pharmacy twice during the thirty days prior to the
interview. Summary information on pharmacy visits is
presented in Table 4.13. Area differences were significant
(F=4.17, df=2, p<.016), with a significant difference
between Mier and Santa Cruz, according to the post hoc
pairwise analysis. The frequency with which an individual
patronizes the same pharmacy varies significantly among the
three areas studied. Half of the elderly in Copacabana
always go to the same pharmacy to purchase their
medications, whereas only one-third do so in the other two
areas. The tendency to "shop around" is greatest among the
elderly in Mier, who probably try to take advantage of some
of the discounts offered in the pharmacies closer to
downtown.


172
the determination of the of hazardous self-medication
occurring as a result of the relaxed commercialization of
drugs. Data gathered in these interviews could be examined
according to the legend/nonlegend distinction in future
analyses.
The findings are generalizable only to the non-
institutionalized elderly in the Municipio of Rio de
Janeiro, and generalizations to the institutionalized
elderly and to other Brazilian municipios is limited. The
variables may be examined in other areas and other age
cohorts, thus allowing for comparison of results. This
might be necessary especially for the increased
understanding of the importance of access to care in
medication use in different contexts.
There are no interaction effects evaluated in this
study. Because different predictor variables emerged for
each area, this suggests that there may be significant
interactions with area, and there are likely to be others
within each area. However, the examination of interaction
effects beyond those with area lies beyond the scope of the
present study.
Timing was of the essence in this study. The timing
was unique in that interviews began soon after and
throughout a very turbulent period of crisis regarding the
price and supply of medications, many of which were
important to elderly patients. As a result, there was


236
Grymonpre, Ruby, Paul Mitenko, Daniel Sitar, Fred Aoki, and
Patrick Montgomery. 1988. "Drug-associated Hospital
Admissions in Older Medical Patients." Journal of the
American Geriatrics Society 36:1092-1098.
Gurwitz, John H., and Jerry Avorn. 1991. "The Ambiguous
Relation between Aging and Adverse Drug Reactions." Annals
of Internal Medicine 114:956-966.
Haak, Hilbrand. 1988. "Pharmaceuticals in Two Brazilian
Villages: Lay Practices and Perceptions." Social Science and
Medicine 27 (12):1415-1427.
Hale, William E., Franklin E. May, Ronald Marks, and Ronald
B. Stewart. 1987. "Drug Use in an Ambulatory Elderly
Population: a Five Year Update." Drug Intelligence and
Clinical Pharmacy 21(6):530-535.
Hallas, J. B., B. Harvald, L. F. Gram, E. Grodum, K. Brosen,
T. Haghfelt, and N. Damsbo. 1990. "Drug-related Hosptial
Admissions: the Role of Definitions and Intensity of Data
Collection and the Possibility of Prevention." Journal of
Internal Medicine 228:83-90.
Hardon, Anita. 1987. "Use of Modern Pharmaceuticals in a
Filipino Village: Doctor's Prescriptions and Self-
Medication." Social Science and Medicine 25(3):277-292.
Haug, Marie, May Wykle, and Kevan Namazi. 1989. "Self-Care
among Older Adults." Social Science and Medicine 29(2):171-
183.
Hepler, Charles D. and Linda M. Strand. 1990.
"Opportunities and Responsibilities in Pharmaceutical Care."
American Journal of Hospital Pharmacy 47(3):533-542.
Horn, James J. 1985. "Brazil: The Health Care Model of the
Military Modernizers and Technocrats." International Journal
of Health Service 15(l):47-68.
"Hospitais Municipais tambm Cobraro de Empresa Privada."
1990. Jornal do Brasil September 1.
Instituto Brasileiro de Geografia e Estatistica (IBGE).
1989. "Acesso a Servigos de Sade." Pesguisa Nacional por
Amostra de Domicilios (PNAD). Vol. 10, Supplemento 3. Rio de
Janeiro: IBGE.
. 1987. Special age tables. Unpublished.
. 1980. Censo Demogrfico. Brasilia:IBGE.


Table 4.19 Most Common Therapeutic Indications for all Drugs for Physician
Prescribed (PP) and Non-physician Prescribed (NPP) Medication Use.
Number of Participants3
Therapeutic Indications15
PP
%
NPP
%
Total
%
Antihypertensive drugs
101
29.5
4
2.7
105
24.1
Diuretics
92
26.9
14
9.4
106
24.3
Congestive health failure drugs
Antirheumatic drugs (incl. anti-
77
22.5
1
0.7
78
17.9
phlogistics)
Analgesic/antipyretics
42
12.3
20
13.5
62
14.2
(non-narcotic)
38
11.1
23
15.5
61
13.9
Other metabolism and nutrition drugs
31
9.1
0
0.0
31
7.1
Vitamins
15
4.4
6
4.1
21
4.8
Coronary vessel dilators
18
5.3
1
0.7
19
4.3
Anxiolytic sedatives
16
4.7
1
0.7
17
3.9
Antiarrhythmic drugs
13
3.8
0
0.0
13
2.9
Antacids
Digestants (incl. stomachics,
11
3.2
4
2.7
15
3.4
choleretics, digestive enzymes)
Water, mineral salts supply (incl.
3
0.8
15
10.1
16
4.1
K+, Ca++)
10
2.9
2
1.3
12
2.7
Antidiabetic
16
4.7
0
0.0
16
3.7
a Numbers listed indicate number of
individuals
taking
at least one drug
in each
category. Total number of participants
using at
. least
one PP
medication
is 342;
the total
number using at least one NPP medication is 148;
Participants may be included in both PP and NPP
the total sample size is
categories.
436.
b Based on WHO classifications. Only partial list of most frequent classes reported.
122!


140
Non-Phvsician Prescribed Medication Use
The distribution of values for the number of non
physician prescribed (NPP) medications was found to be
bimodal and as such not appropriate for multiple regression
analysis. The dependent variable was recoded to reflect two
categories: l=use of one or more NPP medications, and 0=no
use of NPP medications. Logistic regression analysis (PROC
LOGIST in SAS) was then applied in a fashion parallel to the
stepwise backward elimination regression in the previous
analysis, with .10 being the significance level a variable
must have in order for that variable to be retained in the
model.
For this analysis, a dummy variable was included in the
model to control for PP medication use. The reasoning for
this is that, if the patient is receiving prescriptions from
a physician, s/he may be more likely to ask for the
physician's recommendation for any other products that might
be used without a prescription. The correlation matrix
indicates a fairly low yet significant negative relationship
between PP and NPP medication use (r=-.12), suggesting that
a person is less likely to use one category if s/he uses the
other. Furthermore, there is a relatively high utilization
of physician serivces in this sample. The average number of
physician visits per year was 9.31 for this sample,
1 This is based on an extrapolation from the average
of vists for the 30 day period prior to the interview, and,
therefore, is a rough approximation.


193
e.Clerks are usually well informed about medicines.
2. FOLLOW-UP CARE (PERSONNEL SPECIFIC)
a. I think that my pharmacist forgets to ask about
the medications I've had in the past.
b. My pharmacist has ignored things my medical
history when selling me a drug.
c. Clerks are not usually interested in the health
problems I've had in the past.
3. INFORMATION GIVING
a. Pharmacists should be careful to communicate to
the patient about treatments.
b. My pharmacist is careful to explain what I am
expected to do with my medicines.
c. My pharmacist often explains why my doctors order
and medicines and lab tests.
d. My pharmacist is careful to explain the side
effects of the medicines I buy.
e. My pharmacist will explain the side effects of
medicines even when I don't ask.
f. My pharmacist does not always explain the drug
choices open to me.
g. The pharmacy clerks do not always explain the drug
choices open to me.
h. My pharmacist always explains the nature of a drug
so that you can understand how it will affect you.
4. PREVENTIVE MEASURES
a. My pharmacist rarely suggests ways to keep from
getting sick.
b. My pharmacist asks what other medications I am
taking so that I won't mix drugs that I should
not.
c. My pharmacist asks what allergies I have to avoid
allergic reactions.


7
refers to the control by a small number of large
multinational corporations (MNCs) of the means of
production, research and development of most pharmaceuticals
throughout the world. The dependency perspective argues
that this control translates into political and economic
power which, in turn, may be used to manipulate domestic and
foreign policies of countries without a strong domestic
industry. Because they depend on MNCs to provide their
populations with needed medications, other national economic
and health interests may be compromised. On the other hand,
however, there can be no doubt that MNCs do play a vital,
positive role in meeting medication needs in situations
where no one else can do so. Many developing countries may
never be able to sustain a viable national pharmaceutical
industry and must rely on imported products, or products
produced by local MNC subsidiaries. From the industry's
perspective, the problems of providing "the right
medications at the right price" stem from public rather than
private sector inconsistencies and inadequacies (Peretz,
1983).
During the late 1950s and early 1960s, the
pharmaceutical industry world-wide experienced radical
changes in the research and development of new drugs. With
the introduction of expensive and time consuming clinical
trials and new laboratory techniques in drug development,
there was a decline in the rate of innovation, traditionally


55. 0(a) Sr(a). acha que, quando os mdicos receitam um remedio,
1. nSo se deve nunca se desconfiar das rece i tas.
2. poucas vezes d para se desconfiar das rece i tas.
3. muitas vezes d para se desconfiar das receitas.
4. sempre d para se desconfiar das receitas.
213
56.Em geral, na sua experiencia, quais sao as diferengas entre os remdios que precisam de
receita mdica e os remdios que nao precisam de receita mdica? (Resposta "Sim" ou "Nao")
1.
Os
que
precisam
receita sao mais fortes?
a.
Sim b.
Nao
2.
Os
que
precisam
receita sao mais perigosos?
a.
Sim
b.
NSo
3.
Os
que
precisam
receita sao mais eficazes?
a
Sim
b. NSo
4.
Os
que
precisam
de receita mdica sao mais caros?
a.
Sim
b.
Nao
5. Outro
8. NS 9. NR
57.Em relagSo aos remdios caros e remdios baratos, o(a) Sr(a). acha que remdio barato
1. nunca faz nada/no vale nada.
2. s vezes d o mesmo resultado que remdio caro.
3. muitas vezes d o mesmo resultado que remdio caro.
4. em geral, remdio barato d o mesmo resultado que remdio caro.
58. 0(a) Sr(a). acha que quando os mdicos aconselham, eles
1. sempre criam mais problemas do que resolvem.
2. muitas vezes criam mais problemas do que resolvem.
3. algunas vezes criam mais problemas do que resolvem.
4. raramente criam problemas.
[Entrevistador: Alguns dos entrevistados podem se consultar com mais de um mdico. Nesse caso, daqui em
diante, estamos interessados no mdico com quern mais consulta. Se o entrevistado sempre recebe atendimento
mdico da mesma instituigao (ex. hospital de INAMPS) mas nem sempre com o mesmo mdico, substitua a
expresso "seu mdico" para "os mdicos de (nome da instituido)Caso contrrio, alguns entrevistados
nao consultam mdico nunca, ou faz muito tempo que nao procuram atendimento mdico, mas tern direito a
algum, seja pblico ou privado e at de caridade. Sendo assim, o objeto de "seu mdico" seria "o mdico
que atendera em caso de voc precisar de atendimento mdico" ou "mdicos em geral."]
59.Para o tipo de equipamento que o(a) Sr(a). normalmente precisa, o consultrio do seu mdico est
1. muito bem equipado.
2. suficientemente equipado.
3. pouco ou nada equipado.
9. NS


129
respect offered to clients. Mier and Copacabana elders
scored similarly on perceived acceptability of pharmacy
services items, with less positive scores than Santa Cruz
elders. This is consistent with Loyola's observation (1983)
of a qualitative difference in the relationship between
client and pharmacy in areas further away from commercial
centers and of lower socio-economic status.
Perceived Availability of Pharmacy Services
(Avail Pharm Serv): The differences among the three areas
on this measure are similar to the differences found for the
availability of medical services. Availability was measured
in terms of the availability of medicines, convenience,
continuity of service, the supply of pharmacies and
pharmacists, emergency service, and ancillary services.
Copacabana elderly gave significantly higher scores than
each of the other two areas to items measuring availability
of pharmacy services, and there was no significant
difference between Mier and Santa Cruz. As in the case for
medical services, the greater number of pharmacies, and
their relatively high concentration in Copacabana probably
accounts for this.
Perceived Affordability of Drugs (Afford_Druqs):
Significant differences in means for perceived affordability
of medicines were found between Copacabana and Santa Cruz,
and between Mier and Santa Cruz, reflecting differences in
income in the three areas. Therefore, the elders in Santa


136
There is a strong postive correlation between
Accept_Med_Serv and Avail_Med_Serv (r=.50), but no
significant relationship between Accept_Med_Serv and
Afford_Med_Serv. As might be expected, both education and
income are positively correlated with Avail_Med_Serv (r=.23
and r=.23 respectively), and increased number of symptoms is
associated with the perception that medical services are is
less affordable (r=-.23). The Accept_Pharm_Serv is
positively related to the Avail_Pharm_Serv (r=.18).
Avail_Pharm_Serv positively associated with Afford_Drugs
(r=.29). However, there is a mild negative relationship
between Accept_Pharm_Serv and Afford_Drugs (r=-.12). This
supports the observation that drogaras, in contrast to true
pharmacies, offer retail services practically devoid of
professional services. As discussed previously, most
consumers do not expect much professional service in
drogaras, but they do look for lower prices. Consumers
will "shop around" at different drogaras for the lowest
prices, and if there are more available, people are more
likely to get the better prices they seek.
As expected, there is a strong positive relationship
between perceived availability of medical and pharmacy
services (r=.39), and between perceived affordability of
medical services and pharmaceuticals (r=.52). There is also
a strong positive relationship between willingness to accept


139
Table 4.25 Regression Model for Prescribed Medication
Use for Elderly, Rio de Janeiro.
Variable
Regression Coefficients
Beta
Std. Error
Std. Beta
Intercept
. 152
Copacabana
1.082***
.285
.221
Meier
.434
.231
. 090
Gender
.523*
.230
. 110
Age
.054***
.014
. 166
Income
.667*
. 673
. 034
Health Status
- .299***
.060
- .223
No. Symptoms
.916***
. 177
.243
Accept_Med_Serv
.944***
.216
. 191
R2 = .27 N=421;
df=420
*E < .05 **e < .01 ***e < .001
The prediction model, which accounts for 27% of the
variance, follows rather closely the observations from the
correlation matrix. When controlling for area, being
female, being older, having greater incomes, experiencing
more symptoms, and perceiving poorer health status are
associated with increased use of prescribed medications. Of
the access to care variables, both medical and pharmacy,
only Accept_Med_Serv significantly contributed to the model
when controlling for all other significant variables. By
comparing the standardized regression coefficients, we can
see that the number of symptoms has the strongest effect in
the model (b=.24), followed by perceived health status (b=-
.22) and the area, Copacabana (b=.22), where people use more
medications.


126
available to all citizens, either through social security
affiliate status, or indigent status. These services may be
used as a "backup" when private insurance or other private
institutional support is not feasible or practical.
Descriptive results for all item and subtest responses are
presented in Appendix D.
The purpose of assessing these three dimensions of
access to care is to address the question of the adequacy of
a single measure of access as a proxy for its component
parts. In other words, to what extent does the single
measure obscure meaningful relationships that otherwise
might emerge? In this case, we may test for differences in
the means among the three areas for each dimension of access
to determine if differences between areas are the same for
each access variable. The mean scores for the access
dimensions for each area were compared with an analysis of
variance. Scheff's test (with alpha=0.05,
confidence=0.95, d.f.=433, F=3.016) was used for the a
posteriori comparisons where statistical significance was
found. The results are presented in Table 4.22.
Perceived Acceptability of Medical Services
(Accept Med Serv); This was the only dimension of access to
medical care that was not found to be significantly
different for the three areas. The construct of
acceptability of services measured the extent to which the
individual finds the quality of the medical services to


120
Table 4.18 Extent of Physician Prescribed (PP) and Non-
Physician Prescribed (NPP) use of Elderly
Copacabana
(n=138)
%
Mier Sta. Cruz
(n=147) (n=151)
% %
Persons using at least one:
medication (%) 96.4
PP medication (%) 93.5
NPP medication (%) 37.0
86.4
80.3
25.9
82.1
62.9
39.1
Mean no. medications used 3.87 3.07
(SD) (2.23) (2.33)
F=8.11, df=2, pc.001
2.81
(2.41)
Mean no. PP medications
used 3.31 2.57
(SD) (2.18) (2.11)
F=ll.46, df=2, pc.001
2.09
(2.26)
Mean no. NPP medications
used 0.57 0.50
(SD) (0.93) (1.11)
F=1.81, df=2, p=. 16
0.73
(1.18)
Of the 1154 medications used by this sample, 82% were
prescribed by a physician. Most of the NPP medications were
self-prescribed (92.7%), a pharmacist recommended the
medication in 1.1% of the NPP medications, a friend or
family member another 2.9%, and the remaining 3.3% were
recommended by another individual.
The active ingredients of the medications used by the
sample were analysed using the method employed by May et al.
(1982), based on WHO therapeutic classifications. A drug
dictionary was developed that listed active ingredients, and
each ingredient was classified for up to three therapuetic


131
advice about drugs (F=25.96, df=2, p>.0001). Again,
applying Scheff's multiple comparison method, the mean for
Copacabana (x=5.52, sd=1.73) and Meier (x=5.17, sd=1.67)
were found to each be significantly different from the mean
for Santa Cruz (6.79, sd=2.47).
Correlates of Medication Use
In order to identify factors that influence physician
prescribed (PP) and non-physician prescribed (NPP)
medication use and to assess the relative importance of the
factors, 15 predictor variables were chosen, as defined in
Chapter 3. Data from the study were evaluated for the
appropriateness of the normality assumptions required for
linear regression modelling. Five independent variables
with highly skewed distributions (income, ATP, PAXMS, PAVMS,
and number of symptoms) were transformed by taking
logarithms to base e in order to induce normality. The
means and standard deviations of the variables are presented
in Table 4.23.
The measures of associations for the data are presented
in Table 4.24: Pearsons' product moment for interval data,
Spearmans' rank order correlation for ordinal data, point
bi-serial correlations for associations between a dichotomy
and continuous data, and eta correlation ratio for the
associations between ordinal and categorical data. From the
correlation matrix we can get an idea of which predictors,


148
the other two areas. This may be accounted for by the fact
that the people who have lived in Santa Cruz for many years
were originally "rural" residents. This area has become
increasingly suburban only within the last decade.
Typically, in rural Brazil, education levels fall below
those of the more metropolitan areas (NEPP, 1988:280-281).
The relationship between perceived health status and
number of symptoms is strong in all areas, although the
strength of the relationship differs, being particularly
strong in Santa Cruz (r=-.52) and weakest in Copacabana (r=-
.23). The relationship between the Accept_Med_Serv and the
Avail_Med_Serv is also strongest in Santa Cruz (r=.62) and
weakest in Copacabana (r=.29). Similarly, a positive
relationship between Att_Lay_Advice and Accept_Pharm_Serv is
significant in the three areas. However, in Santa Cruz, the
relationship is very strong (r=.49), in Meier it is the
weakest (r=.19).
There is no relationship between Afford_Med_Serv and
Accept_Med_Serv in Santa Cruz nor in Copacabana. If one was
to expect a pattern that follows others present, the first
relationship would be more strongly related in Santa Cruz
than in the other areas. Only in Santa Cruz, the low SES
area, is there a significant relationship between
Afford_Med_Serv and income (r=.26).


84
In order to capture the heterogeneity of the
residential zones in the municipio. the BOAS sample was
drawn from three residential areas representing different
socio-economic strata. Five indicators were used to
identify the census districts to represent these strata. The
indicators included mean household income, availability of
piped water and sewage, the average number of children for
women 15 to 49 years of age, the proportion of elderly in
each district, and the number of banking establishments.
Each of these indicators had been shown to be valid and
reliable markers of community socio-economic status in
Brazil (Veras et al., 1989:3-7).
The original targeted BOAS sample size was to be 780
persons aged 60 years or more, with 260 from each designated
SES area. However, the final BOAS sample consisted of only
738 respondents (see Table 3.2). Moreover, 28 participants
who had served as the pilot sample for the BOAS were not
included in this study because their identity was not
available from the BOAS project staff. Therefore, the base
sample from which this study selected its sample included
only 710 elderly.
In selecting a sample for the BOAS project, twenty-four
census districts were ranked according to scores received on
an index composed of the above listed indicators. The three
districts selected as representative of high, middle, and
low socio-economic status communities were, respectively,


38
discontinuation of badly needed services. Indeed, two
thousand health posts and several public hospitals
throughout the nation were not providing services due to
lack of funds to pay personnel and purchase supplies
('Atraso na verba....", 1990).
The Private Sector
The private health care sector in Brazil includes
services provided by health care corporations for large
companies and institutions (such as banks, and labor
unions), religious and other charitable institutions, as
well as large and small private practices. The delivery
style in the private sector mirrors that of the public
sector and is heavily hospital-oriented. Indeed, the
character of the medical-industrial complex in Brazil is the
result of a symbiotic relationship between private medical
businesses and public funds.
Prior to 1965, there were several health-related
programs, each designed for a separate workers group (i.e.,
railroad workers, steel workers, etc.). When these various
programs were unified, Social Security began to contract
with health care organizations to provide medical services
to some of these groups. Health care corporations and group
practices, generally affiliated with private hospitals,
could be certified by Social Security and negotiate with
businesses and workers groups, and then be reimbursed by
social security. Private, subsidized services were made


240
Patel, Mahesh S. 1983. "Drug Costs in Developing Countries
and Policies to Reduce Them." World Development 11(3):195-
204.
Pedhazur, E.J. 1982. Multiple Regression in Behavioral
Research: Explanation and Prediction. 2nd ed. New York:
CBS College Publishing.
Peltzman, Sam. 1987. "By Prescription Only...or
Occasionally?" AEI Journal on Government and Society 3/4:23-
28.
Peretz, S. Michael. 1983. "Pharmaceuticals in the Third
World: The Problem from the Suppliers7 Point of View." World
Development 11(3):259-264 .
Rabin, David L. 1977. "Prescribed and Nonprescribed Medicine
Use." In Perspectives on Medicines in Society. Eds. Albert
Wertheimer and Patricia Bush. Hamilton, IL: Drug
Intelligence Publications. 58-87.
Ramos, L. R., R. Veras, and A. Kalache. 1987.
"Envelhecimento Populacional: Uma Realidade Brasileira."
Revista de Sade Pblica (SP) 21:211-224.
Rangel, Tereza. 1991. "SUNAB discute Aumentos com o Setor
Farmacutico." Folha de Sao Paulo March 3.
"Remdio para lcera indicado como abortivo." 1991.
Jornal do Brasil January 17.
"Remdios Congelados por 45 dias." 1990. Jornal do Brasil
December 27.
"Remdios tero que Custar Menos." 1990. Jornal do Brasil
December 29.
Segall, Alexander, and Jay Goldstein. 1989. "The Correlates
of Self-Provided Health Care Behaviour." Social Science and
Medicine 29 (2):153-161.
Shannon, G. Skinner, J. and Bashshur, R. 1973. "Time and
Distance: the Journey for Medical Care." International
Journal of Health Services. 3:237-244.
Sharpe, Thomas R., Mickey C. Smith, and Anne R. Barbre.
1985. "Medicine Use among Rural Elderly." Journal of Health
and Social Behavior 26(6):113-127.
Silverman, Milton. 1976. The Drugging of the Americas.
Berkeley, CA: University of California Press.


12
physician offices and hospitals and are, therefore,
relatively accessible (Knox, 1981). In various developing
country contexts, pharmacists and other pharmacy personnel,
whether formally trained or not, are often called upon to
play the role of a culture broker, interpreting and
mediating modern medicine and alternative or popular care
traditions (Woods, 1977; Press, 1969; Fergusen, 1983; Logan,
1983). Because of the relative accessibility of
pharmacists, in those societies where resources for medical
care compete with those for other pressing development
needs, pharmacies may represent an untapped resource by
health care planners in promoting informed self-medication.
Although the potential for pharmacists to serve as
primary providers and health care advocates in countries
like Brazil is apparently great, there are significant
barriers to overcome. Primarily, often, the vendor of
pharmaceuticals is not a pharmacist. Although the need for
a trained pharmacist in the community setting is open to
debate, some reorientation within the profession which re
emphasizes professional responsibilities in the community
pharmacy is clearly required (Cunha, 1987). If a minimum
standard for trained, informed pharmacy assistance for
patients could be established and enforced, the abuses
arising from the precedence of commercial interests over
patient welfare may be curbed.


214
60. Quando o(a) Sr(a). vai ao mdico para urn novo problema de sade, seu mdico
1. sempre examina os seus antecedentes mdicos.
2. s vezes examina os antecedentes mdicos.
3. nunca examina os antecedentes mdicos.
9. NS
61.
Na sua experincia, seu mdico explica seu estado de sade
1. sempre explica
2. muitas vezes explica.
3. s vezes explica
4. nunca explica.
62.Quando seu mdico pede exames de laboratorio ou raios X, ele(a) explica o que espera dos
resultados?
1. sempre explica.
2. multas vezes explica.
3. s vezes explica.
4. nunca explica.
63.Quando o mdico receita um remdio para o(a) Sr(a)., ele(a) explica como e quando tomar o
remdio?
1. sempre explica.
2. mu itas vezes explica.
3. s vezes explica.
4. nunca explica.
64. 0 seu mdico explicou alguma vez o que que o(a) Sr(a). deve ou nao deve fazer para evitar
doen£as, por exemplo, parar de fumar, mudar a dieta, fazer mais exercicio, etc.?
1. Sim
2. Nao 9. NS
65. Seu mdico se preocupa em explicar as coisas para o(a) Sr(a). entender
1. sempre se preocupa.
2. nem sempre se preocupa.
3. nunca explica.
66. Se seu mdico no tiver certeza do problema de um paciente, o(a) Sr(a). acha que ele(a)
1. mandaria a outro mdico que poderia examinar o problema melhor.
2. no mandaria a outro mdico (tentara resolver o problema ele mesmo).
9. NS


174
health services utilization in general, and of medication
use in particular, in the Brazilian urban/suburban context.
As the areas studied were not homogenous, neither were
the elderly within the areas. With the possible exception
of the low SES area, Santa Cruz, the small amount of
variance explained by the prediction models suggests not
only that there are factors not being tapped, but that the
elderly are more heterogenous in some areas than in others.
The findings of this study support the notion of the utility
of the investigation and comparison of smaller geographical
areas for the discovery of meaningful variables and their
relationships. Only by conducting an independent analysis
for each study area, rather than relying on the results of
the aggregate data that controlled for area, was the
relative importance of some access to care measures (for
both medical and pharmacy services), their
interrelationships and relationships with other variables in
the model, observed. Clearly, there is much to yet to be
discovered in this respect, especially with regard to the
relationship between medical and pharmacy services.
Medication use: Medication use rates in this sample
approximates that of some elderly populations in the more
developed countries. Given the average per capita
medication use rates for the general Brazilian population,
these elderly are apparently high volume users of
medications. There can be no doubt that the elderly are a


160
had to increase the dose to .60 mg. in order to
get any effect.
In most cases, it is probable that the physician simply
neglected to tell the patient that the treatment was
temporary. Because these medications can be obtained at the
pharmacy without presenting an updated prescription, the
unwitting patient can easily continue the treatment
indefinitely. In the patient's mind, s/he is continuing to
use a medication that is prescribed by a physician.
The problems of polypharmacy associated with the
consultation with more than one prescribing physician are
likely to be prevalent in this population. At the time of
the interview, half of the sample reported having only one
prescriber, and one-third of the sample reported having more
than one physician prescribing a medication for them. This
is in contrast with an urban elderly sample in the US in
which 75% of the sample had only one prescriber (Ostrum et
al., 1985). The situation is only exacerbated by the
unnecessary continuation of old prescriptions. Without the
coordination of drug therapies, either by a physician or by
a pharmacy keeping prescription records, the probability of
drug-drug interactions, drug duplications, and conflicting
therapies increases. One blatant example includes the
following:
A 76 year old woman (Santa Cruz) consulted three
different general practitioners successively over a
period of five years. Five years ago, the first
physician prescribed a laxative (mineral oil, agar
agar, phenolphthalein) to be taken once a day. At


42
medical attention. Of the urban residents who sought care,
10.5% were persons 60 years old or more. Of the rural
areas, 8.5% of health services users were elderly (IBGE,
1989:4).
The State of Rio de Janeiro is one of the wealthiest
states in Brazil, and boasts one of the largest metropolitan
area in the country. With 68 municipios (counties), and an
estimated population of 14 million, Rio de Janeiro has both
extensive urban and rural areas. In the urban areas of Rio
de Janeiro, 79.5% of the persons who reported having had a
health problem sought medical attention, and 14.4% of all
urban patients were elderly. In the rural areas, 77.5% of
those who reported having had a health problem sought care,
and 11% of these were elderly (IBGE, 1989:322). These
figures suggest roughly equivalent access to care on the
basis of perceived need (ie., having a health problem). The
higher percentage of elderly patients in the urban areas
reflects the relatively greater proportion of elderly in the
urban population than in the rural areas.
Reasons for not seeking care are presented in Table
2.1. Transportation and financial barriers to care were
reported less frequently in urban areas of Rio de Janeiro
than rural areas. On the other hand, scheduling and other
time barriers, probably related to the busy urban working
class lifestyle, were more likely to keep people from
seeking medical attention in urban areas.


182
countries like Brazil is not conducive to some of the
approaches used in examining access to care in the more
developed countries. This study aimed to address some of
these issues for the Brazilian context.
The primary goal of this project was to assess the
relative influence of perceived access to medical and
pharmacy services in determining both physician and non
physician prescribed medication use in a elderly sample in
the Municipio of Rio de Janeiro. The availability and
affordability of care were not found to be significant
factors in prescribed medication use. It may be that, in
this region, the combination of a relatively strong private
and public health sector have helped to reduce these as
barriers. The most important dimension of access to affect
use was the patient's perception of the quality of medical
services (acceptability). The positive relationship between
patient satisfaction, health services utilization, and
positive health outcomes should be the intent of any health
care system.
This study revealed that different dimensions of
perceived access to care were significant factors in
predicting medication use, depending on the area. While SES
status and location were the significant characteristics
that differentiated the study areas, the results indicate
that behavior was affected by more than these two variables
alone. Studies of smaller geographical areas within larger


114
trustworthiness of the pharmacist was more importnat that it
was for the other areas.
The Role of the Pharmacist
The question of the need for a full-time qualified
pharmacist in the pharmacy was posed to the participants.
Eighty-five percent of the sample responded in favor of the
pharmacists' presence, even though most medications are
prepackaged and come with information package inserts. A
test of differences among areas was not statistically
significant at the 0.05 level (X2=5.03, df=2, pc.08).
Most of the responses in favor of a full-time
pharmacist presence in the pharmacy (61%) referred to the
need for a competent person to provide correct information
about medications, and to reassure clients about their drug
regimens. They believe that the pharmacist is not only
appropriately trained, but also is better at explaining
these things than both physicians and balconistas. Reasons
spontaneously given included the following: "pharmacists are
responsible for the control of medications in the pharmacy",
or, "it's the law"; "the balconistas need a qualified
pharmacist to give them training so they can give good
advice to clients"? package inserts are often "confusing" or
"inadequate", and a pharmacist can explain the information
"more clearly" by "interpreting the abbreviations and
symbols"; the pharmacist can be helpful by reading the


229
Modernity
2.24 1.06
a.
The pharmacy keeps up on all the latest
drug discoveries.
Courtesv/Respect
(.59)
1.81 0.45
a.
When I speak to someone at
they always pay attention.
the pharmacy,
2.47 0.73
b.
The pharmacy personnel are
treat me with respect.
courteous and
PERCEIVED AVAILABILITY OF PHARMACY SERVICES (.56)
Availability of Medications
2.17
0.96
The pharmacy always has the medications that
I need.
Convenience
(.44)
3.56
0.75
a.
If I am unable to reach someone at one
pharmacy, I can easily reach someone at
another pharmacy.
1.60
0.49
b.
The pharmacy is always open when I need
it.
3.62
0.86
c.
It is easy for me to get to the
pharmacy.
1.83
0.92
d.
I can always ask the pharmacy to deliver
to my home.
Continuity
2.51 1.25 a. I always go to the same pharmacy.
Supply of Pharmacists
1.66 0.47 a. There are enough pharmacists in my
neighborhood.
Supply of Pharmacies/Dispensaries
1.70 0.45 a. There are enough pharmacies in my
neighborhood.
Availability of Ancillary Services
1.70 0.40 a. The pharmacy personnel can give
injections and/or measure blood
pressure.
Emergency Care (.37)
2.67 1.26 a. Ifl need to speak with someone from the
pharmacy, I can easily reach them at any
time.


170
groups. However, without more precise measures of need,
such conclusions regarding equity may be premature.
Furthermore, alternative sources of care are not taken into
consideration in such conclusions. In the specific case of
medication use, however, there are the four alternatives in
use (use of PP medications, NPP medicines, simultaneous use
of both, or no medicines). Although the present study was
able to capture these alternative, the overall conceptual
model does not allow for the evaluation of the adequacy of
care (or, in this case, drug therapy), as evidenced in the
rationing by patients of physician prescriptions due to
financial difficulty.
Limitations
If a measure is only as good as the yardstick used, the
first limitation in this study is the quality of the
instrument. The instrument used has not been used
previously and so the reliability and validity is limited to
the results obtained in this study. The problem of
translating items into exactly parallel items in Portuguese
and items relevant to the Brazilian health care context make
even items commonly used in the United States essentially
brand new. Further application and review can only help to
refine the instrument.
The correlation of measures of perceived access with
more traditional measures also remains to be examined. This
includes the effect of using personal income versus family


191
b.In an emergency, it's very hard to get to my
doctor quickly.
6. SUPPLY OF DOCTORS
a. There is a noticeable shortage of general
practitioners in this area.
b. There are enough doctors in this area that
specialize.
7. SUPPLY OF HOSPITALS/CLINICS/LABORATORIES
a. More hospitals are needed in this area.
b. More clinics are needed in this area.
c. There are enough laboratories in this area.
E. AFFORDABILITY OF CARE
1. COST OF CARE:
a. Sometimes I delay going to see the doctor until I
can pay.
b. I can pay all of my medical expenses.
c. Someone helps me pay for my medical expenses.
d. The cost of my medical care is reasonable
e. My doctor's fees are too high.
f. The cost of laboratory tests and x-rays is too
high.
g. There have been times when I have needed to see a
doctor but did not because I could not afford it.
h. There have been times I could not afford to see a
doctor, so I bought drugs to treat the problem
myself.
2. PAYMENT MECHANISM
a. You can get emergency care easily even if you
don't have money with you.
b. It's always cash in advance when I seek medical
care.


60
types of pharmacists3 differ in social origin, location of
practice, and practice style and philosophy.
In this typology, therapist-pharmacists are community-
oriented, are familiar with their clients and their families
and lifestyle. These represent the fading "farmacia do
bairro". the neighborhood pharmacy, run by an involved,
active member of the community. This kind of pharmacist
assumes the role of a health care professional, and may even
provide a diagnosis and recommend drug treatment in "banal"
cases. As a professional, he is expected to refer the
client to a trusted physician if deemed necessary.
The second type of pharmacist may be considered the
antithesis of the first. The practice location is generally
in the central business areas, near medical laboratories,
physician offices and clinics. Their identification is with
the medical profession yet their focus is on the commercial
aspects of pharmacy practice. The clientele reflect this:
they too are more closely articulated with the formal health
care system, and tend to be of the more privileged socio
economic groups that utilize the medical services in the
area. As the pharmacist's primary job is generally in
industry, s/he visits the pharmacy for only a few hours a
week, and then only to check the books for the sale of
3 In this discussion, references to pharmacists,
unless otherwise stated, describe the person who works in the
pharmacy/drugstore, regardless of training.


36
for the physician because s/he can then charge on a fee-for-
service basis, even when INAMPS reimburses (Cordeiro, 1984;
World Bank, 1988:44-45).
This unanticipated abuse of the system was not the only
problem with the SNS. There were serious problems with
meeting some of the other reform mandates to provide care to
the needy. Although the SNS promised to give a boost to
traditional public health programs, there was no
administrative mechanism that permitted coordination to take
place between the various agencies, especially the Ministry
of Health and INAMPS. The Ministry of Health actually did
experience a 35.7% budget increase between 1974 and 1975,
but the positive impact of the new reform on the Ministry of
Health was short-lived. New programs were forced to operate
under severe limitations as promised resources never fully
materialized (Braga and Paula, 1980: 97-98). Since the
ministries could not resolve their ideological differences
about health care priorities and coordinate activities, an
informal geographical division grew up between them, with
the Ministry of Health focusing on the Northern regions and
rural hinterlands, and INAMPS on the Southern regions and
industrialized centers. In 1977, a reform within SNS aimed
to resolve the administrative barriers between the
ministries. However, despite these reforms and the
expansion of free-to-patient INAMPS emergency medical


Table 4.24 Intercorrelation matrix of variables included in the hypothesized model for aggregate data.
Variable
*1
X2 X3 x4 X5 x6 X7 X8
x9
X10
X,i
x
x
Xu
x15
Xl6
X17
Gender (0=male)
*1
-.07 -.19* .00 -.41*-.15* .26* .00
.01
-.06
.03
-.15*
.02
.06
-.10*
.16*-
.02
Age
X2
-.03 -.02 .03 -.05 -.08 .02
-.13*
.01
.02
.12*
-.07
-.01
.05
.16*-
.02
Education
x3
-.15* .55* .15*-.23* .00
-.18*
-.06
.23*
.14*
-.30*
.30
.20*
.11*
.01
House, size
*4
-.09*-.00 .08 .07
.08
-.07
.02
-.08
.19*
-.03
-.10*
-.06 -
.06
Income
X5
.17*-.24* .06
-.11*
-.02
.23*
.15*
-.19*
.34*
.25*
.10*
.04
Perc'd health
*6
-.39*-.06
.06
-.05
.16*
.13*
.04
.23*
.18*
-.29*
.09*
No. Symptoms
x7
-.03
.13*
.10*
-.16*
-.23*
-.01
-.21*
-.24*
.29*
.04
Att Med Care
x8
-.14*
-.13*
.19*
.05
.05
.10*
.08
.10*-
.02
AttLayAdvice
X9
-.02
-.10*
-.22
.41*
-.01
-.23*
-.11*
.21*
AcceptMedServ
X10
.50*
.08
.18*
.14*
.14*
.15*-
.10*
Avail Med Serv
Xn
.20*
.01
.39*
.35*
.09*-
.07
AffordMedServ
X
-.11*
.18*
.52*
-.08 -
.04
AcceptPharmServ X13
.18*
-.12*
-.14*
.06
Avail Pharm Serv
Xu
.29*
.02
.02
AffordDrugs
Xl5
-.02
.00
PP
X16
-
.10*
NPP
X,7
N=436; All values greater than or equal to .09 are significant at p=.05 or better.
133


2
The unsupervised access to medications is an indicator
of a larger set of factors that includes access to medical
and pharmacy services, as well as alternative sources of
medications. The receipt of a physician7s prescription
implies access to medical services, whereas the relationship
is not so straightforward with self-medication. The
purchase of pharmaceuticals, with or without a prescription,
is dependent upon access to a commercial source of
medications, directly through pharmacies or drug peddlers,
or indirectly through another party.
The relationship between access to medical services,
commercial and alternative sources of medications, and
medication use is a crucial issue in many developing
countries (Van der Geest and Hardon, 1990). Where there are
significant barriers to medical care, pharmacies may
represent a significant alternative health care resource.
However, for the same reasons, the ill-prepared or
irresponsible pharmacy may pose a serious potential health
threat through the promotion of inappropriate self-
medication with potent pharmaceuticals.
The primary goal of this study was to examine physician
and non-physician prescribed medication use of an
increasingly important segment of Brazilian societythe
elderly. The populations typically targeted as being at
high risk for hazardous self-medication in developing
countries are pregnant women and young children. However,


73
indicators related to patient satisfaction with medical care
in the United States which address issues of perceived
access to medical care. Similarly, McKeigan and Larson
(1989) developed a list of items for pharmacy services.
These indicators served as a guide to identify or formulate
revised items that were relevant to the Brazilian context or
could be appropriately adapted. Responses to items were
scaled in Likert fashion and indicators for all enabling
variables are derived from the summated scores of responses
to each item so that high scores reflect greater perceived
access to care. The items selected for the final analysis
are presented in Chapter Four.
Perceived Acceptability of Medical Services
(Accept Med Serv) and Perceived Acceptability of Pharmacy
Services (AcceptPharm Serv): The first dimension of access
considered is acceptability. Acceptability of services
refers to the extent to which a patient or client is
satisfied with the guality of care received. Traditionally,
in the developed countries, quality of care has been
associated with increased sophistication in medical
technology. More recently, however, the development of a
socially amenable and operational definition for quality of
care that includes aspects of patient-provider dynamics has
become a central concern for health policy analysts:
patients who are unsatisfied with the care they receive are
less likely to continue treatment, and are more likely to


46
higher income groups rely more on clinics and physician
offices than do the lower income groups.
The Pharmaceutical Industry In Brazil
The role of medications in the Brazilian health care
system is not insignificant. In 1989, Brazil was the eighth
largest market in the world for pharmaceuticals. It was
estimated that there were approximately 20,000 products on
the market, utilizing some 2,100 different active
ingredients (Soares, 1989:43). In 1990, this was a US$2.9
billion dollar market, with room to expand. Currently,
multinational corporations control 73% of the market
("Remdios congelados",...1990). Eighty percent of all
physician visits result in a prescription (IBGE, 1989:29),
although complaints of shortages of essential medications,
even in the urban areas, are a constant (Allen, 1989). This
section explores the Brazilian pharmaceutical industry, both
private and public, and industry's recent impact on the
economic and social aspects of medication use.
The Private Sector
By the 1940s, Brazil had an established, if modest,
domestic pharmaceutical industry, including infrastructure
and trained personnel. This was due in part to the
contributions of chemists and pharamcists who immigrated
from a war-torn Europe. Brazil also had by this time an
established medical care system heavily biased in favor of


48.
212
0(a) Sr(a). acha que, se as pessoas tivessem as informagoes ou os livros apropriados para buscar
as informagbes (ex. o motivo da doenga)
1. mu itas pessoas poderiam tratar das doengas igual a urn mdico.
2. algumas pessoas poderiam tratar das doengas igual a urn mdico.
3. quase ningum poderia tratar das doengas igual a urn mdico.
4. ningum poderia tratar das doengas igual a urn mdico.
49.
0(a) Sr(a). acha que para tratar urna doenga, a experiencia
1. muitas vezes vale mais do que cursos na escola de medicina.
2. algunas vezes vale mais do que cursos na escola de medicina.
3. quase nunca vale mais do que cursos na escola de medicina.
4. nunca vale mais.
50.
51.
52.
53.
54.
Quando o(a) Sr(a). se sente doente, o(a) Sr(a).
1. sempre sabe qual o problema.
2. muitas vezes sabe qual o problema.
3. algunas vezes sabe qual o problema.
4. nunca sabe qual o problema.
0(a) Sr(a). acha que quando o pessoal da farmcia d conselhos sobre os remdios,
1. usualmente sao bons conselhos.
2. algunas vezes sao bons conselhos.
3. raramente ou nunca so bons conselhos.
9. nao d conselhos
0(a) Sr(a). j procurou de um amigo ou parente/familiar conselhos sobre os remdios
1. muitas vezes
2. algunas vezes
3. poucas vezes
4. nunca
0(a) Sr(a). j comprou algum remdio por que ouviu um anncio no rdio, leu um artigo no
jornal, ou viu um comercial na televisao sobre esse remdio
1. muitas vezes
2. algunas vezes
3. poucas vezes
4. nunca
Quando o(a) Sr(a). precisa de urna receita mdica,
1. fcil conseguir a receita
2. um pouco difcil conseguir a receita
3. difcil conseguir a receita
9. NS


6
patients assigns a particularly ardent bent to the issue of
self-medication in the developing world.
A global perspective is imperative for an understanding
of the local economic-infrastructural and cultural context
of medication use. This necessarily includes an
appreciation of the role of the international pharmaceutical
industry in providing medications, and the role of retail
pharmacy in promoting pharmaceuticals as an accepted form of
therapy.
The Political and Economic-Infrastructural Context
The international pharmaceutical industry, unlike other
industries, faces a particular scrutiny because the products
involved are health products, many of which hold the balance
between life and death. Since the 1970s, industry behavior
has been severely criticized for failing to uphold the
mandate to responsibly provide pharmaceuticals, particularly
in the developing countries, with respect to questionable,
if not unethical, production and marketing practices. These
multinational corporations (MNCs) have been accused of
compromising their mandate in order to pursue the incentives
that drive any other industry "hungry for profits" (Ledogar,
1975) .
The relationship between the international
pharmaceutical industry and developing countries has been
described as characterized by dependency (CEPAL, 1987;
Evans, 1979; Gereffi, 1983; Jenkins, 1984). This dependency


123
Table 4.20 List of Home Remedies and Reported Purpose.
Remedy
Reported Purpose
Black tea
Arroz do campo, tea
Broto de goiaba, tea
Herbal (various) tea
Avocado leaf, tea
Espinheira Santa, tea
Quebra pedra, tea
Bee pollen
Cononut water
Garlic
Boldo, tea
Cbelo de milho, tea
Camomile, tea
Cana do brejo, tea
Capim de limao, tea
Carambola (Star Fruit)
Carobinha
Carqueja, tea
Onion
Cidreira, tea
Erva doce, tea
Gervao Roxo, tea
Spearmint, tea
Orange, pulp
Lemon, juice
Lojna, tea
Mamao (papaya), juice
Mate, tea
Pata de vaca, tea
Rosa vermelha, tea
Senne, tea
"Vitamina" (fruit drink)
Comfrey, tea
Honey
Sedative
Digestive aid
Antidiarrea
Digestive aid, sedative
Digestive aid
Blood purifier
To treat kidney stones
General tonic, cold remedy
Rehydration, well-being
Tonic, antihelminths
Digestive aid
Diuretic
Sedative
Diuretic
Sedative
Digestive aid
To treat skin irritation
Digestive aid
Heart tonic (prevent heart
problems)
Digestive aid
Diuretic sedative
Liver tonic
Antihelminths
Laxative
Cold remedy
To treat liver illness
Digestive aid
Digestive aid
Antidiabetic
Glaucoma
Cathartic
General tonic
Liver tonic
General tonic


69
self-care as well (Segall and Goldstein, 1989). Indirect
relationships with both prescription and non prescription
drug use in old age have been found through enabling
such as the availability of transportation (Sharpe et al.,
1985) and need variables, such as perceived morbidity, in
studies using path analytic techniques (Bush and Osterweis,
1978).
Gender: Gender has been found to have consistent
relationships with drug use. Women are more likely to use
medicines than men, both prescribed and nonprescribed. In
addition there are differences based on gender in use of
drugs of different therapeutic classes, although the reasons
for this are not always clear (Johnson and Pope, 1983;
Verbrugge, 1982; Verbrugge and Steiner, 1985; Svarstaad et
al., 1987). Furthermore, the effect of gender in old age
appears to be even more dramatic. This is especially true
for the use of prescribed psychotropic drugs, although their
use is less chronic in females than in males. It has been
suggested that the role of gender and age in provoking
"agism" in physician prescribing behavior may be a
contributing factor (Arluke and Peterson, 1981) There is
no apparent reason to suspect major departures from this
pattern for the Brazilian urban elderly.
Household size: In Western countries, studies indicate
that individual medicine use rates, as measured by the
number of medications obtained per individual, for both


163
inversely related to both PP and NPP medication use, whereas
a greater number of symptoms experienced was associated with
increased use of PP medications. However, although the
number of symptoms experienced did not have a significant
bivariate relationship with NPP medication use, it did exert
a significant negative effect on NPP medication use, when
all other variables in the model were controlled for,
including prescription drug use. The decision to control
for PP drug use was based on the postulate that NPP would
likely be discouraged by more frequent physician visits, and
the assumption that use of PP medications indicates
physician contact. The results from this study appear to
support this, suggesting that the more symptoms a person
experiences, the more ill s/he is likely to be, the more
likely s/he is to seek medical attention, and, hence, to
receive a prescription rather than to self-medicate. A more
precise interpretation of this finding is hindered by a lack
of a measure of symptom severity and actual morbidity. Haug
et al. (1989), for example, found that measures of self-
assessed health were related to self-care (including self-
medication) only for those with less severe symptoms.
Furthermore, given the cross-sectional nature of the data,
it is not possible to determine a causal relationship (i.e.
symptoms as a result of or precursor to drug therapy).
The finding that need variables emerge as strong and
consistent predictors of prescribed medications use must be


119
pharmacist should give information if, and only if, it is a
qualified pharmacist that is giving the information.
Medication Use
The majority of elders in the sample (88.1%) reported
using at least one medication at the time of the interview,
or up to two week prior to the interview: 78.4% reported
talking at least one physician prescribed (PP) medication,
and 34% reported aking at least one non-physician prescribed
(NPP) medication use. The number of medications used ranged
from 0 to 11, with a mean of 3.24 (sd=2.36). The average
number of physician prescribed (PP) medications used ranged
from 0 to 11, with a mean of 2.64 (sd=2.23), and the average
number of non-physician prescribed (NPP) medications used
was 0.59 (sd=1.08) with a range of 0 to 7.
Table 4.18 presents summary information on the
frequency of medication use for each study area. In
Copacabana, 93.5% of the elders were using at least one
physician prescribed medication, compared to 80.3% in Mier
and only 62.9% in Santa Cruz. A smaller proportion of
elders in Mier were self-medicating than in the other two
areas. The average number of medications used, and average
number of PP medication used was significantly greater in
Copacabana than in the other two areas. There were no
significant differences between areas for mean NPP
medication use.


77
perceived health status, as in the case of self-medication
for relatively banal health problems.
These measures are not without shortcomings in health
services research, and they bear mentioning. Often, in
research using the HSU model, the researcher presumes an
implicit causal relationship between the patient population
characteristics. For example, the relationship between
symptoms (and health status in general) is assumed to be a
precursor to health services utilization. However, it is
conceivable that the relationship is actually in the
opposite direction and is not discovered given the cross-
sectional nature of the study design. That is to say that a
patient may experience poor health as a result of a
treatment being received. This may be the case with number
of symptoms and side effects in medication use. In the
absence of longitudinal data, inferences should be made
cautiously about relationships that emerge from cross-
sectional data.
Use Variables
The dependent variables examined are number of
physician prescribed (PP) and non-physician prescribed (NPP)
medications used by the participant. The reference period
selected for this study is two weeks prior to the interview.
Participants were asked to recall all medications used
during this period, and to identify who recommended the
medication for them, and for what purpose. Prior to the


27
Melmon, 1971; Tinetti et al., 1988; Hallas et al., 1990;
Hepler and Strand, 1990).
There are several nonmedical drug-related problems that
elderly people may be likely to experience. The elderly are
often unemployed and typically rely on restricted incomes,
factors associated with decreased access to medical services
(Fredman and Haynes, 1985). Patients on chronic
medications, needing several different medications, or
expensive medications, may compromise their drug regimen in
order to economize.
The developing countries may anticipate similar but
more acute difficulties than the developed countries in
meeting the health needs of their elderly (Tout, 1989). It
is widely recognized that many developing countries have
overburdened, inadequate health infrastructures unable to
meet the persistent primary care needs of a younger and
poorer population. Competition for scarce resources may
result in difficult prioritization in resource allocation
(Bicknell and Parks, 1989).
Brazil has been described as a young country growing
old (Veras, 1988). In 1980, eight percent of the population
was 60 years old or more, and nearly 70% of these lived in
urban areas (IBGE, 1987). The elderly have been the fastest
growing age group in Brazil since the 1940s and it is
estimated that by 2025, Brazil will have the sixth largest
elderly population in the world. Between 1980 to 2000, the


161
about the same time she began to self-medicate, daily,
with a naturopathic laxative recommended by a friend.
Use of either of these alone also may affect the
disposition other drugs being used, provoking toxicity
or subtherapeutic levels. Two years later, a second
physician prescribed a diuretic, cinnarizine, and a
vascular vasodilator (flunarizine) to treat
"circulation problems" and "dizziness", and
dexamethasone for an "itch in the ear". Four years
later (one year prior to the interview), a third
physician prescribed Riopan and Mylanta Plus (to be
taken everyday, twice a day) to treat her "belly aches"
(which may have been caused by the dexamethsone). She
continues all therapies, reported her health status to
be "normal", notwithstanding numerous symptoms
reported. The prolonged use of laxatives or antacids
(especially aluminum-based antacids like Mylanta and
Riopan) may affect bone strength, and use of either may
also affect the therapeutic effectiveness of other
medications being used.
Examples such as those mentioned above highlight some
of the difficulties and special considerations reguired for
the definition and operationalization of self-medication
measures in a context like Brazil's. There are implications
for both research and for patient education efforts aimed at
reducing the incidence of inappropriate self-medication. A
mutual understanding of what is considered self-medication
is fundamenta1.
Health Services Utilization and Medication Use
In general, studies that used the HSU framework have
been able to explain, on average, about 25% of the variance
of the dependent measures in the models (Wolinsky et al.,
1989). When applied specifically to medication use, the
results have been similar. For PP medication use, Bush and
Osterweis (1978), who included a perceived availability of
care measure, were able to explain 29% of the variance for


177
significant enough to make a difference in any forthcoming
commissions.
Pharmacy Health Care
The elderly are an interesting group to interview
regarding pharmacy services. They have the advantage of
experiencing the changes in pharmacy practice over time and
are able to compare their recollections of the past with
their perceptions of the present. The elderly who were
immigrants were also able to compare the way pharmacy was
practiced in "the old country" (usually Portugal) with
pharmacy practice in Brazil.
The elderly in this study had very decided opinions
about pharmacy practice in Brazil and lamented the near
extinction of the trusted "farmacia do bairro".
Specifically, the majority of the elderly in this study
(85%) felt the loss of the trained and qualified pharmacist
in the pharmacy, even though the formulating role of the
pharmacist is practically obsolete. The thin relationship
between the pharmacy personnel and their elderly clients was
evident in this study. More than two-thirds reported not
knowing the name of anyone who worked in the pharmacy,
although 33% reported that someone in the pharmacy knew
their name. The primacy of price considerations and the
tendency to "shop around" for the best bargains in this
sample, together with medication scarcities, encouraged the
patronizing of more than one pharmacy. Good relationships


118
explaining about side effects than the doctor"; "sometimes
doctors forget to tell their patients about the medicines
they prescribe"; and, "the pharmacist can be sure that the
patient knows what he needs to know, because pharmacists can
read the doctor's writing on the prescription."
The reverse of some of these arguments were used
against the role of the pharmacist providing clients with
information about their medications. For some, this is the
physician's role: "the patient should have all the
information he needs with the prescription, and anything in
addition that the pharmacist says may confuse the patient"
or "scare the patient into not taking the medication"; "the
physician may not want the patient to know some things about
the medicine"; "it is not their job to inform clients about
their drugs, it is the physician's professional obligation
to do so"; "pharmacists receive training in chemistry,
formulating drugs, and manipulating them" and "they do not
know how these chemicals act on the body"; "pharmacists do
not have sufficient information about the patient to be able
to properly evaluate the effects of a drug on an
individual." The elders who responded that there are times
when a pharmacist should give information about a drug, and
times when he should not, stipulated three kinds of
situations: the pharmacist should give information if, and
only if, the patient requests it; the pharmacist should give
information only for non-prescription medications; the


44
In the municipio (with approximately 6 million
inhabitants), there are 16 municipal hospitals, two major
university hospitals, other state and federal hospitals, and
several private and philanthropic hospitals offering
distinct, specialized services. In addition, there are 70
public health posts and health centers and over 40 INAMPS
facilities. The more urban, metropolitan area also has a
relatively high concentration of private clinics and
physicians. The hospital utilization rates in both the
urban and rural areas do not differ greatly from the
national rate (see Table 2.2). This reflects the high
reliance on the curative, hospital-based health care system,
even though the public system has been struggling to keep
hospitals functioning ("Cremerj vai a Justiga...", 1990).
The decreased reliance on public health posts and centers
and the greater utilization of clinics and physicians'
offices in the urban areas demonstrates the relative
abundance of health care plans/policies available in the
urban areas that are not widely available in the more rural
areas, and, indeed, throughout the rest of the country.
Where one seeks medical attention is related to income
(Table 2.3). Unfortunately, the data do not distinguish
between public and private facilities. Nonetheless, given
our understanding of the health care system, it is not
surprising to find that, in both urban and rural areas,


143
Although perceived health status and number of symptoms
are correlated with PP medication use in all three areas,
the strengths of the relationships vary considerably: they
are strongest in Santa Cruz (r=-.47 and r=.47,
respectively), and weakest in Copacabana (r=-.19 and r=.23,
respectively). Age is significantly related to prescription
medication use only in Copacabana (r=.23) and gender (being
female) is significantly associated with medication use only
in Santa Cruz (r=.35). Gender is also more strongly related
to poor health status and more symptoms in this area. In
Copacabana, positive attitudes toward medical care are
related to use of prescribed medications (r=.21).
In Santa Cruz, Accept_Med_Serv is positively related to
PP medication use (r=20) and Afford_Med_Serv is negatively
related (r=-25) to PP medication use. Afford_Med_Serv is
negatively correlated to PP medication use in Meier (r=-16).
This latter relationship may be understood as reflecting the
situation of an individual who is a heavy user of medical
services with costs associated, as opposed to the well
individual who has no such costs and therefore finds the
cost of care (affordability) not to be a problem.
Measures of access to pharmacy services are related to
PP use only in Meier. In this area, Accept_Pharm_Serv is
negatively related (r=-.16), as is Avail_Pharm_Serv (r=-19).
The relationship may reflect the positive relationship


Table 2.1
43
Reasons why people did not seek medical
attention but had a health problem in Brazil
and the State of Rio de Janeiro, 1986.
Reason
Brazil
Rio de
Janeiro
%
Urban
%
Rural
%
Transportation
problem/distance
10.1
4.4
13.7
Scheduling problem
3.4
6.7
6.4
Long wait time
4.3
5.5
1.5
No need
63.8
62.4
60.0
Financial problem
10.9
5.2
7.3
Other
7.4
15.8
11.1
Total
100.0
100.0
100.0
Source: IBGE (1989), table 7, p. 9 and p. 327.


9
rely on the good faith of the producers and distributors, at
least to maintain the standards of the countries of origin.
The dangers of relying on the industry to uphold such
standards is exemplified by the case of chloramphenicol, an
antibiotic widely dispensed in many developing countries
during the 1970s. In the United States, the indications for
chloramphenicol included only a few life-threatening
infections. Physicians were warned of the risk of inducing
aplastic anemia and other blood disorders with the use of
the drug. In Latin America, however, few warnings regarding
adverse reactions were provided, and indications included
many relatively trivial conditions, such as tonsillitis and
whooping cough (Silverman, 1976:13-150). The combination of
the dangers of the drug and the inappropriate conditions for
which it was being used was a lethal one for the populations
in Latin America.1
The high social and economic costs to many developing
countries of the production, distribution and promotional
practices of MNCs, in both the public and private sector,
prompted many countries to seek alternative means of
providing needed pharmaceuticals to their populations. In
1 In 1977, after the publication of these findings,
the International Federation of Pharmaceutical Manufacturer's
Association (IFPMA) established standards for its members
regarding the provision of correct product information.
Despite concerns regarding the IFPMA's ability to enforce
itself, follow-up studies have indicated some improvement
(c.f., Silverman et al., 1982, 1986).


Table 4.28 Intercorrelation matrix of variables included in the hypothesized model for Meier.
Variable
x,
in
X
X
ro
X
OJ
X
X
o
X
X
00
x9
Xio
X11
X12
X13
Xu
X15
Xl6
X17
Gender (0=male)
*1
.01 -.18* .06 -.54*
.12 .27* .07
.09
.03
-.19*
.10
.07
.09
-.10
.14
.04
Age
x2
-.10 .02 -.04
.02 -.05 -.05
-.01
.07
.05
.08
-.09
-.11
.05
.07
-.10
Education
X3
.12 .26*
.08 -.29* .05
-.03
.15
.08
.05
-.02
.06
.06
-.01
.03
House, size
Xa
.07
.06 -.04 .09
-.01
.18*
.16*
.04
.18*
.19*
-.01
-.12
-.01
Income
x5
.19*-.33*-.01
.01
.02
.13
.08
.11
.13
.19*
.09
.07
Perc'd health
x6
-.38*-.06
.10
.04
.10
.08
.11
.18*
.13
-.26*
.18*
No. Symptoms
x7
-.10
.06
-.19*
-.21*
-.21*
-.19*
-.27*
-.23*
.27*
.10
Att Med Care
X8
.10
-.18*
.18*
.08
.09
.18*
-.01
-.08
.05
AttLayAdvice
X9
-.04
-.00
-.08
.19
.07
-.07
-.09
.18*
AcceptMedServ
X10
.56*
.17*
.16*
-.15
.17*
.11
-.12
Avail Med Serv
X11
.20*
.21*
.33*
.42*
-.02
.01
AffordMedServ
X12
.10
.14
.38*
-.16*
.06
Accept Pharm Serv X13
.54*
.08
-.16*
.06
Avail Pharm Serv
X14
.25*
-.19*
.16*
AffordDrugs
Xl5
-.16*
.10
PP
X16
-.16*
NPP
Xl7
N=147;
All values greater than or equal to .16 are significant at p=.05 or better.
i*
4^
U1


244
the Health Interview Survey." Journal of Gerontology
39:334-341.
Wolinsky, F. D., R. M. Coe, D. K. Miller, J. M. Prendergast,
J. Creel, and M. N. Chavez. 1983. "Health Services
Utilization among the Noninstiutionalized Elderly." Journal
of Health and Social Behavior 24:325-37.
Wolinsky, F. D., B. E. Aguirre, L. Fann, V. M. Keith, C. L.
Arnold, J. C. Niederhauer, and K. Dietrich. 1989. "Ethnic
Differences in the Demand for Physician and Hospital
Utilization among Older Adults in Major American Cities:
Conspicuous Evidence of Considerable Inequalities." The
Millbank Quarterly 67(3-4):412-449.
Wood, Charles H., and Jose Alberto Magno de Carvalho. 1988.
The Demography of Inegualitv in Brazil. Cambridge: Cambridge
University Press.
Woods, Charles, and Thomas Graves. 1973. The Process of
Medical Change in a Highland Guatemalan Town. Latin American
Studies Series, Vol. 21. Los Angeles, CA: University of
California Latin American Center.
World Bank. 1988a. Policies for Reform of Health Care.
Nutrition, and Social Security in Brazil. Population, Health
and Nutrition Department. Report No. 6741-BR (January 6,
1988) .
. 1988b. Brazil Public Spending on Social Programs:
Issues and Options. Vol.1. Report no. 7086-BR (May 27,
1988).
World Health Organization (WHO). 1975. "National Drug
Policies." World Health Organization Chronicle 29:337-349.
. 1980. "Global Strategy for Health for All by the Year
2000." WHO document EB67/PC/WP/3. Geneva: World Health
Organization.
. 1985. Drugs for the Elderly. Copenhagen, Denmark: World
Health Organization, Regional Office for Europe.


I certify that I have read this study and that in my
opinion it conforms to acceptable standards for scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Carole L. Kimberlin, Chair
Associate Professor of Pharmacy
Health Care Administration
I certify that I have read this study and that in my
opinion it conforms to acceptable standards for scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
I certify that I have read this study and that in my
opinion it conforms to acceptable standards for scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.
Donna E. Berardo
Associate Professor of Pharmacy
Health Care Administration
I certify that I have read this study and that in my
opinion it conforms to acceptable standards for scholarly
presentation and is fully adequate, in scope and quality, as
a dissertation for the degree of Doctor of Philosophy.


BIOGRAPHICAL SKETCH
Maria Andrea Miralles received her Bachelor of Arts
degree from the University of California, Los Angeles, in
Latin American studies, with a minor in anthropology, in
1982. She received her Master of Arts degree in
Anthropology from the University of Florida in 1986. The
title of her thesis is "Health Care Seeking Behavior of
Guatemalan Refugees in South Florida." She also holds a
certificate in gerontology from the Center for
Gerontological Studies at the University of Florida. Her
research has taken her to Mexico, Ecuador, India, and
Brazil. Research interests include social pharmacy, aging
in the Third World, and community development.
245


41.
S E 9 o 3 USO DE REMEDIOS
(Entrevistador: "Terminamos as primeiras duas partes do questionrio. Agora eu vou pedir ao(a) Sr(a.) para
trazer todos os remdios que est tomando atualmente, ou que usou durante as ltimas duas semanas. Isto pode
incluir medicamentos, vitaminas, remdios homeopticos, etc. Vamos comegar com os remdios que o(a) Sr(a).
est tomando actualmente que foram receitados por um mdico...]
Nota: OPM=outra pessoa
mdica (veja
d manual)
a. Nome do remdio
b. Oosagem
(exemplo)
a. LANOXIN
b, .25 mg
Razo por
usar
(especificar)
Receitado ou
recomendado por
1. Mdico/OPM
2. Farmacutico
3. Amigo/familiar
4. Outro (espec.)
5. Ninguem
(auto-receitado)
8. NS (nao lembra)
9. NR
Como usa
(frequncia)
1. todos os di as,
x vezes por di a
2. <7 vezes/semana
4. <3 vez/semana
5. so quando precisa
6. parou de tomar
7. outro
8. NS 9. NR
Dura^ao
(# meses)
98. NS
99. NR
'
Toma
1. regularmente
2. se esquece de
tomar de vez
em quando
8. NS 9. NR
0 remdio
Serve?
0. Nao
1. S i m
8. NS
9. NR
Percebe problema
com o remdio?
0. Nao
1. S i m
(esperi fique)
8. NS
9. NR
1. a
b.
2. a.
b.
3. a
b
4 a
b.
(Entrevistador: Leia a lista dos remdios ao entrevistado para verificar os nomes e para que sao usados.
IMPORTANTE: Pergunte sobre os remdios que o entrevistado tomou as ltimas duas semanas mas que nao tem na
casa atualmente. Se o entrevistado disser todos os remdios, marque "NA" na primeira coluna. |
208


124
A list of the the home remedies used by the sample, and
their purported use, is provided in Table 4.20. In all
cases but one, the purported use was consistent with that
listed in either Martindale's The Extra Pharmacopoeia
(1992), or in the compilation of by Mello and Carrara (1982)
of Brazilian popular medicines. The exception was the
reported use of black tea as a sedative. Many of the
remedies that were used as digestive aids have documented
choleretic properties and may be considered to be
digestants. Most of the teas are available in pharmacies.
Measures
The internal consistency of measures related to
attitudes toward medical care (Att_Med_Care), attitudes
toward lays advices about drugs (Att_Lay_Advice), and all
measures of perceived access to medical and pharmacy
services were examined using Cronbach's coefficient alpha.
This coefficient is often used to estimate the internal
consistency of items which have a wide range of scoring
weights, such as those on attitude inventories (Crocker and
Algina, 1986:117, 138). In measurement terms, this
coefficient is a way of expressing the reliability of a
composite, or total test score, in terms of total and true
score variances. Because alpha is a function of item
covariances, and high covariance between items can be the
result of more than one common factor, alpha is not to be


81
chronogram were presented at the first session. This
allowed potential interviewers to decide whether or not they
could commit their time for the project, and three did drop
out at this point.
The interviewers reviewed the questionnaire for
content, readability, and clarity in a second meeting. Each
interviewer was asked to complete three questionnaires for
elders not included in the study sample. Results were
discussed in a third training session after which the
questionnaire was again modified to accommodate the
observations and comments offered by the team.
Approximately four weeks after the pilot, interviewers were
asked to. re-interview one of the three subjects previously
interviewed. This allowed for the evaluation of the changes
made in the instrument as well as to establish a test-retest
reliability (stability) coefficient for unchanged items.
For unchanged items, those which had coefficients of .70 or
higher were maintained, and others were eliminated or
revised.
The survey was conducted between October 1990 and March
1991. Each interviewer was assigned a quota of interviews
for selected clusters and areas.1 Interviewers were
provided with the names, addresses, and if available,
1 Three of the original interviewers resigned from the
team during the course of the survey, and replacements were
trained. Two other interviewers were dismissed during the
survey due to research fraud.


183
regions should continue to explore the dynamic between area,
individual, and society.
A secondary goal of this study was to describe the
medication use of the sample. The medication use rates in
this population matched those of the elderly in the more
developed countries, although there were differences in
therapeutic indications for use of the medications used, and
self-medication was relatively infrequent. Although only a
superficial review of medication use was provided in this
study, this information provides the basis for further
examination and comparison of findings from other areas in
Brazil as well as other countries. Indeed, this study
confirms that the elderly in Brazil share many of the same
health-related concerns of the elderly in some of the more
developed countries. In particular, medication use plays a
significant role in their health seeking.
The elderly provide a view to a past from which many
lessons can be learned. The elderly also provide a view not
to the future, but rather to many future possibilities. The
growing importance of this population as users of health
care services in many developing countries is evident.
Comparative analyses of the experiences of the lesser
developed countries with those of the more developed
countries provide many clues not only for understanding
behavior, but also for formulating relevant proactive
policies to enhance the quality of care for all patients.


141
compared to 4.8 per year for the United States (Simonson,
1984:9), which may account for the larger number of PP
medications than expected relative to NPP.
Table 4.26 presents the results from the logistic
regression analysis. The model may be evaluated in terms of
the ratio of the concordant to discordant pairs, and
described by the D statistic, an index of the rank
correlation between predicted probabilities and the
dependent variables, which may be likened to the R2 in
multiple regression analysis. This prediction model for NPP
medication use yields a D statistic of .33.
Table 4.26 Logistic Regression Model for Non-Physician
Prescribed Medication Use for Urban Elderly,
Rio de Janeiro.
Variable
Regression Coefficients
Beta
Std. Error Std.
Beta
Intercept
3.615
Copacabana
- .196
.296
.050
Meier
. 304
.283
.079
PP med. use
. 681*
.288
.153
Household size
.122*
.059
. 135
Att Lay Advice
1.003**
.324
.202
Health status
- .132
.071
.125
No. Symptoms
- .624**
.223
.206
Concordant pairs=
Discordant pairs =
Tied pairs = 0.4%
(39480 pairs)
66.6%
: 33.1%
Somers' D = .33
*px2 < 05
**px2 < .01
***px2 < .001


149
Modeling Medication Use for Areas
Prescription Medication Use for Areas
The same procedures used in the previous analyses for
PP and NPP medications use were applied to each area
separately. All variables were entered into the regression
equation, and the backward elimination selection procedure,
with the significance level to stay in the model being .10,
resulted in the prediction models presented in Table 4.30.
The variable selection procedures resulted in different
equations for each area. Not only are the variables
different, but the amount of variance that is explained by
each model is quite different as well.
Copacabana: The prediction model for this area
includes three variables: age, Att_Med_Care, and number of
symptoms. The number of symptoms has the strongest effect
with Att_Med_Care exerting a positive influence about equal
with age. The model accounts for 16% of the total variance
in prescribed medication use for this area.
Meier: Household size, Accept_Med_Serv,
Avail_Pharm_Serv, and number of symptoms were selected for
this area. The model explains 45% of the variance.
Controlling for Accept_Med_Serv, Avail_Pharm_Serv, and
number of symptoms, elders living in larger households use
fewer prescription medications. Similarly, when controlling
for all other variables, those who perceive a greater
availability of pharmacy services use fewer prescription


58
high concentration of pharmacies, as much as two or three
per city block, and sometimes even more, as in the
commericial district of Copacabana. The vast majority of
registered pharmacists are employed in industry (personal
communication, CRF), although there is a small and lucrative
business in specialty pharmaceuticals, primarily
dermatological products, as well as several homeopathic
pharmacies that compound their own products.
Pharmacy Practice and Self-Medication
A significant proportion of private health care
spending in Brazil represents drug purchases occurring
outside the direct control of the formal medical care system
(McGreevey, 1988:158). The frequency of self-medication in
Brazil has been estimated to be approximately 50% to 60% of
all medication use (Giovanni, 1980:132; Haak, 1988:1420;
Cordeiro, 1985:190). However, because commercial pharmacies
do not typically keep records of prescriptions, and due to
the lack of other systematic record keeping, there is
relatively little known about both self-medication and
prescription medication use.
Today, pharmacists, or otherwise qualified technicians,
are hard to come by in the community setting. A consumer is
more likely to interact only with salespersons (balconistas)
with no formal training in pharmacy at all. According to
Giovanni (1980), the disappearance of the community
pharmacist was inevitable. Giovanni argues that there is no


190
c.Sometimes I think that my doctor acts like he/she
is doing me a favor by treating me.
D. AVAILABILITY OF MEDICAL CARE
1. ACCESSIBILITY
a. I can reach my doctor to ask questions about my
health at any time.
b. If I can't reach my doctor, I can reach another
doctor to ask questions.
c. If I have a health problem, I'm not always sure
that I can get the care I need.
2. CONVENIENCE
a. My doctor's office hours are good for me.
b. My doctor's office is in a very convenient
location.
c. Getting to the doctor's office is a problem.
d. My doctor will make a house call if I ask.
e. It takes a long time to get to my doctor's office.
f. I can usually get to see a doctor in the evening
if I'm busy during the day.
3. CONTINUITY OF CARE
a. I have had the same doctor for several years.
b. My doctor treats others in my family.
c. I see the same doctor every time I go for a
consultation or examination.
4. EASE OF APPOINTMENT
a. It's usually easy to get an appointment to see my
doctor right away.
5. EMERGENCY CARE
a.
In an emergency, I can always get a doctor.


202
15. Quantas vezes o(a) Sr(a). foi a um consultrio mdico ou hospital nos ltimos trinta dias?
vezes 98. NS 99. NR
16. Por favor, eu gostaria de saber aproximadamente quanto (dinheiro) o(a) Sr(a). gastou em despesas
mdicas ltimos trinta dias?
despesas .00
NS 8000008
NR 9000009
17. Em geral, quern paga a maior parte da despesa mdica do(a) Sr(a)?
1. instituigo pblica.
2. o entrevistado.
3. a familia ou prente (ex. marido, filho, sobrinho, cunhado, etc.)
4. seguro/plano mdico particular/privado
5. outro (especifique)
8. NS 9. NR
18. Quantas vezes o(a) Sr(a). se consultou com urna pessoa nao mdica sobre um problema de sade nos
ltimos trinta dias?
vezes 98. NS 99. NR
19. Em geral, quando o(a) Sr(a). precisa de um remdio, onde o consegue?
1. o mdico
2. posto de sade
3. farmcia particular
Que tipo? a. drogara (farmcia comercial comum)
b. de homeopata
c. outro
4. dispensrio de urna instituigo mdica/hospital
5. outro (especifique)
7. NA (nao usa remdio nunca)
8. NS 9. NR
20. Quantas vezes o(a) Sr(a). utilizou urna farmcia para comprar algum remdio nos ltimos trinta
dias? (inc. telefonou, foi, mandou algum, etc.)
vezes 98. NA 99. NR
21. Por favor, eu gostaria de saber aproximadamente quanto (dinheiro) o(a) Sr(a). gastou em remdios
nos ltimos trinta dias.
despesas
NS
NR
8 0 0 0 0 0 8
9 0 0 0 0 0 9
.00


197
b. I need help to pay for my medications.
c. Someone helps me pay for my medications.
d. The cost of my medications is reasonable.
e. I have sometimes needed drugs but could not afford
to buy them.
f. Sometimes I try to make my medicines last longer
to save costs.
g. When I stop taking a drug and still have some left
over, I save it for future use.
h. Sometimes, a friend or family member will lend me
a drug they have so I don't have to buy it.
i. I often loan medicines to friends who need them.
j. The price of prescription medications is very
high.
k. The cost of non-prescription medications is very
high.
l. I have had doctors recommend a drug but I did not
take them because I could not afford them.
2. PAYMENT MECHANISM
a. You can get emergency medications easily even if
you don't have money with you.
b. It's cash in advance when I need to buy my
medications.
c. My pharmacist will let me pay later if I'm short
of cash.
d. If you can't prove that you can pay, you can still
get the medicines you need at the pharmacy.
3. INSURANCE (IF PATIENT HAS INSURANCE)
a. My medical insurance pays for all of the
medications I need.
b. I am satisfied with the coverage provided by my
medical insurance with respect to medications.
c. My insurance only pays for "cheap" drugs.


61
controlled substances, such as potent narcotics. The volume
of drugs dispensed is large in these establishments and
there is little opportunity and no expectation for any
professional-client relationships to develop. A similar
characterization of pharmacy practice has been described for
urban pharmacy practice in Cost Rica (Low, 1981).
Given their "strictly business" orientation, commercial
pharmacies are more likely to engage in illegal
"empurroterapia" (push therapy). This practice, which
involves pushing products onto gullible clients with little
regard for therpeutic usefullness, evolved from the custom
of paying pharmacy salepersons (balconistas) on a commission
basis. Enforcement of regulations regarding the sale of
medications was and continues to be beyond the capacity of
enforcement agencies. Therefore, if the intent of the law
that encouraged the evolution of drugstores was to make
medications more accessible to the publig the secondary
effect was the loss of control over their appropriate
commercialization and use.
Some of the concerns regarding the recommendations lay
salespeople might offer to clients for the purposes of self-
medicating is exemplified by the following recent example
that involved an ulcer medication, Cytotec (a prostaglandin)
that was being pushed as an abortifacient. A study
conducted by the Federal University of Cear (UFC) in 1990
used a "shopper" technique to determine the extent to which


Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
ACCESS TO CARE AND MEDICATION USE
AMONG THE AMBULATORY ELDERLY IN
RIO DE JANEIRO, BRAZIL
By
Maria Andrea Miralles
August, 1992
Chairman: Carole L. Kimberlin, Ph.D.
Major Department: Pharmacy Health Care Administration
This study examines physician and non-physician
prescribed medication use of an increasingly important
segment of Brazilian societythe elderly. The elderly are
a rapidly growing segment in many developing countries,
including Brazil. Although the hazards associated with
medication use in the elderly have been well documented in
several developed countries, little is known about geriatric
drug use in the developing countries.
Medication use was modeled as a function of individual
and community level factors in the Municipio of Rio de
Janeiro, Brazil. The variables examined are based on a
behavioral model for health services utilization adapted to
medication use in the Brazilian context. Variables include
predisposing sociodemographic characteristics, enabling
variables reflecting aspects of access to care, and need for
IX


142
The model indicates that, controlling for area and PP
medication use, household size, Att_Lay_Advice, health
status and number of illness symptoms are significant in
predicting NPP medication use. When controlling for all
other significant factors, a larger household increases the
probability of using NPP medications. This suggests that
there is support for the conventional wisdom that the
sharing of medications and/or information about treatment
with medications occurs more frequently in larger
households. As expected, even when controlling for other
relevant variables, better perceived health status decreases
the probability of NPP medication use. However, even
controlling for perceived health status, the greater number
of symptoms an individual experiences also decreases the
probability of NPP use. This may be reflective of the
situation that symptoms were often considered part of normal
aging, an not an "illness" per se. Notably, no access
variables were significant.
Correlates of Medication Use for Areas
The correlation matrices for each area are presented in
Tables 4.27, 4.28 and 4.29. In comparing the matrices,
various similarlities and differences are evident, and,
patterns begin to emerge.


206
[ENTREVISTADOR: Favor resumir (ex: Terminamos a primeira sego...) e explicar o objetivo da seguinte
sego (ex: agora vamos falar sobre ).
SEQO 2 SADE FSICA
35. Em geral, o(a) Sr(a). diria que sua sade est: (Q14:13)
1. muito ruim (Ler p/o entrevistado as opges)
2. ruim
3. na mdia (regular)
4. boa
5. muito boa 8. NS 9. NR
36. Em geral, o(a) Sr(a). diria que, em comparago com a ltima vez que foi entrevistado(a),
a sua sade est:
1. melhor (Ler p/o entrevistado as opges)
2. mesma coisa
3. pior
4. muito pior 8. NS 9. NR
37. Em comparago com as outras pessoas da sua idade, o(a) Sr(a). diria que sua sade esta:
(Q16:13)
1. muito pior (Ler p/o entrevistado as opges)
2. pior
3. igual (na mdia)
4. melhor
5. muito melhor 8. NS 9. NR
38. 0(a) Sr(a). tem algum problema de sade que nao est tratando com remdio?
0. Nao (marque 7. NA na Q39 e v para Q40a)
1. Sim Quantos?
8. NS 9. NR
39. 0(a) Sr(a). acha que deve tratar desses problemas com remdio?
0. Nao
1. Sim Quantos?
7. NA
8. NS
9. NR


This dissertation was submitted to the Graduate Faculty
of the College of Pharmacy and to the Graduate School and
was accepted as partial fulfillment of the requirements for
Dean, Graduate School


112
Table 4.15 What do you like most about the pharmacy(ies)
where you buy your medications?
Copacabana
(n=131)
%
Mier
(n=129)
%
Sta. Cruz
(n=139)
%
Nothing special
3.1
4.6
7.9
Location
25.9
23.2
8.6
The pharmacist is
trustworthy
0.8
4.6
12.9
The prices are good/
discount is offered
34.4
39.5
41.7
The clerks are
trustworthy
2.3
10.8
6.5
The inventory of
drugs is good
3.8
5.4
7.2
The guality of the
drugs sold is good
4.6
0.0
2.9
The pharmacy sells other
useful merchandise 3.8 1.5 0.7
I can order by telephone
I can pay the pharmacy
in installments (credit)
10.7
CO

o
o

o
o

o
o

o
1.4
9.2
7.2
10.1
Other


c. My doctor will let me pay later if I'm short of
cash.
3. INSURANCE (IF PATIENT HAS INSURANCE)
a. My medical insurance pays for all of the medical
expenses I have.
b. I am happy with the coverage provided by my
medical insurance.
c. I think that my medical insurance should cover
more things than it does.
d. You don't get what you pay for with medical
insurance.
F. ACCEPTABILITY OF PHARMACY SERVICES
GENERAL:
a. For the most part, I am satisfied with the
pharmacy/dispensary where I receive my
medications.
b. Most people in this area get pharmacy services
that could be much better.
c. I usually have to a pharmacist when I go to the
pharmacy.
d. There are many things about pharmacy services that
could be much better.
SPECIFIC:
1. Complete facilities
a. I think that the pharmacy I usually go to is
complete with all the necessary facilities and
medicines.
b. My pharmacy sometimes does not carry the medicine
I need.
c. There is always a trained pharmacist in the
pharmacy.
d. Clerks who work in the pharmacy are carefully
supervised by a pharmacist.


155
the medical services was the only access variable that was
found to be a predictor of use of physician prescribed
medications. Enabling (access) variables were not found to
be significant predictors for non-physician prescribed
medication use in the aggregate data.
Residential areas were found to affect the
interrelationships between predisposing, enabling, and need
variables for both PP and NPP medication use. In the high
SES area (Copacabana), for example, access variables were
not significant predictors of PP medication use, but they
were in the other two study areas. Access factors played a
minimal role in NPP medication use in all three areas.
Furthermore, different combinations of predisposing, need
and access variables were found to be significant for each
area. The ability of the prediction models to explain the
total variance of the samples varied greatly among the
areas. The following chapter discusses these results, and
the limitations of the study, in greater detail.


Legend: municipio boundaries
+++++ municipal railroad
Shaded areas represent study areas
Figure 3.1
Study areas in the Municipio of Rio de Janeiro, Rio de Janeiro, Brazil.
00
-J


CHAPTER 3
METHODOLOGY
Introduction
This project required the development of a survey
instrument that would measure the access dimensions of
interest since there was no instrument available for the
Brazilian context. This entailed a process that began with
a general model of medication use that included variables
believed to be relevant based on previous studies in Brazil
and elsewhere. Item selection for the access variables
involved the adaptation of items used in the United States,
the participation of experts in the field in the translation
and formulation of new items, revision as a part of the
interviewer training, and field testing of the instrument,
which resulted in further revisions of the instrument. This
chapter discusses each step of the instrument development,
the selection of the sample, the research procedures and the
analysis strategy.
Building a Medication Use Model for Brazil
The theoretical framework that was used to analyze
medication use behavior among the noninstitutionalized
elderly in Brazil was based on the health care utilization
model developed by Andersen and Newman (1973), discussed in
Chapter 1, and builds upons previous studies of medication
65


230
1.29 0.78 b. In case of an emergency, the pharmacy
will allow me to pay later for my
medication if I don't have the money at
the time I need it.
PERCEIVED AFFORDABILITY OF DRUGS (.61)
2.58
0.65
a.
I have never had to wait to buy a
medication I needed because I could not
pay for it.
1.87
0.33
b.
I have never had to lower/skip a dose of
a medication in order to economize.
ATTITUDES TOWARDS
MEDICAL CARE (.49)
SkeDticism toward
modern medicine (.67)
2.44
0.83
a.
Medicine can cure all serious illnesses.
2.08
0.87
b.
In twenty years, modern medicine will be
able to cure all serious illnesses.
Reluctance to Accent Medical Care (.321
1.37
0.67
a.
When doctor's give advice, they usually
create more problems that they solve.
1.58
0.79
b.
When the doctor prescribes a medication,
one should always doubt the
prescription.
The opinion
that
the individual understand his/her health
better
than
the doctor (.421
1.33
0.47
a.
When the doctor tells the patient to do
something that the patient does not want
to do, the patient should not do it.
2.17
1.09
b.
If people had the information or the
books to look up the information, many
people could treat illness as well as a
doctor.
2.55
1.00
c.
In order to treat an illness, experience
is worth more than medical school,


171
income, as well as measures of time and distance travelled
to receive care, and number of facilities located within a
given area. However, this requires a valid measure that was
not afforded at the time of the investigation given the
instability in service availability (number of operating
hospitals, number of available hospital beds, and other
physician services) at the time of the investigation. Use
of existing "official" statistics about the availability of
such services alone would have been misleading. These
concerns are left for future research.
In this study, self-medication was broadly defined to
include the use of legend and non-legend pharmaceuticals
without a physician's prescription as well as other
medicines (home remedies). This project did not distinguish
between categories of legend and nonlegend drugs. This
precludes comparison of the results in this study with
studies conducted elsewhere which distinguish between
prescription and OTC categories. Although the extent to
which the self-medication that was reported may be
considered dangerous was not directly examined in this
study, it is of relevance to the issue of the unrestricted
access to many potent legend medications. Given current
pharmacy practice standards in Brazil, the OTC verses legend
distinction is, for all practical purposes, a moot concern.
However, from a health policy perspective, an evaluation of
the use of medications in these categories is required for


105
initially is often a family member or a friend: 24.2% in
Copacabana, 28.6% in Mier, and 8.7% in Santa Cruz.
Relatively few elders reported seeking assistance from
a nurse or pharmacist in any of the three areas: non
physicians were sought for 4.6% of the patients in
Copacabana, 8.1% in Mier, and 14.5% in Santa Cruz. In all
cases where a nurse was mentioned as the primary recourse,
the nurse was a family member, and the regular physician was
from a public institution.
Table 4.9 When you have a health problem, whom do you
usually seek for help first?
Copacabana Mier Sta. Cruz
% % %
No one
0.7
2.7
2.6
Physician
(public institution)
6.5
42.9
43.7
Physician
(private institution)
39.1
17.7
8.6
Physician
(private)
47.8
28.6
30.5
Nurse
1.5
0.0
2.0
Pharmacist
0.7
0.0
2.0
Lay person
2.2
2.7
5.9
Other
0.9
5.4
4.6
Total
100.0
100.0
100.0
N
138
147
151
Alternative, or lay,
sources
for assistance
in both
Mier and Santa Cruz (n=15) included religious institutions
or "spiritual" beings, such as spiritual guides (guias
espirituaes) and physician spirits (espritos mdicos), the


113
area (45.3%). That the pharmacy sold other useful
merchandise (sundries) was mentioned by nearly half of the
participant in Copacabana (47.3%), but only 19.4% of the
reposndents in Santa Cruz. Being able to order medicines by
telephone was appreciated by 40% of the elderly in
Copacabana, and 16.3% of those in Mier. This was not a
meaningful category for many Santa Cruz residents because
they have no telephones.
"Other" characteristics mentioned included: the clients
are well attended (good service), the pharmacy (as opposed
to the individuals who worked in the pharmacy) is well-known
and trusted (it has a good reputation), the pharmacy offers
some convenience (e.g., open 24 hours, has a weight scale,
would search for a medication elsewhere if the pharmacy did
not have on hand), and the cleanliness of the pharmacy.
Overall, the single most important characteristic that
clients appreciated about the pharmacy they patronized was
that the prices were good, or that a discount was offered
(see Table 4.15). This was especially true for respondents
in Santa Cruz. This corresponds with the prevailing public
concern about the cost of medications in general at the time
of the interview so that getting a good price was important.
Location was mentioned by a quarter of the elderly in
Copacabana and Mier as the most significant aspect, but was
mentioned much less frequently in Santa Cruz, where the


91
commerical activity in these neighborhoods. There are two
medical clinics, and the two pharmacies in Pacincia carry
only a minimal supply of medications.
Analysis Strategy
All measures of interest were measured using summated
scales of relevant items. These summated scale scores were
evaluated for internal consistency reliability using
Cronbach's coefficient alpha. Modifications were made in
the measures when appropriate (e.g. when an item greatly
reduced thge internal consistency of the scale, it was not
part of the summated scale but was analyzed as an
independent item).
Correlation coefficients were examined to determine the
significance and strength of the bivariate relationships
among predisposing, enabling, need and use variables. Next,
a stepwise multiple regression analysis was performed in
which number of physician prescribed (PP) and non-physician
prescribed (NPP) medications used during the reference
period (preceding two weeks) were treated as dependent
variables and all other factors as independent variables.
With this method, the independent variables are allowed to
"compete" with each other in order to identify the best set
of predictors of each of the medication use variables
measured.
Often, residential area has been included as one of the
indicators of the social structural dimension of the


56
supermarket chains are trying to gain the right to sell
pharmaceuticals, only establishments such as hotels or non
profit, philanthropic organizations are currently permitted
to sell or otherwise dispense non-legend (OTC) medications,
and these only to their clients (CRF-8, 1983:120-121;136-
141) although the illegal sale of medications outside of
pharmacies has been documented (Costa et al., 1988).
Pharmacists are responsible for the direct sale to
consumers of medications and other pharmaceutical
specialties, but Brazilian law also stipulates that others
may also have this responsibility (Decreto No. 20.377,
8/9/31). This includes individuals who may have some
limited formal training or apprenticeship, but are not
registered pharmacists, known as "orticos11 and "oficiales".
In 1960, these practitioners were permitted to register with
the regional boards of pharmacy to qualify as a technician,
capacitated with all the rights of a pharmacist except in
the formulation of medications. This includes the right to
own and register a pharmacy and to give injections. Law No.
5,991 (17/12/73) and Decree No. 74,170 (10/6/74) stipulate
that the presence of the responsible technician (either
pharmacist or other technician) is obligatory during all
commercial hours, but a pharmacist is not required to be
present at all times.
The concern for ensuring access to medications to all
communities is also cited as the rationale for legislation


110
Table 4.13 Utilization of Pharmacies
Copacabana Mier Sta. Cruz
% % %
Mean no. pharmacy visits
per month
2.03
2.15
1.31
(SD)
(2.33)
(2.87)
(2.81)
F=4.17, df=2,
p<.016
How often do
you go to the
same pharmacy?
Always
53.4
35.7
34.5
Often
13.7
7.7
15.1
Sometimes
22.1
20.2
30.2
Never
10.7
36.4
20.1
N=
131
129
139
X2=33. 45, df=6, p<.0001
Participants were asked to identify the characteristics
they appreciated of the pharmacy they most frequently
patronized. Categories were provided and any number of
items could be selected, including an option for "other"
(see Table 4.14). Of those who go to a pharmacy to purchase
their medications, the elders in Copacabana were most
pleased about the location (75.6%), the prices (67.9%) and
the quality of the medications sold (51.9%) in the
pharmacies. In Mier, the majority elders were most pleased
about the prices (76.7%), location (62.0%), and the
inventory (selection of products) (40.3). In Santa Cruz, as
in Mier, the prices of the drugs was the most frequently
mentioned characteristic (60.4%), followed by location


30
like Brazil, accustomed to being concerned about the
expanding bottom of their population pyramids, to look up
and refocus.
The methodology employed for the development of a model
to describe medication use for the urban Brazilian elderly
is presented in Chapter 3, including the operational
definitions of variables and their measurement, selection of
the sample and data collection techniques. Descriptive
results are presented in Chapter 4, along with the results
of analysis modeling medication use. Conclusions and
recommendations for future research are presented in Chapter
5.


181
prescription status in the pharmacy (with refills continuing
indefinitely), casts a particularly significant
responsibility on physicians to confirm that proper drug
therapy is currently appropriate for all of their patients.
It will be interesting to see if the recent growth of a
consumer protection movement will have any real impact on
drug use related problem. The potential for a change in
pharmacy practice can only increase if the efforts of the
CFF and the consumer movements were combined.
Conclusions
The large body of research on modern pharmaceuticals in
developing countries confirms the central role of
medications in every day health seeking behavior, their
potential benefit and harm to these populations. This
research also indicates that the extent to which
generalizations about factors affecting drug use from more
developed countries can be applied to the situations of the
lesser developed countries, and even to situations from one
developing country to another, is limited. Differences in
the structure and organization of formal and informal health
care systems between and within countries which influence
medication use behavior, particularly self-medication, are
difficult to control for, not well understood, and yet
critical to an understanding of health services utilization
(Kroeger, 1983; van der Geest, 1984). In addition, the
rather precarious status of health care services in


APPENDICES
A ITEM SELECTION CANDIDATES 184
B INSTRUMENT 198
C LETTER OF INTRODUCTION TO STUDY PARTICIPANTS... 223
D ACCESS TO CARE AND ATTITUDE MEASURES 225
REFERENCES 2 32
BIOGRAPHICAL SKETCH 245
viii


Table 3.1
Variables and their measurement
Variable name
Predisposing variables:
Age
Gender
Household size
Education
Income
Attitudes toward medical care
(Att_Med_Care)
Attitudes toward lay advice about
drugs (Att_Lay_Advice)
Enabling variables:
Perc'd acceptability of medical services
(Accept_Med_Serv)
Perc'd availability of medical services
(Avail_Med_S erv)
Perc'd affordability of medical services
(Af ford_Med_S erv)
Measurement
Number of years of age
0=male, l=female
No. persons living in the home
No. of years of schooling completed
Estimated personal monthly income,
adjusted for monthly inflation
Summated score of 7 items
(ordinal measures)
Summated score of 3 items
(ordinal measures)
Summated score of 15 items
(ordinal measure)
Summated score of 11 items
(ordinal measures)
Summated score of 2 items
(ordinal measures)


115
package insert to illiterate clients; the pharmacist is
"almost a physician" and, especially in emergency
situations, can be very helpful by prescribing a remedy, or
even giving stitches and first aid; "the pharmacist is an
important source for health care for those who can't afford
to go to a physician"; and, "some medications have special
formulas and still need to be made by a pharmacist."
Those who said that pharmacists are not needed (14.2%
of the entire sample) gave the following reasons: "a patient
gets all the information necessary from the physician and
the package insert", "there is no longer any need to make
formulas" (because all medications are industrialized), "you
can't trust those who work in the pharmacy", they are "false
pharmacists" or "just ignorant balconistas."
When the patient has a question about a medication, the
usual source for information varies by area (see Table
4.16). Elders in Copacabana were more likely than those in
Mier and Santa Cruz not to ask anyone if they had a
question about their medications, but if they did ask, they
were more likely to ask a physician. Elders in Santa Cruz
were most likely to ask someone, and those in both Mier and
Santa Cruz were more likely than those in Copacabana to seek
non-physician advice (X2=30.90, df=4, pc.0001).


Table 4.29 Intercorrelation matrix of
variables included
in the hypothesized model
for
Sta.
Cruz.
Variable
Xi x2 x3
x4 x5 X6
x7
x8
x9
X10
X11
X12
xi3
X14
X15
Xi6
Xi7
Gender
X1 -.03 -.16*-
.03 -.40*-.20*
.32*
.06
.02
.00
.14
-.20*
.06
.02
.03
.35*-
.06
Age
X2 -.22*
.03 .08 .03
-.04
.02
-.15
-.04
-.04
.07
-.02
-.04
-.00
.11
.03
Education
x3
.06 .32* .14
-.12
-.14
-.14
.11
.15
.14
-.24*
.18*
.22*
.09
.00
House, size
X4
-.13 -.00
.05
.09
-.04
-.01
.01
-.04
.04
-.06
.06
.01
.24
Income
x5
-.19*
-.15
.08
-.09
.01
.17
.26*
-.04
.26*
.26*
-.13
.07
Perc'd health
x6
-.52*
-.16*
.04
.17*
.12
.18*
.12
.30*
.23*
-.47*-
.06
No. Symptoms
x7
.15
.11
-.10
-.13
-.34*
.01
-.22*
-.33*
.47*
.04
Att Med Care
x8
-.13
-.09
.20*
.01
.01
.06
.09
-.16*
.08
AttLayAdvice
x9
-.01
-.12
.20
.49*
.03
-.32*
-.05
.22
AcceptMedServ
X10
.62*
.09
.23*
.22
.18*
.20*-
.23
Avail Med Serv
X,1
.13
.05
.39
_ *
.32
.14 -
.23
AffordMedServ
X
-.11
.13
.58*
-.25*-
.00
AcceptPharmServ
X13
.31*
-.14
-.10 -
.03
Avail Pharm Serv
X14
.22*
-.04 -
.08
AffordDrugs
X15
-.14 -
.00
PP
X16
-
.13
NPP
X,7
--
N=151;
All values greater than or equal to .16 are significant at p=.05 or better.
H
.P


29
investigate the relative importance of perceived access to
medical and pharmacy services. In the context of
uncontrolled commercialization of medications characteristic
of many developing countries, including Brazil, where the
risks associated with self-medication are increased, this
relationship assumes particular interest. The specific case
of Brazil, including the health care system, pharmaceutical
industry, and retail pharmacy in this nation, is discussed
in Chapter 2.
The determination of the extent to which the dimensions
of perceived access influence medication use behavior in
different areas within an urban setting is also a focus of
this study. Areas may be distinguished by locational,
socioeconomic and cultural factors. Areas are not only
composed of groups of individuals, but they may also be
understood as in themselves influencing individual
attitudes, and exerting some influence on perceived access
to care.
The specific population of interest in this study is
the urban, noninstitutionalized elderly. The elderly
represent a segment of the population in developing
countries which will be commanding increased attention. The
economic, social, and political impact of the health and
illness of a growing elderly population will need to be
considered in assessing the relative value of competing
health policies. Changing demographics will force countries


47
an individual-curative model of medicine. All thses factors
contributed to make Brazil particularly attractive for
investment by foreign pharmaceutical firms in the 1950s.
A major transformation in the make-up of the
pharmaceutical industry occurred in the early 1960s. An
extended period of political crisis triggered economic
stagnation that lasted until 1967 (Baer, 1983:93-97). The
impact was hardest on national firms: between 1960 and 1962,
75 national pharmaceutical firms disappeared from the
industry. After the military coup of 1964, strict
stabilization reforms were introduced which favored foreign
investment, and between 1966 and 1969, five of the largest
remaining Brazilian pharmaceutical firms were bought out by
international companies (Evans, 1979:125).
The local Brazilian firms that survived the waves of
denationalization seemed to have done so on the basis of
their successful commercial and marketing capacities rather
than competiveness in research and development (CEPAL,
1987). The top firms concentrated on specific therapeutic
classes and market power was gained from brand preferences.
However, each firm's power was limited by the presence of a
large number of close subsitutes, indicating a market
characterized by an undifferentiated oligopoly.
Furthermore, although there was a large diversity of
different products, the required technology was relatively
simple and unconcentrated so that the market for the


APPENDIX C
LETTER OF INTRODUCTION TO STUDY PARTICIPANTS


90
bus lines that go into the downtown area from Santa Cruz,
they are relatively expensive and not practical unless one
can afford to go by "frescao", an air-conditioned express
bus that goes straight to downtown Rio de Janeiro.
Santa Cruz is a rapidly developing suburban area, yet
it still has a rural flavor. Only the principal streets are
paved, and construction is relatively simple, and there are
still many open spaces. The population density in the area
is relatively low compared to the other two study areas.
The estimated number of elders living in this area in 1988
was 11,249.
In Santa Cruz, there is a public hospital, some clinics
scattered about, and various small pharmacies, three of
which are within walking distance of the train station.
There is a large military base and a new industrial complex
near Santa Cruz that provide employment for some residents,
but many residents must commute into the city for their
jobs.
Although there are obvious signs of prosperity in some
of the houses in Santa Cruz proper and neighboring Sepetiba
(approaching the coast), this is less so for the adjacent
neighborhoods of Pacincia and Cosmos. In these
neighborhoods there are more dwellings in various stages of
a slow construction, or, as the case may be, deconstruction.
A local public elementary school lies in half completion,
and the sewer drainage is open. There is minimal


97
illness and death, and change of address was greatest in
Mier.
Descriptive Results
Health Status
The participants were asked to evaluate their health
status on two items rated on a five point Likert-type scale.
The first item asked the participants to evaluate their
current health status from very poor to very good. These
categories were then collapsed into three categories in
order to obtain sufficient cell frequencies for the
application of statistical tests of association. Summary
information is given in Table 4.3.
Table 4.3 Self-Reported Health Status
Copacabana Meier Sta. Cruz
(n=138) (n=147) (n=150)
My health is:
Very poor/poor 10.9
Average 38.4
Good/very good 50.7
xz=7.95 df=4 p=0.09
Compared to others my age,
my health is:
Much worse/worse 6.0
Same 41.4
Better/much better 52.6
18.4
46.3
35.4
9.5
36.5
54.0
14.7
44.4
40.7
13.9
33.6
52.5
x2=5.41, df=4, p=0.25


3
the elderly are a rapidly growing segment of many Third
World populations, including Brazil (Kinsella, 1988; Ramos
et al., 1987). The hazards associated with the use of
medications (prescribed and non-prescribed) in the elderly
have been well documented in several developed countries
(Beadsley, 1988; Chapron, 1988; Johnson and Pope, 1983;
Moore and Teal, 1985; Simonson, 1984). However, little is
known about geriatric drug use in the "aging" developing
countries.
In this investigation, medication use was modeled as a
function of various individual and community level factors
which were related to access to medical and pharmacy
services in the Municipio (county) of Rio de Janeiro,
Brazil. Self-medication was defined as the use of a
pharmaceutical or other medicinal product (including home
remedies) not prescribed or recommended by a physician for
the patient. The variables examined in the model are based
on the Andersen and Newman (1973) behavioral model for
health services utilization (HSU) and adapted to medication
use in the Brazilian context. Variables include
predisposing sociodemographic characteristics, enabling
variables reflecting aspects of access to care, and need for
care variables.
In this study, access to medical and pharmacy services
are analyzed according to their component dimensions of
perceived availability, perceived affordability, and the


194
d. My pharmacist recommends ways for me to recall to
take my medicines when I should so that I won't
forget.
5. PRUDENCE/DISCRETION
a. My pharmacist would never recommend an unnecessary
drug.
b. When my pharmacist is unsure about what is wrong
with a patient, he/she would refer to a physician
or other specialist.
c. It is possible that my pharmacist might recommend
one drug when another drug would be better.
d. It is possible that clerks recommend unnecessary
drugs.
e. My pharmacist has continued to treat some of his
patients even when he/she was unsure about what
was wrong with them.
6. MODERNITY
a. In general, the pharmacies in my area are somewhat
out-of-date.
b. My pharmacist keeps up on all of the latest drug
discoveries.
7. THOROUGHNESS (INFORMATION TAKING)
a. My pharmacist does not ask questions about my
problem before selling me a drug.
b. Sometimes my pharmacist misses important
information when I talk to him/her.
c. Clerks frequently miss important information when
I talk to them.
d. My pharmacist lets his/her patrons tell him/her
everything that is important.
8. CONSIDERATION
a. My pharmacist does not seem to care if I don't get
better.
b. My pharmacist never keeps his patrons waiting.


95
Table 4.1 Summary Statistics of Study Participants
Copacabana
(n=138)
Meier
(n=147)
Sta. Cruz
(n=151)
Gender
Female (%)
63.8
57.8
65.6
Male (%)
36.2
42.2
34.4
Mean age (years)
72.58
72.16
70.69
(SD)
(7.27)
(7.09)
(6.37)
Civil status
Married (%)
50.0
62.6
42.4
Not Married (%)
50.0
37.4
57.6
Race
White (%)
87.7
57.1
43.1
Non-white (%)
12.3
42.9
56.9
Literacy
100.0
92.5
74.8
Religion
Catholic (%)
73.9
61.9
55.0
Other Christian (%)
6.5
12.2
23.2
Spiritualist (%)
8.7
16.3
13.9
Other non-Christian
(%)
2.2
0.0
1.3
None (%)
8.7
9.5
6.6
Elders living alone (%)
15.9
4.8
11.3
Mean no. persons living
1.75
2.26
3.21
with elder (SD)
(1.31)
(1.68)
(2.50)
Employed (%)
13.0
9.5
18.5
Personal monthly income
209,688
47,688
29,687
(Cr$, 3/91) (SD)
(245,273)
(67,023)
(53,162)


24
4) Which therapeutic classes of medications are most
frequently used by the elderly in the sample? How
frequently are different classes self-prescribed?
Significance
In 1985, the World Health Organization published Drugs
for the Elderly, a concise report on issues in geriatric
drug therapy. These include high rates of medication use
relative to other age groups, and the increased risks for
clinical and non-clinical drug-related problems.
Nonetheless, as a treatment modality, the cost-benefit ratio
of pharmaceuticals is often favorable relative to other
modalities for many of the conditions that typically afflict
the elderly. The timeliness of the WHO publication for
developing countries derives from by the fact that large
elderly populations are no longer confined to the developed
Western world (Kalache et al., 1987; Kinsella, 1988) and
there is relatively little known about geriatric drug use in
less developed countries.
The health care needs of the elderly have demanded the
attention of policy makers in the more developed countries
for many years. Of increasing importance is the widespread
use of both prescribed and non-prescribed medications.
Indeed, in many Western, developed nations, medication use
has been found to be more the rule than the exception among
the elderly (cf. Rabin, 1977; Simonson, 1984; Lipton and
Lee, 1987; Cartwright and Smith, 1988), and consequently,


79
these services relevant to the issues of accessibility,
availability, and affordability were identified and modified
for the Brazilian context. These items (see Appendix A),
together with new items developed for the purpose of model
building and medication use, were reviewed by Brazilian
health care professionals and social scientists, including
two sociologists, two physicians, a dentist, a pharmacist, a
social worker, a psychologist, and a nurse.
Preliminary "test runs" on a small independent sample
of individuals, elderly and not, indicated that response
sets which required responses to items on a five point
"strongly disagree" to "strongly agree" scale, used in the
above mentioned studies, were not successful. It was noted
that these tended to result in monotonic response sets with
little to no variation, and increasingly so as the interview
progressed. This may have been due to the fact that, unlike
the previous studies, items were stated verbally by the
interviewer and subjects were not permitted to read their
alternatives. The use of an interview format rather than
the written questionnaire used in previous studies was
thought necessary to increase response rates and to control
for the effects of high rates of illiteracy. Because of the
problems with five point response scales, the statement
format of the items was changed to a question format
requiring responses which were more concrete, making
reference to actual experiences, and had a more limited


APPENDIX B
INSTRUMENT


72
informed about the income contributions of other household
members. In this study, because the number of individuals
who were not able to report an estimated household income
was relatively large, severely affecting the sample size,
personal income was used. Personal income was adjusted for
inflation on a monthly basis using FIPE/IPC (Fundago de
Investigago e Pesquisa Econmica/Indice de Pregos ao
Consumo) estimates, and standardized to March, 1991 values.
Attitudes toward Medical Care (AttMed Care): The
indicators for measuring attitudes towards medical care are
adapted from Stoller (1988). Items included in a summated
ratings include skepticism regarding the efficacy of medical
care, reluctance to accept professional recommendations, and
belief that a person understands his or her own health
better than a physician. High scores indicate positive
attitudes toward modern medicine.
Attitudes toward Lav Advice about Drugs
(Att Lav Advice): The items for this measure tap the
willingness to accept non-professional advice about
medications. The measures are derived from the summated
scores of responses to each item. High scores indicate a
greater willingness to accept non-professional (lay) advice
about medications.
Enabling Variables
Enabling variables address various aspects of access
to care. Ware and Snyder (1975) have identified several


173
likely to be an effect of that historical period on the
responses. Further analyses may help determine if there was
an effect of the point in time the data were collected and
the effects it had on the results.
Several restrictions on the interpretation of results
emanated from limitations imposed by the use of cross-
sectional data in conjunction with the general HSU
conceptual model. Notwithstanding the temptation to infer
process and causality, the relationships revealed in the
study can only suggest several avenues for future
investigation.
Policy Implications
Health Care and Medication Use amona the Elderly:
Access to care: In general, the study indicates that
barriers to care related to the perceived supply of services
(availability) and price (affordability) are minimal for the
aggregate Rio de Janeiro data. Rio de Janeiro is a
relatively wealthy state and is endowed with a greater
health care resources than many other regions in Brazil.
Within each area there are various health care alternatives,
including services of the public medical and health care
sector, despite their various shortcomings. The dimensions
of access related to the cost and availability of services,
therefore, appear not to be significant barriers to care.
Instead, the perceived quality of the services received (or,
patient satisfaction) is likely to be a better predictor of


104
Table 4.8
What is the most important problem
in obtaining your medication?
you have
Copacabana
Mier
Sta. Cruz
(n=138)
(n=147)
(n=151)
%
%
%
No problem
64.5
59.9
35.8
Financial
11.6
29.3
50.3
Hard to find
drug(s) 14.5
2.7
3.3
Other
9.4
8.1
10.6
X2=67.54 df=6 p<.001
The Role of the Physician
Participants were asked to identify their usual first
recourse for help in the event of a health problem (see
Table 4.9). Nearly half (47.8%) of the elders in Copacabana
reported that they usually seek help from a private
physician, and 39.1% from a physician from a private
institution with which the elder is affiliated (for example,
an HMO-type of facility for bank employees). Few elders in
this area (6.5%) rely on a physician from a public
institution, or on any other source of assistance. In
contrast, a much greater proportion of elders in the other
two areas rely on a physician from a public institution:
42.9% of the elders in Mier and 43.7% of those in Santa
Cruz seek physicians from a public institution, usually a
state institution, such as the organization for state
employees, or a federal institution such as INAMPS.
However, these results obscure some important relationships.
For some elders, the "private" physician which is consulted


TABLE OF CONTENTS
P-aqe
ACKNOWLE DGEMENTS iii
ABSTRACT viii
CHAPTERS
1 MEDICATION USE AND THE ELDERLY IN BRAZIL 1
Introduction 1
Background: Medication Use in the Third World... 5
The Political and Economic-Infrastructural
Context 6
The Social and Cultural Context 10
Theoretical Framework 13
Health Services Utilization and Medication
Use 13
Conceptualizing Access to Care 16
Access to Care and Medication Use 2 0
Research Questions 2 3
Significance 24
Summary 28
2 MEDICAL AND PHARMACY SERVICES IN BRAZIL 31
Health Care in Brazil 31
The Public Sector 32
The Private Sector 38
Health Services Utilization in Rio de Janeiro.... 41
The Pharmaceutical Industry in Brazil 46
The Private Sector 48
The Public Sector 51
Economic and Social Aspects of Drug Use 55
Pharmacies and Drugstores 58
Pharmacy Practice and Self-Medication 63
Conclusion 65
3 METHODOLOGY 65
Building a Medication Use Model for Brazil 65
Predisposing Variables 66
Enabling Variables 72
Need Variables 7 5
Use Variables 77
vi


Verbrugge, Lois M. 1982. "Sex Differences in Legal Drug
Use." Journal of Social Issues 38:59-76.
243
. 1984. "Longer Life but Worsening Health? Trends in
Health and Mortality in Middle-aged and Older Persons."
Millbank Memorial Fund Ouarterlv/Health and Society
62(3):475-519.
Verbrugge, Lois M., and Richard P. Steiner. 1985.
Prescribing Drugs to Men and Women." Health Psychology
4(1):79-98.
Victora, Ceasr. 1982. "Statistical Malpractice in Drug
Promotion: a Case-Study from Brazil." Social Science and
Medicine 16:707-709.
Von Mering, Otto, G. Shannon, W. Deal, and P. Pischer. 1976.
"A Long Day's Journey to Health Care." Human Organization
35(4) :381-89.
Von Wartensleben, Aurelie. 1983. "Major Issues Concerning
Pharmaceutical Policies in the Third World." World
Development 11(3):169-175.
Wan, Thomas T. H. 1982. "Use of Health Services by the
Elderly in Low-Income Communities." Millbank Memorial Fund
Ouarterlv/Health and Society 60(1):82-107.
Wan, Thomas T. and S. Soifer. 1974. "Determinants of
Physician Utilization: a Causal Analysis." Journal of Health
and Social Behavior 15(2):100-112.
Wang'ombe, Joseph and Germano M. Mwabu. 1987. "Economics of
Essential Drugs Schemes: The Perpectives of the Developing
Countries. Social Science and Medicine 25(6):625-630.
Ware, John E. and Mary K. Snyder. 1975. "Dimensions of
Patient Attitudes Regarding Doctors and Medical Care
Services." Medical Care 13(8):669-681.
Wolinsky, F. D. 1978. "Assessing the Effects of
Predisposing, Enabling, and Illness-Morbidity
Characteristics on Health Services Utilization. Journal of
Health and Social Behavior 19(4):384-396.
Wolinsky, F. D., and C. L. Arnold. 1988. "A Different
Perspective on Health and Health Services Utilization."
Annual Review of Gerontology and Geriatrics 8:71-101.
Wolinsky, F. D. and R. M. Coe. 1984. "Physician and
Hospital Utilization among Elderly Adults: An analysis of


59
data to justify the claim of a pharmacist shortage and that
the laws mentioned above were based on questionable, if not
false, premises (1980:104-105). These laws served to
conspire with the pharmaceutical industry to promote
drugstores as efficient commercial outlets for their
products. The traditional pharmacy that formulated its own
drugs could not compete with the industries that operated
with large economies of scale. As pharmacists no longer
held exclusive rights to operate establishments for the sale
of pharmaceuticals, this represented a virtually untapped
market for the entrepreneur. By the end of World War II,
the drugstore boom had begun and pharmacists left the
community setting and headed for industry.
The impact of these changes on pharmacies and practice
has not been uniform. In some areas, especially where
medical care is scarce, the pharmacy still represents an
important health care resource. In an ethnography of two
neighborhoods in the Rio de Janeiro suburb of Nova Iguaz,
Loyola (1983) describes two general types of practicing
community "pharmacists": practitioners who provide
therapeutic assistance ("farmacuticos-praticantes" or
"farmacuticos-terapeutas") and commercial or business
"pharmacists" ("farmacuticos-comerciantes"). These two


APPENDIX D
ACEESS TO CARE AND ATTITUDE MEASURES


186
b. When I feel ill, I can usually cure the problem
without seeing a physician.
c. Doctors make us think that medicine is more
complicated than it really is.
d. Most people, if they had the right books to look
up information, could do just as good a job as a
physician in treating illness.
e. Experience with illness makes people a lot better
at treating sickness than going to medical school.
B. ATTITUDES TOWARDS DRUGS
1. SKEPTICISM REGARDING THE EFFICACY OF DRUGS
a. Most of the time, when people are ill, they will
eventually get well without drugs
b. Nearly all serious illness can now be cured by
drugs.
c. There will always be some serious illnesses that
cannot be cured by drugs.
d. It is best to let illnesses that are not very
serious run their course without resorting to
drugs.
2. WILLINGNESS TO ACCEPT NON-PHYSICIAN ADVICE ABOUT DRUGS
a. When a pharmacist gives advice about drugs, it is
usually good advice.
b. It's not always a good idea to try the remedies
that pharmacy clerks prescribe.
c. My friends often have good advice about
medications they have taken for health problems
like mine.
d. It is usually best not to deviate from the
doctor's advice about drugs.
e. I have bought/tried a medicine because I saw it
advertized for a particular problem I have.
3. BELIEF THAT DRUGS ARE SAFE
a.
Most drugs are dangerous.


50
operating suboptimally, especially in the production of
medications.
The failure of the program has been a great
disappointment politically, economically and socially
(Evans, 1979, Landmann, 1982; Cordeiro, 1985; Cunha, 1987;
Soares, 1989). The negative implications of its failures
have been ballooning during the last few years. A recent
study by the Health Commission of the Legislative Assembly
in Rio de Janeiro reported that CEME spent 95% of its budget
on the acquisition and distribution of medications and that
contracts with private firms accounted for nearly 55% of
this amount, approximately CR$10 billion, in 1990 ("Deputado
diz...", 1991; "CEME nega...", 1991). The dependence on
private firms became a problem when government price-fixing
of medications was terminated, beginning in August, 1990,
and prices began to rise at unprecedented rates. The cost
of doing business with private firms became untenable and,
in the face of dire shortages for many drugs, CEME was
forced to look elsewhere for the medications it required.
In January, 1991, the president of CEME, Antonio Carlos
Alves dos Santos, asked that 16 state laboratories expand
production as a means to alleviate the shortages ("Verba
para os laboratorios...", 1991). Whether or not this was a
"reasonable" request, whether production capacity could be
expanded, and so on, is questionable.
Economic and Social Aspects of Drug Use


134
by themselves, appear to be related to medication use, and
how highly correlated the predictors themselves are.
Perceived health status and number of symptoms are the
variables most highly correlated with PP medication use:
better perceived health status is related to less PP
medications use (r= -.30), and increased number of symptoms
is related to use of more PP medication use (r=.29).
Perceived health status and number of symptoms are, as
expected, negatively correlated (r=-.39): good health status
is related to fewer symptoms. These are consistent with
findings from previous studies (Bush and Osterweis, 1978;
Sharpe et al., 1985; Stoller, 1988).
The predisposing sociodemographic variables, with the
exception of household size, are mildly correlated with
increased PP medication use: being female (r=.16), older
(r=.16), more educated (r=.ll), higher income (r=.10), and
having positive attitudes toward medical care (r=.10). The
relationships among gender, education, and income are not
surprising: there is a strong positive relationship between
education and income (r=.55). In addition, the bivariate
relationships between gender and both education (-.19) and
income (-41) reflect the relatively low levels of education
and income among women.
None of the sociodemographic variables are correlated
with NPP medication use. There is a weak, yet significant,
relationship between more positive self-reported health


20
medical treatment may seek to supplement or substitute a
physician's treatment with the advice of another, more
"acceptable" health professional, or other alternative.
Along these lines, Loyola (1983), in her ethnography of
health care services utilization in the city of Nova Iguaz
(Rio de Janeiro), suggests that an individual's attitudes
towards health care alternatives are influenced not only by
the physical environment, but also by the social environment
in which the drama of health and illness takes place.
Through what Loyolla calls the "efeito do bairro," or,
neighborhood effect, attitudes toward services are shaped by
a kind of dialectic interaction between the relative and
absolute poverty (or wealth) of the community and the
internal and external social cohesion of the community.
Access to Care and Medication Use
Several studies have incorporated some aspects of the
HSU framework for examining different kinds of medication
use (for a review see Sharpe et al., 1985). However, few of
these have incorporated measures of perceived access to
care. Bush and Osterweis (1978) included in their model of
medication use behavior for American adults in Baltimore a
measure for perceived availability of care. Although
measured by only one item on a four point ordinal scale, the
results indicate that the more people perceived care as
available, the more likely they were to use a prescribed
medication and less likely to use a non-prescribed


48
introduction of new products was fragile. The basis of
competitiion for control of the pharmaceutical market in
Brazil, therefore, was in the area of production of
pharmaceutical specialties, including new combination drugs,
and new dosage formulations, not the development of new
drugs per se. Indeed, since Brazil has not recognized
patent protections since 1969, any laboratory could submit
registrations for any product. The small national firms
took advantage of this by registering copies of all the most
commercially important products, the vast majority of which
were MNC products. For example, in 1982, apart from
Beecham's brand of amoxycillin, under patent protection in
the United States, and that of their licensed subsidiary,
there were 17 other brands available on the market, with
many more registered (Adler, 1982:627).
The Public Sector
In 1971, CEME (Central de Medicamentos) was established
as a crucial element of the Brazilian government's answer to
the ever increasing costs of medical care in general, and
medications in particular. The stated purpose for the
creation of CEME was to provide essential medications, as
listed on the national formulary (Relatrio Nacional de
Medicamentos), free of charge or at a reduced rate to that
segment of the population determined unable to afford them
on the open market, which at the time of CEME's inception
was estimated at 90 million people (Cordeiro, 1985) CEME


23
research, predictors of medications use for the different
SES areas were examined both collectively and for each area
individually.
Research Questions
In order to address the stated goals of this study, the
following specific research questions were investigated:
1) Which variables of the hypothesized medication use
model (predisposing, enabling, and need) emphasizing
perceived access to medical and pharmacy services are most
important in explaining prescribed medication use, and which
are most important in explaining self-medication in the
sample of Brazilian urban elderly in the Municipio of Rio de
Janeiro? Do residential areas with different socioeconomic
characteristics affect these interrelationships, and if so,
in what ways?
2) How well does the conceptual model fit the
utilization of physician and non-physician prescribed
medication in the low, medium, and high socioeconomic status
areas in the municipio of Rio de Janeiro? What variables
are the best predictors of self-prescribed and physician
prescribed medication use in these areas?
3) What proportion of medications being taken are
prescribed by a physician and what proportion are self-
prescribed?


216
enfermeiras, etc.) sao
1. todos gentis e simpticos.
2. alguns sao gentis e simpticos.
3. poucos s3o gentis e simpticos.
4. nenhum e' gent i 1
9. NS
75. 0(a) Sr(a). acha que seu mdico The atende com respeito
1. sempre atende (o) Sr(a). com respeito.
2. nem sempre atende (o) Sr(a). com respeito.
3. nunca atende (o) Sr(a). com respeito.
76a.
0(a) Sr(a). acha que alguma vez o mdico lhe atendeu com m vontade?
1. nunca atendeu com m vontade.
2. algunas vezes atendeu com m vontade.
3. imitas vezes atendeu com m vontade.
4. sempre atendeu com m vontade.
76b. Em geral, o horrio do consultrio do seu mdico bom para o(a) Sr(a).?
1. N3o
2. Sim
76c. Se o(a) Sr(a). tivesse algum problema, o(a) Sr(a). poderia falar com o mdico a qualquer
hora, dia ou noite?
1.
fcilmente, a qualquer hora, dia e noite.
2.
com alguna dificuldade.
3.
com bastante dificuldade.
4.
com muita dificuldade.
9. NS
77. Para o(a) Sr(a). marcar urna consulta com seu mdico,
1. fcil
2. un pouco difci 1
3. difcil
4. muito difcil 9. NS
78. fcil para o(a) Sr(a). ir ao consultrio do seu mdico?
1. fcil
2. um pouco difcil
3. difcil
4. muito difcil
79. 0 seu mdico atendera na sua casa se o(a) Sr(a). quisesse?
1.
2.
Nao
Sim
9. NS


4
sociocultural acceptability of services. Typically, access
to services is evaluated with secondary data and use
indicators such as the distribution or number of hospital
beds or physician offices as indices of the availability of
services. Similarly, the affordability of services is often
evaluated by measures such as regular source of care, income
and insurance status. However, the assumptions implicit in
these traditional measures fail to capture other dimensions
of access that may be of particular relevance to some
patient subgroups such as the elderly or patients with
particular illnesses. Given the special socioeconomic,
psychosocial, and health status considerations of the
elderly patient, an understanding of the patient's
perceptions of access to needed services may be useful in
understanding behavior. The relative importance of these
variables and their interrelationships were examined for
elderly residents in three socioeconomic areas of the
Municipio of Rio de Janeiro.
A secondary goal of this project was to begin to
describe medication use in the Brazilian elderly. Such a
description not only provides the foundation for future
evaluations of drug therapies, particularly of the extent of
inappropriateness or potential danger in self-medication,
but also allows for cross-cultural comparisons of geriatric
drug use.


49
was to develop and produce medications as well as contract
out to private firms to make up for production
difficiencies.
Ideally, the merits of adopting essential drug policies
may be phrased in terms of health benefits and potential
savings, not only on the national level (Lilja, 1983;
Wang'ombe and Mwabu, 1987), but on the individual consumer
level as well (Patel, 1983). However, the promises of the
essential drugs program in Brazil were never to be
fulfilled. In 1974, over half (57%) of household health
budgets in Brazil was spent on medications (Musgrove,
1983:252), compared to 34% in the more prosperous urban Rio
de Janeiro (Cordeiro, 1985:181). Similarly, a comparison of
four communities in Sao Paulo demonstrated that the
proportion of health care expenditures related to medication
use was greatest for the poorest socio-economic strata
(Giovanni, 1980:129). In 1990 CEME revealed that as much as
55% of the targeted population was not being served.
CEME never became the national industrial contender
some would have had it become. In 1975, CEME was
dismembered: distribution services were allocated to the
Ministry of Welfare, while research, development, and
production were incorporated into the Ministry of Trade and
Commerce. As of 1985, CEME administratively resides under
the auspices of the Ministry of Health, but remains


242
"Susep elabora Projeto para Sade em Grupo." 1991. Jornal do
Brasil January 10.
Svarstad, Bonnie. 1987. "Gender Differences in the
Acquisition of Prescribed Drugs: An Epidemiological Study."
Medical Care 25(11):1089-1098.
Temporo, Jos Gomes. 1986. A Propaganda de Medicamentos e o
Mito da Sade. Rio de Janeiro: Ediges Graal.
Tinetti, Mary E., Mark Speechley and Sandra F. Grinter.
1988. "Risk Factors for Falls among Elderly Persons Living
in the Community." The New England Journal of Medicine
319(26): 1701-1707.
Tout, Ken. 1989. Ageing in Developing Countries. New York:
Oxford University Press.
Van der Geest, Sjaak. 1982. "The Illegal Distribution of
Western Medicine in Developing Countries: Pharmacists, Drug
Pedlars, Injection Doctors and Others." Medical Anthropology
Fall:197-219.
. 1984. "Anthropology and Pharmaceuticals in the Third
World: The Local Perspective." Medical Anthropology
Quarterly 15:59-62, 87-90.
. 1987. "Self-Care and the Informal Sale of Drugs in
South Cameroon." Social Science and Medicine 25(3):293-305.
Van der Geest, Sjaak and Anita Hardon. 1990. "Self-
Medication in Developing Countries." Journal of Social and
Administrative Pharmav 17(4):199-204.
Van der Geest, Sjaak, and Susan Reynolds Whyte. 1988. The
Context of Medicines in Developing Countries. Dordrecht,
Netherlands: Kluwer Academic Publishers.
Velho, Gilberto. 1973. A Utopia Urbana: Un Estudo de
Antropologa Social. Rio de JAneiro: Zahar Ediges.
Veras, Renato. 1988. "Considerages Acerca de um Jovem Pais
que Envelhece." Cadernos de Sade Pblica (RJ) 4(4):382-392.
Veras, Renato, Sidney D. Silva, Cristina Souza, Rosane
Milioli, and Ftima Ventura. 1989. "Um Inqurito Domiciliar
com Populages Idosas na Cidade do Rio de Janeiro: Urna
Proposta Metodolgica." (Mimeo).
"Verba para os Laboratorios CEME destina CR$3 bilhes para
Aumentar Produgo de Unidades nos Estados." 1991. Jornal do
Brasil January 19.


APPENDIX A
ITEM SELECTION CANDIDATES


41. (cont. 3)
Nota: OPM=outra pessoa mdica (veja o manual)
a. Nome do remedio
Razao por
Recei fado ou
Como usa
Duragao
1
Toma
0 remedio
Percebe problema
usar
recomendado por
(frequncia)
(# meses)
Serve?
com o remdio?
b. Dosagem
(especificar)
1. Mdico/OPM
1. todos os dias,
1. regularmente
2. Farmacutico
x vezes por da
0. Nao
0. Nao
3. Amigo/familiar
2. <7 vezes/semana
2. se esquece de
4. Outro (espec.)
4. <3 vez/semana
tomar de vez
1. Sim
1. Sim
(exemplo)
5. Ninguem
5. so quando precisa
em quando
(especifi que)
a. LANOXIN
(auto-receitado)
6. parou de tomar
98. NS
8. NS
8. NS
b. .25 mg
8. NS (nao letfera)
7. outro
99. NR
9. NR
8. NS 9. NR
8. NS 9. NR
9. NR
9. NR
9. a.
b.
10.a.
b.
11.a.
b.
12.a.
b.
[Entrevistador: Leia a lista dos remdios ao entrevistado para verificar os nomes e para que sao usados.
IMPORTANTE: Pergunte sobre os remdios que o entrevistado tomou as ltimas duas semanas mas que nao tem na
casa atualmente. Se o entrevistado disser todos os remdios, marque "NA" na primeira coluna.
210


180
become a matter of policy for the national professional
pharmacy association, the Conselho Federal de Farmcia
(CFF), yet many barriers have been identified. These
include the cost to the pharmacy of employing a pharmacist
who has become accustomed to the salaries offered in
industry.
That the distinction between a licensed pharmacist and
a salesperson was not as meaningful to some elderly clients
as to others may have some positive implications for the
difficulties the CFF expresses regarding the feasibility of
having a greater professional presence in the community.
Some balconistas have many years of work experience, they
pick up on some aspects of the "trade", and do adopt a
professional posture toward their work. A more complete
evaluation of this important figure in community pharmacies
in Brazil may reveal practical alternatives to the presence
of a full-time professional pharmacist in the pharmacy.
These may be akin to the oficiales or orticos (assistants
trained through practicum or apprenticeship), but with a
minimum of formal training reguired to accomplish the basic
goals of the CFF of preventing certain drug-related problems
that do not require the exercise of professional judgement.
Future research may focus more on client expectations of
pharmacy services with an eye to developing an "appropriate"
assistant. Until then, the prevalence of prepackaged dosage
forms and the lack of control or verification of


234
Clark, Margaret. 1970. Health in the Mexican-American
Culture. Berkeley, CA: University of California Press.
Cohen, Jacob. 1977. Statistical Power Analysis for the
Behavioral Sciences. Revised ed. Orlando, FL: Academic
Press.
Cordeiro, Hsio. 1984. As Empressas Mdicas: as
Transformaces Capitalistas da Prtica Mdica. Rio de
Janeiro: Graal.
Cordeiro, Hsio. 1985. A Industria da Sade no Brasil. 2nd
ed. Rio de Janeiro: Graal.
Costa, Teresa C., Luciana M. Kerber, Nadia M. Volpato, Alex
Cauduro, Homero N. Machado, Tania B. Pasa, Jose Senna, Rose
Vianna, and Eloir P. Schenkel. 1988. "Comercializago de
medicamentos em bares/lancherias e armazns/fruteiras em
Porto Alegre." Ciencia e Cultura 40(3):285-288.
"Cremerj vai Justiga contra o abandono do Getlio Vargas."
1990. Jornal do Brasil. September 14.
CRF-8 (Conselho Regional de Farmcia-8). 1983. Leaislaco
para o Farmacutico. 3rd ed. Sao Paulo: Artpress.
Crocker, Linda, and James Algina. 1986. Introduction to
Classical and Modern Test Theory. New York: Holt, Rinehart
and Winston, Inc.
Cuhna, Bruno Carlos de Almeida. 1987. Sade: A prioridade
Esguecida. Petropolis: Vozes.
Dantas, Fernando. 1991. "Projeto Obriga Empresas de Planos
de Sade a Optarem pelo Seguro-Sade." Jornal Gazeta
Mercantil. January 9.
Dean, Kathryn. 1989. "Conceptual, Theoretical and
Methodological Issues in Self-Care Research." Social Science
and Medicine 29(2):117-123.
Delafuente, Jeffrey C., and Ronald B. Stewart. 1988.
Therapeutics in the Elderly. Baltimore, MD: Williams and
Wilkins.
"Deputado diz que CEME atravessadora." 1991. Jornal do
Brasil January 2.
Donabedian, A., Wheeler J. R., and Wyszenwianski L. 1982.
"Quality, Cost, and Health: An Integrative Model." Medical
Care 20:975-992.


221
109.Se o(a) Sr(a). nao consegue falar com o pessoal de urna farmcia, o(a) Sr(a). conseguiria falar com
o pessoal de outra farmcia
1.
san
dificuldade.
2.
com
alguna dificuldade.
3.
com
bastante dificuldade
4.
com
muita dificuldade.
9.
NS
110.A farmcia est aberta sempre que o(a) Sr(a). precisa?
1. sim
2. no
7. NA
111.Para o(a) Sr(a). ir farmcia,
1. fcil
2. um pouco difcil
3. bastante difici1
4. muito difcil
7. NA Por que?
112. 0(a) Sr(a). pode pedir farmcia para entregar em casa?
1. Sempre pode pedir para entregar em casa.
2. Algunas vezes pode pedir.
3. Nunca pode pedir.
113. 0(a) Sr(a). sabe o name de algum que trabalha na farmcia, seja balconista ou farmacutico?
1. No
2. Sim
0(a) Sr(a). sabe se algum que trabalha na farmcia sabe o seu nome
1. No
2. Sim


88
value of the property. Previously, it was dotted by beach
houses used by vacationing middle class families from the
older, more established parts of the city (Velho, 1973).
Now, apartment buildings are the modal dwelling
structure and the principal streets are bordered by busy
groundlevel shops and boutiques (i.e., a horizontal
distinction between residential and business and commerical
areas). Mass transportation in the form of buses are
plentiful, their routes criss-cross major avenues, and lead
directly to important points in the city. Most of the
residents in this area are white collar workers and
professionals. Although no longer the most wealthy part of
the city (the money has since moved south to Barra de
Tijuca), the level of infrastructural completeness and
wealth of Copacabana relative to other areas remains high.
There is a INAMPS hospital in Ipanema, known for being
one of the best, and inumerous physician offices and clinics
as well as smaller private hospitals. In addition, compared
to the other two study areas, this area is the closest in
proximity to larger facilities in the center of the city.
Pharmacies of various types of pharmacies (homeopathic,
herbal, specialty), are plentiful, with as many as two or
more to a block. The BOAS project estimated that 45,775
elders lived in this area in 1988.


204
26. Quando o(a) Sr(a). precisa ir farmcia, o(a) Sr(a). sempre vai mesma farmacia?
(Ler p/o entrevistado os tens)
1. sempre
2. multas vezes
3. as vezes
4. nunca
8. NA (nunca vai)
27. Em geral, o(a) Sr(a). est satisfeito(a) com a farmcia onde o(a) Sr(a). consegue os remdios?
1. bastante satisfeito(a) (Ler p/o entrevistado os itens)
2. satisfeito(a)
3. insatisfeito(a)
4. bastante insatisfeito(a)
8. NS 9. NR
28a. Quais dos seguintes aspectos lhe agradam da farmcia onde o(a) Sr(a.) usualmente
consegue os remdios?
Entrevistador: leia a lista de alternativas e marque todas que sao aplicveis
01.
o entrevistador nao relata nada especial
02.
bom local
03.
o farmacutico de confianza
04.
os pregos sao razoveis / d descont
05.
os balconistas sao de confianga
06.
sempre tem os remdios que precisa
07.
os remdios que se vende sao de boa qualidade
08.
vendem outra mercadoria alm dos remdios que
so teis
09.
pode fazer pedidos pelo telefone / entrega o
domicilio
10.
pode comprar remdio a prazo
11.
outro
97.
NA (nunca vai a nenhuma farmcia)
98.
NS 99. NR
28b. Qul o aspecto que mais lhe agrada da farmcia?
Entrevistador: leia a lista de novo e marque o nmero do item que mais agrada ao entrevistado.
(nmero de s um i ten) agrada mais.


167
perceived access to care in predicting medication use varied
for each area.
The hypothesized access-oriented behavioral model was
much more effective in explaining the variance in the lower
SES area (Santa Cruz) than for the other two areas, for both
PP and NPP medication use, explaining 45% and 48% of the
variance for each, respectively. In Copacabana, the
prediction model for PP medication use explained 16% of the
variance, and NPP model explained 18% of the variance. The
PP model for Meier explained 15% of the variance, and the
NPP model explained 41% of the variance.
In high SES, metropolitan Copacabana, with a high
concentration of medical and pharmacy services, perceived
access to care was not related to medication use. In the
multivariate analysis, attitudinal measures emerged as more
important predictors for both NPP and PP medication use in
this area. Other critical factors are clearly not being
addressed in the model for this area. For example, the role
of private health insurance, particularly in this area, may
be significant. It may be that the level of medication use
is more closely related to the particular prescribing habits
of private physicians (not constrained by the national
formulary) versus physicians of public institutions or to
the kinds of physicians (specialists) most frequently
visited by patients in this area. These are questions yet
to be investigated.


92
predisposing component. In regression analyses, this leads
to the creation of one or more dummy variable(s) whose
parameter estimates reflect additive differences between
areas. In doing so, however, such analysis assume that the
effects of the other populations7 characteristics are the
same for each of the areas studied. This assumption does
not allow for different structures to emerge when various
outcomes are assessed within separate groups. Therefore, in
order to examine the difference between predictors for the
aggregate data versus examining predictors for groups in
smaller geogrpahical locale, separate regression analyses
were also conducted for each area independently.
A drug dictionary was compiled of the medications used
by the sample. This included a listing of all active
ingredients for each medication. Each active ingredient was
coded according to therapeutic class, for a maximum of three
codes per ingredient. This code was based on a modification
of the WHO therapeutic classification for drugs, and is used
by the research team on geriatric drug use in Dunedin,
Florida (May et al., 1982). A drug received a single
identifier number for different brand and/or generics of the
same product.
Summary
This chapter reviewed the methodology employed for the
study of medication use of the non-institutionalized urban
elderly in Rio de Janeiro. This is a cross-sectional survey


53
Sen. Dantas Street, a package of Venalot for
Cr$471.50. One week later, at the same pharmacy,
the drug cost me Cr$l,374, which took into account
the 15% discount [for seniors] (...). Within a
week there was an increase of 342.9%. (...)
Fritz Berg (RJ) (Jan. 19, 1991).
The beginning of 1991 was marked by a series of
hearings by the National Secretary of Economic Rights (SNDE)
in which 17 major pharmaceutical firms were summoned to
formally justify their price increases. Only one firm,
Fontoura Wyeth, refused to lower its prices and was found
guilty of violating the antitrust law ("Governo
encerra....", 1991). These actions provoked a heated
exchange between the producers, wholesalers, and retailers,
each accusing the other of illegally increasing prices
(Lapa, 1991). By February, the Secretary of the Economy was
forced to announce the return of price-fixing for
pharmaceuticals ("Governo tabela...", 1991).
The price scandals in early 1991 resulted in some
remarkable, if not positive, changes in industry behavior.
Industry, rather ironically, responded by terminating the
production of certain product lines, or certain dosage
forms, that, in reality, may be considered irrational from a
therapeutic perspective to begin with. For example, when
the price for the 30 dose package of Vibramicina, a wide
spectrum antibiotig was fixed with a ceiling very close to
that for the 15 dose package, Pfizer stopped marketing the
unnecessary 30 dose package (Rangel, 1991).


13
Theoretical Framework
Health Services Utilization and Medication Use
Medication use may be considered a subset of health
services utilization. However, there is an important
distinction between utilization of pharmaceuticals and
utilization of other health care services. Pharmaceuticals
are a market commodity, and many drugs are available to the
general public in a relatively uncontrolled environment.
Therefore, consumers are allowed greater leeway in terms of
personal decision-making about drug use than patients
seeking care in treatment facilities (Kloos et al.,
1986:670). Individuals may chose to self-medicate, to use
only prescribed medications, or to be "non-compliant" with a
physician's prescription. The latitude for action is
subject to certain constraints on access to care imposed by
various individual and local factors. These constraints may
include, for example, legal constraints, financial
limitations and other barriers to care, beliefs and
perceptions of health and illness, and access to alternative
sources for care.
A number of national and cross-national studies of
medication use have examined the bivariate relationships
between patient sociodemographic variables and medication
use in primarily Western societies in Europe and North
America (see review by Blum and Kreitman, 1981). Cross
national medication use studies generally do not take into


Table 4.27 Intercorrelation matrix of variables included in the hypothesized model for Copacabana.
Variable
x,
x2 x3 x4
X5
X6
x7
*8
x9
X10
Xn
X12
*13
X14
x
X16
*17
Gender (0=male)
x,
-.73*-.35*-.01
-.51*
-.11
.20*
.01
.04
.16*
.03
.06
.05
.08
-.12
-.04
-.07
Age
X2
fH
o
CO
o
1
-.04
.02
-.09
-.05
-.13
.02
.04
.08
.07
-.00
.00
.23*
.02
Education
*3
-.13
.49*
.21*
-.07
-.03
-.12
.07
.23
.09
-.18*
.17*
.09
.01
.04
House, size
*4
.05
-.02
.13
.11
.11
-.04
.06
-.13
.13
.02
-.01
.06
.10
Income
x5
.15
-.09
.00
-.02
.04
.18*
.07
-.15
.28*
.21*
.03
-.02
Perc'd health
X6
*
CO
CsJ
1
.08
.03
-.05
.29*
.06
-.07
.19*
.15
-.18*
.13
No. Symptoms
*7
-.07
.15
-.03
-.01
-.07
.00
.04
-.01
.23*
-.01
Att Med Care
x8
-.21*
-.12
.16*
.05
.07
.05
.15
.21*
-.03
AttLayAdvice
x9
-.12
-.14
-.20*
ro
00
*
.01
-.18*
-.05
.18*
AcceptMedServ
X10
_ *
.29
.05
.10
.01
.16*
.14
.05
Avail Med Serv
Xn
.26*
-.ii
.35*
.36*
.01
.04
AffordMedServ
X12
-.06
.27*
.49*
.06
-.04
Accept_Pharm_$erv X13
.05
-.12
.03
.12
Avail Pharm Serv
X14
.32*
.02
.02
AffordDrugs
X15
-.01
-.07
PP
X,6
-.16*
NPP
*17
--
N=138 All values greater than or equal than .16 are significant at p=.05 or better.
144


117
The elders who reported that pharmacists should explain
the effects of medications to clients consider this to be
nothing short of the pharmacist's professional obligation.
This professional responsibility referred to the role of
pharmacists as the producers of medications; "they make the
drugs, they are logical ones to provide the information
about the products they make"; "pharmacists are trained,
they know about drugs and make them." Similarly,
professional responsibility referred to the role of
pharmacists as the providers of medications: "ordinary
people generally are not knowledgeable about modern drugs
and a pharmacist's advice or explanation can only help the
client in the pharmacy"; "pharmacists can inform clients so
they won't make mistakes (about when and how to take their
medications)"; "pharmacists can inform or warn clients so
that they will be prepared for any adverse effects"; and,
"pharmacists can reassure clients who are insecure or
worried about their drug regimen."
Many people indicated that the clients who would most
benefit from a pharmacist's orientation are those who can't
read the package inserts, or have no one else (friend or
family) to help them to understand their drug regimen: "a
pharmacist may reinforce what the physician has already told
the patient"; sometimes the pharmacist is "better at


154
services as acceptable, and experiencing fewer symptoms are
the best predictors of NPP medication use for elders in this
area.
Summary
This study found that the majority of medications used
by the elderly in the Municipio of Rio de Janeiro are
physician-prescribed. Self-medication is not as prevalent
as expected, given reports from previous studies for Brazil
and other developing countries on medication use.
Medication use rates varied among the areas, with the higher
SES area residents using, on average, more prescribed
medications, and low SES area residents using the least.
The most frequently used therapeutic classes of
medications are antihypertensives, diuretics, and congestive
heart failure drugs. The relative frequency of their use
varies greatly from that evidenced in studies in the United
States. The most frequently used therapeutic classes in
self-medication are analgesics/antipyretics, antirheumatic
drugs, digestants and diuretics. Home remedies used are
primarily for these last two purposes.
Of the patient population characteristics
(predisposing, enabling, and need), need variables were
found to be consistently the most important in predicting
both PP and NPP prescribed medication use. However, both
need variables together were not always good predictors in
the separate area analyses. The perceived acceptability of


135
status with NPP medication use (r=.09). Slightly stronger
associations were found between the willingness to accept
non-medical advice about medicines and NPP medication use
(r=.21).
There were no significant correlations between the
sociodemographic variables and Att_Med_Care. However, age,
education and income are all negatively correlated with
Att_Lay_Advice (i.e., people who are older, those who are
more highly educated, and those with higher incomes are less
likely to accept lay advice about medicines).
Of the perceived access to medical services variables,
Accept_Med_Serv and Avail_Med_Serv have fairly low
correlations with PP medication use (r=.15 and r=.09
respectively). The lack of a significant relationship
between Afford_Med_Serv and medication use (both PP and NPP)
probably reflects the presence of a strong public medical
care system that difuses the issue of cost of care. There
is a negative association between Avail_Pharm_Serv and PP
medication use (r=-.14), which may is most likely to reflect
better better health status/fewer symptoms in areas with
greater concetrations of pharmacies. The negative
association between Accept_Med_Serv and NPP medication use
(r=-10), albeit a weak, confirms the notion that individuals
who are more satisfied with the medical care they receive,
are less likely to seek care elsewhere.


179
ambivalence about having a pharmacist available to provide
more professional, patient-oriented services (such as
follow-up on prescription drug use). This is due in part to
the idea that pharmacists do not usually have sufficient
patient-specific information, even if they are the most
qualified drug experts. Some concern was raised not so much
about the ability of the pharmacist to perform this
function, but rather about the logistics of doing so,
including the large number of clients, and the business
(movement) in the pharmacy. However, as the study showed,
although most of the elderly patronize the same pharmacy
most of the time, the primary motive is not for the
professional (or personal) services they received, but
rather for the price of the medications sold. Therefore, it
was not surprising that there was considerable concern over
the possibility (probability?) of the pharmacist charging an
extra fee for these services.
The conflict between the ideal and the real rages
strongly within the pharmacy profession as well. It is
ironic that in Brazil, where pharmacists have been subsumed
into industry and have had no relationship with the public
for many years, there is a renewed professional interest in
returning to the community, while the future of community
pharmacists in some more developed countries has been
questioned (Hepler and Strand, 1990). The challenge of
offering more professional services to the community has


11
example, lay individuals who make a hobby of collecting and
studying package inserts (bula) are called "bulistas11.
Indeed, some researchers have suggested that, based on
existing international mortality data, there is no evidence
to date to support the claim that requiring a prescription
renders medication use any safer than self-medication
(Pelztman, 1987). Therefore, the concern regarding
irrational physician prescribing and developing national
formularies is necessarily extended to self-medication
practices.
Fergusen (1981) suggests that the medicalization of
illness, the definition and treatment of certain illnesses
as medical problems, is different in developing countries
than in the more developed countries and that this accounts
for differences in self-medication behavior. The way in
which modern pharmaceuticals are integrated into self-care
practices in these societies reveals a reliance on a type of
therapy which is based on the notion that the solution to
illness resides in the consumption of medications rather
than on the consult with a medical professional. The
"commerciogenisis" of pharmaceuticals has been described for
several developing countries (cf., Hardon, 1987; Greenhalgh,
1987; Igun, 1987; Logan, 1983), including Brazil (Temporo,
1986) .
In this schema, pharmacists often play a crucial role.
Pharmacies tend to have a less centralized distribution than


40a. 0(a) Sr(a). tern alguns dos seguintes sntomas atualmente ou com frequncia?
40b. Quais sntomas sao causados principalmente por um remdio que o(a) Sr(a). esta tomando?
a. SNTOMAS b.CAUSADO POR REMDIO?
Sim Nao Sim Nao/N.A.
1.
Sem f lego
1
0
1
0
2.
Palpitagoes
2
0
2
0
3.
Com prisao de ventre
3
0
3
0
4.
Diarria
4
0
4
0
5.
Se sent indo mal
5
0
5
0
6.
Indigestao
6
0
6
0
7.
Falta de apetite
7
0
7
0
8.
Boca seca
8
0
8
0
9.
Dor de cabega
9
0
9
0
10.
Dor da coluna, outras
dores nos bragos, pernas,
ou outras extremidades
10
0
10
0
11.
Fraqueza, tonteira
ou se sent indo estranho
11
0
11
0
12.
Insnia
12
0
12
0
13.
Sonolento
13
0
13
0
14.
Nervoso
14
0
14
0
15.
Deprimido, triste
15
0
15
0
16.
Esquecimento, falta de
memoria
16
0
16
0
17.
Confusao
17
0
17
0
18.
Erupges, coceira
18
0
18
0
19.
Incontinencia
19
0
19
0
20.
Problema de ouvido (audigao)
20
0
20
0
21.
Problema de vista (visao)
21
0
21
0
22.
Outro
22
0
22
0
23.
Outro
23
0
23
0
24.
Outro
24
0
24
0


176
dose of a package, s/he terminates treatment prior to
obtaining the desired therapeutic response. Only two such
cases (one involving an antibiotic and the other an
antihypertension medication) were identified in this study.
Given the chronic nature of many of the illnesses and
therapies of the elderly, this issue merits further
investigation.
A significant proportion of the household health-
related expenses is medication expense. In the study sample
there was considerable concern expressed by the participants
regarding the availability and cost of commonly used
medications during the crisis at the time of the study. It
was apparent that many elderly who were eligible to receive
government subsidized medications (through CEME) free of
charge, did not receive them (indeed, many of the drugs used
by the elderly surveyed are theoretically available as CEME
products). There may be various reasons for this besides
the scarcity of CEME products in this region. They may
include, for example, "inconsiderate physician prescribing
(when a physician simply does not bother to verify whether a
CEME product is appropriate), various patient-specific
prescribing considerations (especially in the case of
convenient combination drugs), or patient preference for
name brand products. It is certainly conceivable that
pharmacy personnel have a role in promoting a particular
product over the other, especially if price differences are


Access to Care and Attitude Measures
Label (Cronbach's alpha)
Item
Mean SD
PERCEIVED ACCEPTABILITY OF MEDICAL SERVICES (.84)
Completeness
2.35
0.69
a.
For the type of care I normally require,
my doctor's office is well equipped.
Follow-
-us.
2.60
0.72
a.
When I go to the doctor for a new health
problem, s/he always reviews my medical
history.
Offering Information (.67)
3.35
1.03
a.
My doctor always explains my health
status.
3.74
1.03
b.
When the doctor prescribes a medication
for me, he always explains when and how
to take it.
2.77
0.54
c.
My doctor always explains things so that
I can understand.
Prevention
1.79
0.40
a.
My doctor has explained to me what I
should and should not do in order to
keep from getting sick.
Prudence/Competence
2.51 0.59 a. If my doctor recommends a treatment for
me I would have complete confidence that
it would be the best treatment for me.
Modernity
2.33 0.92 a. My doctor always keeps up with the
latest medical advances.
Asking the Patient for Information
2.66 0.72 a. When I go to see the doctor, the
questions s/he asks about my problem are
usually good questions.
Courtesv/Respect from Doctor (.66)
3.66
0.72
a.
My doctor always lets me say everything
that is important.
2.90
0.32
b.
When I speak to my doctor, s/he always
pays attention.
226


25
the elderly may be identified as a high risk group for
experiencing serious drug-related problems (Strand, et al.,
1990). In the United States, for example, the elderly made
up approximately 12% of the population in 1986, but received
32% of all prescription medications (Baum et al., 1987). In
addition, it has been estimated that roughly one-third of
all medications taken by the aged are over-the-counter (OTC)
products, and as many as 75% or more of the elderly in the
United States use at least one OTC at any time (Simonson,
1984:14-15).
One of the most consistent findings in geriatric drug
use research is the increase in the number of medicines used
with increasing age. Between 1977 and 1985, prescribing for
the elderly in Great Britain increased 27% compared to a
decrease of 6% among the non-elderly population (Cartwright
and Smith, 1988:1-2). In a longitudinal study of ambulatory
elderly in Florida, the average number of medications used
increased significantly from 3.22 in 1978-9 to 3.94 in 1987-
9 (Stewart et al., 1991). The absolute number of
medications used not only increases with age, but the nature
of the medications most commonly used also changes. These
changes would appear to follow the nosological alterations
accompanying the aging process (Knoben and Wertheimer,
1976).
The elderly are more likely to suffer from chronic,
degenerative, and disabling conditions than younger adults,


37
services, private health care expenditure did not decrease
(Musgrove, 1983).
The mid-1980s marked the beginning of the return of
democracy to Brazil. With it came a flood of proposals for
a more democratic health care system which resulted in the
creation of the new Unified System for Services (Sistema
Unificado de Sade, or SUS). In sharp contrast to previous
efforts, SUS aims to improve the efficiency of the public
sector by decentralizing its administration and allowing
states and local municipalities to take on a larger role in
administrating and coordinating local health care services.
It is too soon to evaluate the impact of SUS on health
care, but the heritage of the system that developed in the
decades prior to SUS is not likely to be easily shaken. The
inefficiencies of the bureaucracy which proliferated with
each successive administrative reform have been harshly
revealed in the face of the recent national economic crisis.
In August, 1990, INAMPS announced that it would be
"trimming" some of its more redundant, dispensable personnel
(50% of which worked in Rio de Janeiro), including some
physicians ("INAMPS afasta...", 1990). While apparently a
sensible motion, it was disconcerting to the public for two
reasons: firstly, public servants (traditionally a very
secure type of position in Brazil) do not typically lose
their jobs, and, secondly, despite assurances to the
contrary by officials, the public feared the further


66
use. The unique aspect of the model presented is the
emphasis on subjective measures of access to both medical
and pharmacy services in relation to prescribed and
nonprescribed medication use. Each variable to be examined
and its measurement is listed in Table 3.1, and will be
discussed in this section.
Predisposing Variables
The predisposing variables examined in this model
include the patient's age, gender, education, household
size, income, as well as attitudes toward formal medical
care, and attitudes toward accepting lay advice about
pharmaceuticals.
Age: The elderly are defined as 60 years old or more,
which is the definition currently accepted for many
developing countries. Age, in this study, is measured as a
continuous variable.
An increase in prescription drug use has been found to
correspond with an increase in the age of the patient in
studies in Western countries (see review in Stewart, 1988;
Dunnell and Cartwright, 1972). This trend probably reflects
normal physiological changes in health status over time.
However, the rate of nonprescription drug use appears to
stabilize and in some reports it has been found to drop with
increasing age (cf. Simonson, 1984; Johnson and Pope, 1983).
The reasons for this phenomenon are not well understood,
although similar patterns have been noted for other forms of


178
cannot be established and fostered without frequent and
regular contacts between the pharmacist (or pharmacy
personnel) and the client.
The pharmacist is still considered to be a valuable
source of information, especially for patients with limited
access to medical care, lack of caregivers (responsible
friends and family), and in the case of illiteracy. The
pharmacist was also portrayed as a partner in health care
with the physician, providing specialized information,
although in an unequal partnership with the physician in
charge. It is from this partnership relationship that the
pharmacist derives most of his/her respect.
Although there is respect for the profession as the
most knowledgeable about medications, this respect does not
necessarily extend to contemporary community pharmacy
practice. Distrust and some skepticism of pharmacy services
was particularly evident when participants interviewed used
terms such as "false pharmacists" to describe pharmacy
personnel qualifications, and phrases such as "they only
want to sell you something" to describe the motivations of
pharmacy personnel in general. These descriptions are in
sharp contrast to those used for a "true pharmacist", who
would be most concerned with the patient's welfare.
There is, nonetheless, a clear dissonance between the
patient's perceived ideal and perceived real role of
community pharmacy. Specifically, there is a some


CHAPTER 4
RESULTS
This chapter presents the results of the data analysis.
The chapter begins with a discussion of the sample
characteristics, including health status, health care
expenses, and utilization of medical and pharmacy services.
Some of the salient opinions and attitudes of the elderly
regarding the role of the pharmacist in Brazil are also
presented. This is followed by a description of medication
use by the sample, including home remedies, and the
freguency of different reported therapeutic indications for
medication use. Finally, the results of the modelling of
prescribed and non-physician prescibed medication use are
presented for the sample as a whole, and for each area
separately.
Sample Characteristics
A total of 436 subjects were interviewed for the
survey: 138 in Copacabana, 147 in Mier, and 151 in Santa
Cruz. Summary information of the sample for each area is
presented in Table 4.1. Compared to the BOAS sample, there
are no statistically significant differences in the
proportion of women to men for any of the areas. As
expected, mean age is slightly greater in the sample for the
participants in this study.
94


21
medication. People were more likely to self-medicate if
care was perceived as less available. Furthermore, in this
study, perceived availability of medical care was not
related to the travel time to the site of care.
In another model developed by Sharpe et al. (1985) for
medication use among the rural elderly in Mississippi, a
measure for perceived availability of physician services and
one for perceived availability of pharmacy services were
included. These measures represented indices of the
summated scores for various items. Results showed that
perceived availability of pharmacy services exerted a
significant negative effect on both prescription and non
prescription (OTC only) drug use, while perceived
availability of physician services was not a significant
factor in the analysis. The unexpected, counterintuitive
finding of a negative effect of the perceived availability
of pharmacy services on medication use may have been due to
the operationalization of the construct, and/or the
inclusion of the ordinal variable in a regression model.
The present study builds upon this previous research by
focussing on the relationship between perceived access to
medical and pharmacy services and medication use. It adapts
the behavioral HSU model to include three dimensions of
perceptions of access to care (acceptability, availability,
and affordability) as the enabling variables of interest.
These measures complement more traditional measures, and


93
design. The project involved various stages, from
instrument development to carrying out the survey. The
analysis strategy includes the examination of relevant
bivariate relationships and other descriptive statistics.
Multivariate regression techniques were used to evaluate the
medication use model developed in this study. The following
chapter presents the results from the anlyses.


17
specific models of utilization for specific populations and
services. Indeed, access is a relative term which may be
conceptualized to acknowledge socioeconomic, cultural,
physical, psychological and organizational aspects of
access. At the very least, it incorporates the aspects of
the availability, affordability of health care, as well as
the acceptability, in terms of patient satisfaction and
trust, of care (Fosu, 1989).
Medical geographers are often concerned with access to
care in terms of physical distance. Spatial analytic
studies examine actual distance and the effects of distance
decay on service utilization. Spatially discrete
concentrations of health care services inevitably make
physical access an important issue in more rural developing
countries (Kroeger, 1983), as well as inner city areas
everywhere (Shannon et al., 1973; Kloos, 1986; Igun, 1987).
The underlying assumption in this approach is that physical
accessibility to services implies minimal time and cost
involved in travel, thereby releasing a greater proportion
of household income for expenditure on consumption and
making a greater amount of time available for other
activities.
Health care economists often operationally define
access to care to include the affordability of care in
addition to the availability of health care faciliies.
Common indicators for affordability of care that have been


107
physicians prescribing medications at the time of the
interview varies accordingly (F=11.22, df=2, pc.0001). The
mean for the aggregate was 1.20 prescribing physicians
(s.d.=0.96). Paired comparisons of the areas revealed that
only the difference between means for Copacabana (1.47) and
Santa Cruz (0.95) were statistically significant. Similar
analysis indicates that although elders in Copacabana see
more physicians, the mean number of physician visits that
occurred during the thirty days prior to the interview is
signficantly greater in Mier (1.09) than in the other two
areas (F=6.18, df=2, pc.001). The average number of
physician visits reported for the thirty day period prior to
the interview was 0.78 (s.d.=1.37). Fifty-six percent of
the sample reported not having had any physician visits.
Table 4.
10 Utilization
of physician
services
by area.
Copacabana
(n=138)
Mier
(n=147)
Sta. Cruz
(n=151)
Mean no.
of physicians
1.96
1.55
1.14
(SD)
(1.21)
(1.11)
(0.93)
Mean no.
of prescribing
physicians
1.47
1.21
0.95
(SD)
(0.99)
(0.94)
(0.88)
Mean no.
physician visits
30 days prior to inter-
0.69
1.09
0.56
view
(SD)
(1.15)
(1.77)
(1.02)
Over half (58.5%) of elders were of the opinion that
one should completely trust their physician to prescribe
appropriately, 33.9% reported that there are times when one


To
Naly G.


ACCESS TO MEDICAL AND PHARMACY SERVICES
QUESTIONNAIRE ITEM SELECTION CANDIDATES1
A. ATTITUDES TOWARD MEDICAL CARE
1. SKEPTICISM REGARDING THE EFFICACY OF MEDICAL CARE
a. Most of the time, when people are ill, they will
eventually get well without medical care
b. Nearly all serious illness can now be cured.
c. Someday, all serious illnesses will be able to be
cured.
d. It is best to let illnesses that are not very
serious run their course without resorting to
medical treatment.
e. Doctors should continue to treat their patients
even when they are unsure of what's wrong.
2. RELUCTANCE TO ACCEPT PROFESSIONAL CARE
a. When doctors give patients advice, it is in the
patient's best interest to do as he/she is told.
b. When doctor's give a patient a piece of advice it
is likely to create more problems that it solves.
c. The patient should do everything the doctor tells
him to do, even if he does not want to follow the
advice.
d. When the doctor advises a patient to do something
that the patient does not want to do, the patient
should talk to another doctor, and then decide
what to do.
3. BELIEF THAT THE INDIVIDUAL UNDERSTANDS HIS/HER OWN
HEALTH BETTER THAN THE PHYSICIAN
a. When I feel ill, I usually know what's wrong with
me.
1 Items are adapted from Ware and Snyder (1975) and
MacKeigan and Larson (1989).
185


137
lay advice about medications and the acceptability of
pharmacy services (r=.41).
Modeling Medication Use
In exploratory studies, regression analysis is
generally of secondary importance. However, when many
independent variables are correlated among themselves, there
is some redundancy in the correlations, and an analysis of
only simple correlations will not reveal relationships among
variables which may emerge or be substantially altered when
the effects of several variables are considered
simultaneously. In these instances, regression analysis
allows for these relationships to emerge. As such,
regression analysis, and variable selection methods in
regression analysis, can be a valuable descriptive tool in
helping to point to influential determinants of behavior,
and for suggesting avenues for expanded research (Afifi and
Clark, 1984:165).
Prescription Medication Use
The original model for this problem is
Y = a + bjXi + b2X2 + ... b15X15 + e
The model may be considered to be overspecified in that not
all variables are expected to be significant predictors. No
interaction terms are included in this analysis because the
primary interest is in identifying important variables for


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Torrens. New York: John Wiley and Sons. 51-76.
Adler, Henry. 1982. "Pharmacy in Brazil" (letter to the
editor). The Pharmaceutical Journal June 5: 626-627.
Allen, Sergio E. 1989. "Falta de medicamentos" (letter to
the editor). Jornal do Brasil August 6.
Andersen, Ronald, and John Newman. 1973. "Societal and
Individual Determinants of Medical Care Utilization in the
United States." Millbank Memorial Fund Quarterly 51:95-124.
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Arluke, Arnold and John Peterson. 1981. "Accidental
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Christine Fry. New York: Praeger Press.
"Atraso na Verba do SUS Deixa Hospitais sem Material
Bsico." 1990. Jornal do Brasil October 24.
Autran, Margarid. 1990. "Consumidor Europeu Denuncia
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Autran, Margarida. 1991 "Sade Libera a Venda de Mais uma
Droga a Base de Dipirona". Jornal do Brasil January 2.
Banta, H. David. 1986. "Medical Technology and Developing
Countries: the Case of Brazil." International Journal of
Health Services 16(3):363-373.
Baum, C., D. L. Kennedy, D. E. Knapp, G. A. Faich, C. A.
Nello. 1987. Drug Utilization in the U.S.1986. Rockville,
232


211
S E g A O 4 OPINES
[Entrevistador: "Esta parte do questionrio trata de suas opinides. Vamos comegar com as suas impresses
da medicina em geral. Depois vamos concentrar na sua prpria experiencia com atendimento mdico e a farmacia."
Ler p/o entrevistado tocias as opgoes.]
42.
0(a) Sr(a). acha que, em relago s doengas graves, hoje em da, a medicina pode curar
1. todas as doengas graves.
2. multas doengas graves.
3. algunas doengas graves.
4. nenhuna doenga grave.
43.
44.
0(a) Sr(a). acha que, em vinte anos, a medicina conseguiria curar
1. todas as doengas graves que hoje em dia nao tem cura.
2. muitas doengas graves que hoje em dia nao tem cura.
3. algunas doengas graves que hoje em dia nao tem cura.
4. nenhuna doenga grave que hoje em dia no tem cura.
Na sua opino, das doengas graves que hoje em dia nao tem remdio, o(a) Sr(a). acha que, em vinte
anos,
1. todas sero curadas com remdios.
2. multas sero curadas com remdios.
3. algunas sero curadas com remdio.
4. poucas sero curadas com remdios.
45.
Em relago s doengas nao graves, o(a) Sr(a). acha que
1. sempre a gente se cura sem ir ao mdico ou hospital.
2. muitas vezes a gente se cura sem ir ao mdico ou hospital.
3. algunas vezes a gente cura sem ir ao mdico ou hospital.
4. nunca a gente se cura sem ir ao mdico ou hospital.
46. Quando o mdico manda o doente fazer algo que o doente nao quer, o(a) Sr(a). acha que o doente
1. sempre deve fazer o que o mdico manda.
2. nem sempre deve fazer o que o mdico manda.
3. nunca deve fazer o que o mdico manda.
47. Algumas pessoas acham que os remdios podem fazer mal. Outras pessoas acham que remdio que no
faz bem topouco faz mal. 0(a) Sr(a). acha que
1. a maioria dos remdios no fazem mal.
2. alguns remdios fazem mal, outros no.
3. a maioria dos remdios fazem mal sim.
9. NS


241
. 1977. "The Epidemiology of Drug Promotion."
International Journal of Health Services 7(2):157-166.
Silverman, Milton, Philip Lee, and Mia Lydecker. 1982.
Prescription for Death: The Drugging of the Third World.
Berkeley, CA: University of California Press.
. 1986. "Drug Promotion: the Third World Revisited."
International Journal of Health Services 16(4):659-667.
Simmons, Ozzie. 1958. Social Status and Public Health.
Social Sciences Research Council, Committee on Preventive
Medicine and Social Science, Pamphlet No. 13.
Simonson, William. 1984. Medications and the Elderly: A
Guide for Promoting Proper Use. Rockville, MD: Aspen
Systems.
Singer, Paul, Oswaldo Campos, and Elizabeth M. de Oliveira.
1981. Prevenir e Curar: O Controle Social Atravs dos
Servicos de Sade. 2nd ed. Rio de Janeiro: Editora Forense
Universitaria.
Soares, Barbara Musumeci. 1987. "Farmcias Homeopticas do
Rio de Janeiro: de Volta ao Futuro." Cadernos do IMS 1(3).
Rio de Janeiro: Instituto de Medicina Social/UERJ.
Soares, Jussara Calmon Reis de Souza. 1989. "Poltica de
Medicamentos no Brasil e Misria Filosfica." Sade em
Debate 25:42-46.
Stein, Maurice R. 1972. The Eclipse of Community. Expanded
edition. Princeton, NJ: Princeton University Press.
Stewart, Roal B. 1988. "Drug Use in the Elderly." In
Therapeutics in the Elderly. Eds. Delafuente, Jeffrey, and
Ronald Stewart. Baltimore, MD.: Williams and Wilkins.
Stewart, Ronald B., Mary T. Moore, Franklin E. May, Ronald
G. Marks, and William E. Hale. 1991. "Changing Patterns of
Therapeutic Agents in the Elderly: a Ten-year Overview."
Age and Ageing 20:182-188.
Strand, Linda M., Peter Morley, Robert Cipolle, and Ruthanne
Ramsey. 1990. "Drug Related Problems: Their Structure and
their Function." DICP Annals of Pharmacotherapy (6).
Stoller, Eleanor P. 1988. "Prescribed and OTC Medication
Use by the Ambulatory Elderly." Medical Care 26(12):1149-
1157.


Many thanks are extended to the interviewers: Nelson
Lopes de Azevedo, Ana Lcia Barbosa, Marcelo Bessa, Marco
Aurlio P. Carvalho, Vanderlei R. de Carvalho, Liane
Esteves, Edmeire O. Exaltago, Anglica Fonseca, Veronica
Hamilton, Herminia Helena da Silva, Marta Cristina Nogueira,
Cristina A. M. Souza, and Eduardo Vilarin. Also, for help
with drug coding and data entry checking, thanks to Ligia M.
Soares, M.D., and Alexei Soares.
The elderly participants in this study who graciously
opened their doors to be interviewed provided a powerful
stimulus to completing the project, especially when train
trips and bus rides seemed tedious and interminable, and the
days too hot and dusty, or too hot and humid. Their
expressed interest in the subject and willingness to share
their thoughts and experiences, sometimes for hours at a
time, was extremely rewarding. In particular, there will
always be a special place in my heart for Dona Maria, Senhor
Ary, Dona 01inda, Dona Engragada, and Senhor Antonio.
An important source of professional and moral support
for this project was the Conselho Federal de Farmcia. the
Brazilian national professional pharmacy association. I am
deeply grateful and honored to have had the opportunity to
participate in some very exciting discussions regarding the
future of community pharmacy practice in Brazil. For this,
I thank Luiz talo Niero, Thiers Ferreira, M. Cristina F.
Rodrigues, Vicente T. de Araujo Junior, and other directors
IV


ATTITUDES TOWARD LAY ADVICE ABOUT DRUGS (.53)
Willingness to accept lav advice about medicines (.53)
231
2.40
1.02
a.
When the pharmacy personnel give advice
about medicines, it is usually good
advice.
1.46
0.81
b.
I have often sought the advice of a
(lay) friend or family member about a
medicine.
1.88
1.09
c.
I have often bought medicines because of
an announcement I heard on the radio,
saw on television, or read in a journal.


166
direction of the relationship cannot be conclusively
determined.
This study measured the number (volume) of prescribed
medications used, and not the number of prescriptions
received, possibly obscuring some significant aspects of the
relationship between affordability of medications and
availability of services. Some individuals reported
purchasing medications for only a portion of the
prescription they received. Examples include the following:
A 66 year old man (Santa Cruz) had received a
prescription for four medications (Higroton,
Organo Cerebral, Stugeron, and Theragram M), but
he could not afford them. He reported using no
medications at all.
A 74 year old man (Santa Cruz) received a
prescription for Drenol (hydrochlorothiazide),
Adalat (nifedipine) and aspirin. He is only using
Drenol, because he said he could not afford the
other medications.
It is worth noting that in the few cases that were
documented of prescriptions received, but not used (due to
high cost to the patient), the individuals did not
substitute with other drugs.
Access to Care and Medication Use in Areas
The increased specificity obtained by examining each
residential area separately allowed for the important
relationships among predisposing, enabling, need, and use
variables to emerge. In particular, the utility of
examining each area independently was revealed with the
finding that the significance of the different dimensions of


227
3.53
0.66
c.
In general, my doctor is very careful
when s/he examines me.
3.86
0.38
d.
My doctor has never treated me
grudgingly.
Considerateness
2.40
1.19
a.
I never have to wait very long in the
doctor's office.
Courtesv/Resoect from Staff
2.53
0.62
a.
The people who work at the doctor's
office are all courteous and pleasant.
PERCEIVED AVAILABILITY OF MEDICAL SERVICES (.69)
Convenience (
. 50)
1.84
0.36
a.
The doctor's office hours are good for
me.
3.56
0.83
b.
It is easy for me to get to the doctor's
office.
1.50
0.50
c.
My doctor would make a house call if I
asked.
3.47
0.92
d.
It is easy to make an appointment to see
my doctor.
2.64
0.64
e.
It is easy for me to get a prescription
from the doctor if I need one.
Continuity of
Care
1.72
0.44
a.
I always see the same doctor.
Emercrencv Care
3.05
1.00
a.
If I had a health problem, I could reach
the doctor at any time, day or night.
3.32
0.98
b.
In case of emergency, I can get medical
care right away.
Supply of Physicians
1.46 0.49 a. There are enough doctors in my
neighborhood.
Supply of Hospitals/Clinics and Laboratories (.62)
1.27
0.44
a.
There are enough
neighborhood.
hospitals/clinics in my
1.37
0.48
b.
There are enough
neighborhood.
laboratories in my


164
carefully interpreted. In the case of medical services, for
example, Aday and Anderson (1981) have argued that the
primacy of need characteristics as predictors of utilization
indicates that there is equitable access to care (ie., those
who need care, get it). However, Wolinsky et al. (1989)
have argued that such findings alone cannot be interpreted
as an indicator of equitable access to care. The
implication of this debate emerges in the following
discussion of findings for the separate study areas.
Access to Care and Medication Use
In this study, the perceived availability and the
perceived affordability of medical and pharmacy services,
and drugs were not significant predictors of either PP or
NPP medication use for the aggregate data. These finding
support the observation that the public health care services
(including INAMPS) in Rio de Janeiro do help to eliminate
these barriers to obtaining medical care. These results are
also consistent with previous utilization studies for the
general population for the region, as discussed in Chapter 2
(IBGE, 1989) that indicated that financial considerations
did not keep patients from seeking care when needed. Time
barriers (including waiting time) were probably less
significant for elderly than for the general population.
Researchers in the United States have also questioned the
affordability measures in predicting physician and hospital
utilization since the instigation of Medicaid and Medicare,


101
Medical and Medication Expenses
Many elders (40%) interviewed pay for their own medical
expenses. This question excluded medications, which was
evaluated separately. Approximately one-fourth rely on a
relative to pay for them. As shown in Table 4.6,
significantly more elders had private health insurance in
Copacabana (25%) than in the other areas, whereas more
elders relied on free services provided by public
institutions in Mier (24%) and Santa Cruz (32%) for their
medical care (x2=55.66, df=6, pc.001) and therefore had
minimal out of pocket expnses.
Table 4.6 Who usually pays for
medication expenses?
your medical
and
Copacabana
(%)
Mier
(%)
Sta. Cruz
(%)
Medical expenses:
Public institution
5.2
24.7
32.9
Interviewee
48.5
37.0
36.2
Relative
20.6
30.8
22.8
Private insurance
25.7
7.5
8.1
Total
100.0
100.0
100.0
N
138
147
151
X2=55.66, df=6, pc. 001
Medication expenses:
Public institution
0.0
0.7
11.3
Interviewee
75.4
65.5
56.3
Relative
23.2
33.1
29.8
Private insurance
1.5
0.7
2.7
Total
100.0
100.0
100.0
N
138
147
151
X2=36.60, df=6, pc.001


18
used in the United States include health insurance coverage
and family income. The assumption is that having health
insurance coverage or higher incomes enable a person to
receive services. Results have suggested that insurance
status, including public programs such as Medicaid, may have
reduced the financial barriers to care for poor patients
(Wan, 1982; Wolinsky et al., 1989).
Accessibility also implies the more qualitative aspects
of opportunity and choice in use so that physical distance
and price may not always be meaningful factors in and of
itself. The combined effect of perceived distance, the
perceived availability of transportation, costs, and
facility characteristics, has been found to affect health
care services utilization (Joseph and Reynolds, 1984; Knox,
1979). Indeed, distance may not be a relevant factor at all
for some groups of patients (von Mering et al., 1976), or it
may only be relative to all other available health care
alternatives or options (Gesler and Meade, 1988). Cross-
cultural studies confirm that greater utilization of health
care services correlates with higher socioeconomic status,
but only when such services operate on a fee-for-service
basis (Kleinman, 1980). Some studies indicate that lower
socioeconomic status patients are more likely than higher
status patients to utilize a greater number of health care
sectors (popular and professional), and a broader range of
health care practitioners so that increased income and


CHAPTER 5
DISCUSSION AND CONCLUSION
Medication Use Among the Brazilian Elderly
There is a caricature in Brazil, recognized by all, of
the fellow who takes a drug for every problem and a drug for
everything that is not yet a problem. This is the fellow
who visits the pharmacy once a week to ask "What's new?".
There is also the popular figure of the bulista, the drug
information package insert junkie. These two figures,
however humorous in their representations, may indeed
reflect some prevailing attitudes and behaviors in Brazil.
But not, apparently, among the elderly.
The results from this study suggest that self-
medication may not be as prevalent among the elderly as for
other segments of the population in Brazil. The proportion
of elderly who use at least one medication (prescribed or
non-prescribed) in this study (88.1%) and the average number
of medications used (3.20) is roughly consistent with some
previous studies in the United States (cf. May et al.,
1982; Darnell et al., 1986; Stoller, 1988; Hale et al.,
1987) However, only 18% of all medications taken by this
Brazilian sample were reported to be NPP, compared to 31% in
a British sample (Cartwright and Smith, 1988:16-17) and 30%
156


162
their sample of American adults, but only 6% of the variance
for non-prescription medication use. The study by Sharpe et
al. (1985), which included a measure of perceived
availability of pharmacy services, was able to explain 28%
of the variance for the prescription medication use in their
rural elderly sample, and 14% of the variance for OTC
medication use. In the present study of the urban and
suburban Brazilian elderly examining perceived access to
medical and pharmacy care, the model for the aggregate data
explained 27% of the variance for physician prescribed
medication use, and 33% of the variance for non-physician
prescribed medication use.
Patient Population Characteristics and Medication Use
The two models of medication use (PP and NPP) that
emerged for the aggregate data were guite distinct. Of the
predisposing variables examined in this study, gender, age,
and income were found to be significant predictors of PP
medication use, when controlling for other effects in the
model. Household size and attitudes towards lay advice
about pharmaceuticals were the only predisposing variables
identified in the model as significant predictors of NPP
medication use.
As expected, of the patient population characteristics
identified in this study, the need variables (number of
symptoms and perceived health status), were the major
predictors of medication use. Perceived health status was


15
characteristics, health care beliefs and attitudes.
Enabling variables typically encompass various measures of
access to services and are selected to identify potential
barriers to seeking care when care is needed. Need
variables describe the extent to which the individual feels
the need for a given service and is frequently measured by
actual or perceived morbidity. Resources include the
distribution, volume and organization of the health care
system. Utilization may be measured in terms of the type,
site and quantity of health services used, and the time
interval separating use or the frequency of services used.
The HSU behavioral model has become a significant
paradigm for studying the health and health care seeking
behavior, even of the elderly patient population (Wolinsky
et al., 1990). However, this is not to say that the model
is not without its limitations. In a review of the utility
of the application of the HSU model, Wolinsky and Arnold
(1988) point out that need variables are consistently the
most significant determinants of health services
utilization, and that the contribution of predisposing and
enabling characteristics are often insignificant.
Furthermore, the total amount of variance explained by the
model is usually minimal.
Often, studies employing the HSU paradigm are
constrained by the type of data available. Traditional
models that provide measures of existing services employ


74
seek alternative care than satisfied patients (Donabedian,
1982) .
Perceived Availability of Medical Services
(Avail Med Serv) and Perceived Availability of Pharmacy
Services (AvailPharm Serv): Availability suggests not only
locational dimensions, but also convenience in terms of
operating hours, and assurance of regularity of services.
In rural areas, for example, where distances are greater
than in urban areas, transportation appears to be a
significant factor affecting medication use patterns among
the elderly (Sharpe et al., 1985). Bush and Osterweis
(1978), interested in perceived access to services, found
that although there was a positive association with
prescription medicine use, there was an inverse association
with OTC use. The authors suggest that OTC use may be a
substitute for physician visits when access to medical care
is perceived as inconvenient. Sharpe et al. (1985) also
suggest a substitution effect when perceived access to
pharmacy services was found to be inversely related to
prescription medication use in their rural sample. Some
elderly may be particularly handicapped by disability or
disease such that the perceived availability of services is
of particular importance.
Perceived Affordability of Medical Services
(Afford Med Serv) and Perceived Affordability of Drugs
(Afford Drugs): Affordability, the third dimension of


55
amounts of the active ingredient (Autran, 1990). The study
revealed that 32% (142) of the German products sold in
Brazil in 1984/1985, and 37% (127) of those distributed in
1988, were considered to be inadequate. Of the Swiss
products put on the Brazilian market, 44% were inadequate.
Dipirone, a very controversial analgesic that is prohibited
in Germany, the United States, and other nations, was among
the products listed as inadequate yet currently available in
at least 99 different products in Brazil (Autran, 1991).
Pharmacies and Drugstores
Up to this point, the discussion has focussed on the
production and consumption of medications. In between these
two polar ends of the path to medication use, there remains
the point of interface between the medication and the
consumer, namely, the pharmacy. According to Brazilian law
(Lei No. 5.991, 17/12/73; Decreto No. 74.170, 10/6/74),
medications may only be dispensed from four different
places; a pharmacy (farmcia). a drug store (drogara)2. a
health/medication post (including mobile posts), and
hospital dispensaries. Medicinal plants are also restricted
to sale in pharmacies and herbal stores. Although
2 Technically, pharmacies are distinct from drug
stores in that pharmacies are allowed to formulate
medications, and drug store are strictly retail outlets for
prepackaged medications. This distinction is of little
practical significance in contemporary Brazil because tha vast
majority of pharmacies no longer formulate medications.
Hence, the term pharmacy will be used interchangeably for
both.


14
account the various social, economic, and cultural
dimensions of access to care that are likely to influence
behavior differently in different places (Rabin, 1977).
In order to address some of these aspects of access to
care, some researchers have found it useful to incorporate a
multivariate approach to understanding medication behavior
in smaller populations. One such approach is based on the
health services utilization (HSU) model, originally
developed by Andersen and Newman (1973) and expanded by
colleagues (Aday and Shorten, 1988). The HSU model has
been widely used to analyze use of different kinds of
physician and hospital services by various populations,
including the elderly (Evashwick et al., 1984; Eve and
Friedsam, 1980; Wan and Soifer, 1974; Wolinsky, 1978;
Wolinsky et al., 1983; Wolinsky et al., 1989). Variations
of the health services utilization model have also been
applied to studying factors related to prescribed and non-
prescribed medication use for urban adult samples (Bush and
Osterweis, 1978; Segal and Goldstein, 1989), including the
urban elderly in particular (Stoller, 1988), and a rural
sample (Sharpe et al., 1985).
The HSU model focuses on the unique characteristics of
the population at risk, and the resources of the health care
system. The characteristics of the population at risk
include predisposing, enabling, and need variables.
Predisposing variables include social and demographic


71
The relationship between education and health services
utilization and other care seeking behavior is a relevant
issue in Brazil (Singer et al., 1981) and other countries
with high levels of illiteracy. In particular, there is a
well known inverse association of female (and to a lesser
extent, male) education with infant and child mortality and
fertility, through a variety of intervening factors,
including greater use of health care services (Wood and
Carvalho, 1988:170-2).
In 1990, a significant proportion of the urban
Brazilian elderly (41%) were considered illiterate (IBGE,
1987). There is no reason to suspect that the relationship
between education with health services utilization among the
elderly would differ from that for the general population.
With respect to medication use in particular, the
relationship between education and prescribed medication use
may be considered a proxy for use of medical services.
Conversely, lower levels of educational achievement may be
associated with increased self-care behaviors, including
self-medication.
Income: For the purposes of this study, education and
income will be included as separate variables, while
recognizing their close relationship. Generally, household
income is considered a more reliable indicator in health
services utilization, however, it is a more difficult
measure to obtain because it requires that the respondent be


33
national public health programs, such as maternal and child
health and nutrition programs as well as vaccinations.
Financed through federal payroll tax revenues, INAMPS, until
recently, has been primarily responsible for providing
curative, hospital-based services to its beneficiaries.
Since the 1940s, and until 1975, the public health and
social security curative care subsystems had little to do
with each other. The Ministry of Health held low political
priority and struggled with limited budget resources to deal
with the major public health problems, whereas social
security programs were politically far more important to a
rapidly industrializing country. As social security
benefits were extended to more individuals, revenues
increased. The curative hospital-based system of the social
security medical benefits program grew at a cumulative
average annual rate of almost 20 percent for more than a
quarter of a century, while public health programs
floundered (Braga and Paula, 1980: 101).
The growth in social security medical care was directed
primarily to very costly medical treatments that were so
concentrated that they benefitted only a relatively few
patients. This style of health care delivery, which began
as a deliberate strategy of the populist political figures
to woo the emerging urban working and middle classes,
ultimately evolved to reflect the tastes of the military
technocrats for modern science and large, centralized


96
A record was kept of persons who were contacted but who
refused to be interviewed, persons unavailable for interview
due to illness, persons who had died since the BOAS study
had been conducted, and persons who were otherwise not
available for an interview. Refusal to participate,
mortality, morbidity, and other known and unknown reasons
for non-participation are reported in Table 4.2.
Table 4.2 Reasons for Non-participation, by Area.
Reason Copacabana Mier Santa Cruz Total
Refused
31
21
10
62
Death
6
13
8
27
Illness
9
14
5
31
Moved
5
17
9
28
Travelling
6
2
2
10
Other known3
11
9
6
27
Not knownb
16
24
49
89
Total
85
100
89
274
a Includes address not known and four defrauded
questionnaires in Copacabana that were not recuperable.
b Individuals not interviewed due to completed quota for a
given area.
The refusal rate was highest in Copacabana. This was due in
large part to the actual or perceived threat on the part of
elderly residents of crime (break-ins, theft) in their
apartment buildings. The difficulty associated with
conducting interviews in this area was also documented in
the BOAS study (Veras, et al., 1989: 12-13). In addition,
however, many people stated that they were no longer
interested in giving interviews. Non-participation due to


28
proportion of the population over 60 years old is expected
to increase 107% in contrast to that proportion of the
population 15 years old and less, which is expected to
increase only 14%. Brazilian gerontologists are concerned
that Brazilian authorities are already facing the problem of
an aging population comparable to that experienced by the
developed countries with all its implications for the health
and social care system (Ramos et al., 1987).
Summary
Brazil shares with other developing countries the
problems regarding access to needed essential medications
and the inappropriate use of medications (Allen, 1989;
Soares, 1989). Medications, whether in the form of
vaccines, antibiotics, or analgesics, are an integral
element of public health and primary care as well as in the
management of chronic and degenerative diseases. An
understanding of the factors that influence access to and
the appropriate use of medications is of extreme relevance
for all patient/client groups, including the elderly.
The purpose of evaluating perceived access to care in
the study of health care services utilization is to identify
barriers to care, or, conversely, facilitating factors.
Access to care necessarily incorporates dimensions of
acceptability, availability, and affordability of care. In
the study of medication use, both with physician prescribed
and non-physician prescribed drugs, it is meaningful to


Satisfaction with Pharmacy Services." Medical Care
27(5):522-536.
239
Malloy, James. 1977. "Authoritarianism and the Extension of
Social Security Protection to the Rural Sector in Brazil."
Luzo-Brazilian Review 14(2):195-210.
Manasse, Henry Jr., 1989. "Medication Use in an Imperfect
World: Drug Misadventuring as an Issue of Public Policy:
Part 1." American Journal of Hospital Pharmacy 46:929-944.
Martindales. the Extra Pharmacopoeia. 1992. Vol. 72, via
CCIS (May 31). Denver, Colorado: MicroMedics.
Mathews, H. F. 1982. "Illness Classification and Treatment
Choice: Decision Making in the Medical Domain." Reviews in
Anthropology Spring:171-186.
May, Franklin E., Ronald Stewart, William Hale, and Ronald
Marks. 1982. "Prescribed and Nonprescribed Drug Use in an
Ambulatory Elderly Population." Southern Medical Journal
75(5):522-528.
McGreevey, William. 1988. "The High Cost of Health Care in
Brazil." PAHO Bulletin 22(2):145-166.
Mello, Carlos Gentile de, and Douglas Carrara. 1982. Sade
Oficial. Medicina Popular. Rio de Janeiro: Eidtora Marco
Zero.
Melrose, Dianna. 1982. Bitter Pills, Medicines and the Third
World Poor. London: OXFAM.
Mesa-Lago, Carmelo, 1978. Social Security in Latin America:
Pressure Groups, Stratification and Inequality. Pittsburgh:
University of Pittsburgh Press.
Miller, Michael B. and Dian F. Elliott. 1976. "Errors and
Omissions in Diagnostic Records of Patients to a Nursing
Home." Journal of the American Geriatrics Society 34(3):.
Musgrove, Philip. 1983. "Family Health Care Spending in
Latin America." Journal of Health Economics 2:245-257.
Ncleo de Estudos de Politicas Publicas (NEPP). 1988. Brasil
1986: Relatrio Sobre a Situaco Social do Pads. Campinas,
Brasil: Universidade Estaudal de Campinas.
Ostrum, Jana R., E. Roy Hammarlund, Dale Christensen, Joy B.
Plein, and Alice Kethley. 1985. "Medication Use in an
Elderly Population." Medical Care 23:157-164.


of the various regional offices. I hope that this project
will help to guide the Conselho in its efforts to meet the
difficult challenges ahead.
For keeping their doors open, permitting countless
hours of extemporaneous teaching, special recognition is
extended to Dr. Charles H. Wood, sociologist/demographer,
Dr. Otto Von Mering, Director of the Center for
Gerontological Studies, Richard A. Angorn, J.D., R.Ph., and
Paul Doering, M.S.P., Director of the Drug Information
Center, at the University of Florida, and to Dr. Howard Eng,
at the University of Arizona, Health Sciences Center.
Through gestation to conclusion, this project was met
with encouragement and support from all of the faculty,
staff, and fellow students of the Department of Pharmacy
Health Care Administration at the University of Florida,
especially committee members Drs. Carole L. Kimberlin,
Charles D. Helper, and Donna Berardo. A great debt of
gratitude is due to Dr. Kimberlin. An exceptional mentor,
her unwavering patience, willingness to explore new ideas,
and high principles are to be emulated.
Finally, thanks to my husband, Glucio Ary Dillon
Soares, friend and companheiro for more than a decade.
v


57
regarding the number and distribution of pharmacies
permitted in any area. New pharmacies must demonstrate a
need for services, based on a population-to-service ratio,
in order to be licensed. If no pharmacists are available in
a given area, other qualified technicians can be designated
as the responsible party. Furthermore, pharmacies are
required to participate in a rotation system with other
pharmacies to ensure the uninterrupted provision of pharmacy
services in a given area. In the event that there is a
demonstrated need but neither qualified technicians nor
pharmacies are available, there are provisions for the
licensing of postos de medicamentos. which are simply
medication outlets of limited capacity that carry only the
most basic supplies (CRS-8, 1983:117-159).
In 1991, there were 2,851 pharmacies and drugstores
(excluding hospital pharmacies and dispensaries) registered
in the state of Rio de Janeiro. Forty-four percent of these
(1,241) were in the metropolitan area so that the
population-to-pharmacy ratio was approximately 4,100:1.
There were 3,870 pharmacists (including 300 oficiales and
praticos) registered with the state, and 63% (2,439) were
registered in the municipal area. Although the data are not
broken down into smaller geographical units, the
distribution of pharamcies in the city is not uniform.
Regulation regarding distribution did not affect established
pharmacies, so older sections of the city have a relatively


128
which s/he has access acceptable or satisfactory. Overall,
the mean score for each area is fairly high, indicating a
positive patient perception of acceptability of care.
Perceived Availability of Medical Services
(Avail Med Serv; Perceived availability of medical
services differed significantly between Copacabana and
theother two areas. The construct of availability included
items assessing convenience, continuity of care, emergency
care, the supply of physicians and hospitals. That
Copacabana scored highest reflects both the higher
concentration of services in this area and the easy access
to a very effective mass transportation service in
Copacabana.
Perceived Affordability of Medical Services
(Afford Med Serv); The elderly in both Copacabana and Mier
scored higher than Santa Cruz on affordability. The
difference between Copacabana and Mier was not
statistically significant. As expected, therefore, the
poorer Santa Cruz residents were more likely to have delayed
seeking medical care for financial reasons, and more likely
to have concerns about the costs of medical exams.
Perceived Acceptability of Pharmacy Services
(AcceotPharmServ): This measure included items on the
selection of medications available, the competence,
prudence, and considerateness of the pharmacy personnel,
exchange of information, modernity, and the courtesy and


26
and these conditions often entail long-term medication use
(Verbrugge, 1984). Many treatments involve complex drug
therapies, such that the elderly who use medications are
also likely to use more than one medication. Polypharmacy
(the use of multiple drugs) has been associated with
multiple prescribers, particularly for patients suffering
from several ailments and who are under the care of more
than one physician. Lack of coordination in drug therapy,
confusion about drug use, and non-compliance are often
associated with more complex drug regimens (German and
Burton, 1989) .
With polypharmacy, the likelihood of the occurrence of
an adverse drug reaction (ADR) and drug-drug interaction, as
well as drug duplication, increases. However, many ADRs are
considered to be predictable and, therefore, preventable.
Yet, because many ADRs manifest differently in the elderly
than in younger patients, a vicious cycle may result as
medications are prescribed for treating the symptoms of the
side effects of a previous medication. Some side effects
manifest as behavioral disorders which may be misdiagnosed
as senile dementia by an untrained physician (Beardsley,
1988; Miller and Elliot, 1976). The costs of ADRs
associated with hospitalizations, prolonged
hospitalizations, and heroic life-saving measures may be
high, the preventable loss of life unmeasurable (Manasse,
1989; Grymonpre et al., 1988; Gurwitz and Avorn, 1991;


39
available to salaried industry workers and various tertiary
sector (mostly commerical and services) workers. The
extension of services by the private sector to non-Social
Security beneficiaries occurred in 1974. At this time, the
right to emergency care was extended to all citizens.
Most of the empresas mdicas (medical corporations) are
non-profit organizations. Many offer pre-paid health plans
to members in a kind of HMO structure. Parallel to the
development of these group practices, physician cooperatives
also began to compete for patients. The cooperatives are
ideologically opposed to the closed-group, pre-payment
structure of group practices, and may be likened to the
preferred patient programs in the United States.
As Social Security grew in Brazil, extending coverage
to include more benefits to a broader population base, the
subsidized business for the private medical sector also
grew. Cordeiro (1984) argues that the increase in contracts
between Social Security and private health care
organizations indicated dissatisfaction on the part of
beneficiaries with the services provided directly by Social
Security physicians and hospitals, and that demand for these
services exceeded supply. The preference by certain
industries and businesses to contract with the health care
organizations was also a politically safe and economical
means of satisfying worker's demands (Cordiero, 1984:64-86).


151
medications in Mier. However, the strongest relationships
in the model are greater acceptability of medical care,
controlling for all other variables, and increased number of
symptoms, controlling for all other variables, both of which
are related to increased use of prescription medications.
Number of symptoms excerted the strongest effect (std.
b=.283).
Santa Cruz: The resulting prediction model for Santa
Cruz included seven variables, five of which are significant
at the p=.05 level. When controlling for all other
variables, being female, older, with greater income, greater
perceived acceptability of medical care, and more symptoms,
all are related to an increase in prescription medication
use. Greater perceived affordability of medical care, when
controlling for the other variables (including income and
health status), is associated with lower levels of PP
medications. An examination of the standardized betas
indicate that health status, by far, had the largest impact
(std.b=-.417). The model accounts for 45% of the variance
in the sample.
Non-Phvsician Prescribed Medication Use for Areas
The models for NPP medication use for each area are
presented in Table 4.31. The same procedures were followed
for logistic regression for each area as for the total
sample. All variables were entered into the equation,
including a dummy variable to control for use of


76
available for HSU studies, and, hence, perceived health
status and symptom experience are the most commonly used
indicators. Measures of health status typically are the
strongest predictors of health services utilization
(Wolinsky and Arnold, 1988), and, by extension, of
prescription drug use (Bush and Osterweis, 1978; Sharpe et
al., 1985, Stoller, 1988). The relationship between
perceived health status and self-medication, or use of OTC
medications, has not been found to be as signficant. These
findings suggest that prescription medications are used for
more serious health problems among the elderly, whereas OTC
medicines are used for less serious conditions.
The measure of health status used in this study results
from the summated scores for two items; perceived current
health status, and perceived health status relative to
others of the same age. By including an item of relative
health status, one may control for possible confounding of
perceived morbidity and what might be perceived as the
effects of normal aging.
Number of symptoms experienced by an individual is also
used in this study as a need variable. Although a very
crude measure which does not take into account severity of
symptoms experienced, when analysed together with perceived
health status, it may provide some insight to use of
medications in the presence of a few or many symptoms, given


63
Summary
This chapter outlined the context of health services
utilization in Brazil. Brazil's health care system includes
an expansive, yet cronically troubled, public sector. The
difficulties it faces have risen from conflicts between
promises to provide first-rate medical attention to certain
segments of the population while neglecting basic primary
care needs of other segments, and the constraints placed on
a Third World nation suffering an economic crisis. A
private sector dominated by large health care corporations
was able to flourish on the promises of the public sector
(through subsidies) and the expecations of their clients.
In addition, the private sector promised less bureacracy, no
endless lines and waiting, and a diminished threat of
shortages in manpower and supplies; in short, it promised
that "private is better than public". Public facilities
became the principal source for medical care for the poor
and otherwise marginal or disenfranchised, and for a few
beneficiaries, a source for otherwise expensive, high
technology procedures free of charge.
The availability of medications has been a concern in
health care politics in Brazil since the 1930s and 1940s,
especially following the development of new antibiotics and
vaccines, and the advent of the industrialization of
pharmaceuticals. Prepackaged medications could be sold in
drugstores, where the presence of a professional was no


CHAPTER 1
MEDICATION USE AND THE ELDERLY IN BRAZIL
Introduction
Medications play a significant, albeit somewhat
insidious, role in both the preventative and curative
spheres of health care: "properly" used, they may save lives
and contribute to an improved quality of life; misuse or
abuse, however, is associated with increased costs of care
and decreased quality of life. It is because of these
characteristics that the demand for modern medicines, their
availability, and their proper use are of global concern
(WHO, 1980).
The central issues of medication use in most developing
countries revolve around two related concerns about access
to medicines: the scarcity of "essential medicines"
(restricted access), and the popular use of a broad spectrum
of legend and non-legend medications outside the purview of
medical supervision (unsupervised access). In particular,
self-medication, the use of medicines without the
recommendation or guidance of a qualified health care
professional, often extends beyond the use of non-legend,
over-the-counter medications (OTCs) to include many legend
drugs that are designed to be taken under medical supervision.
1


2.
3.
9.
nan sempre acompanha de perto.
nunca acompanha de perto.
NS
220
101.
0(a) Sr(a). acha que, em geral, o sortimento de remdios na farmacia completo/incompleto?
1. completo
2. falta alguma coisa
3. falta muita coisa
9. NS
102. J aconteceu com o(a) Sr(a). de a farmcia nao ter o remdio que o(a) Sr(a). procurava?
1. aconteceu muitas vezes
2. aconteceu algunas vezes
3. aconteceu poucas vezes
4. nunca aconteceu.
103.
Quando o(a) Sr(a). fala com urna pessoa da farmcia, o(a) Sr(a). acha que ele(a) presta atengo?
1. presta atengo.
2. no presta atengo. 9. NS
104.
Quando o(a) Sr(a). consulta algum na farmcia, o(a) Sr(a). acha que, em geral, as perguntas que
ele(a) faz sobre seu problema
1. no tem nada a ver.
2. tem pouco a ver.
3. so boas perguntas.
8. NA 9. NS
105. 0(a) Sr(a). acha que o pessoal da farmcia realmente quer que a gente fique bem de sade?
1. Sim.
2. No. 9. NS
106. Em geral, a pessoa da farmcia que lhe atende.
1. faz outras coisas primeiro e depois lhe atende, ou
2. lhe atende logo.
9. NS
107. 0(a) Sr(a). acha que as pessoas da farmcia so
1. todos ou quase todos corteses e atendem com respe i to.
2. alguns so corteses e atendem com respeito.
3. poucos so corteses e atendem com respeito.
9. NS
108. Na farmcia onde o(a) Sr(a). conseque os remdios.
1. sempre h algum de confianga para atender gente.
2. imitas vezes h algum de confianga para atender gente
3. s vezes h algum de confianga para atender gente.
4. nunca h algum de confianga para atender gente.


82
telephone numbers of subjects. The interviewers were
provided with letters of introduction (Appendix C) which
could either be presented personally to the subject or sent
in the mail. These letters advised the subject that they
would be contacted by someone from the research team in
order to make an appointment for an interview.
Each interviewer was accompanied by the principal
investigator for the evaluation of at least one interview
prior to the completion of the interviewer's fifth
interview. The principal investigator observed the
interview and filled in a questionnaire as the interviewer
proceeded with the interview in order to determine the
inter-rater reliability of the instrument. In all cases,
there were no discrepancies between scores. This was
probably due to the closed nature of the response sets which
left little room for interpretation. However, interviewers
had been instructed to note in the questionnaire any
pertinent observations or comments on the survey form,
including responses that did not correspond to any of the
options provided. The principal investigator was then able
to return to the subject at a future date for further
clarification of responses or to re-address a question if
needed.
Quality control mechanisms were in place throughout the
survey, and several cases of fraud in the data collection


54
Brazil has not had a tradition of consumer interest
groups. Therefore, it is worth noting that the health care
professionals and consumers also responded, in organized
fashion, to the situation that appeared to be getting out of
(the government's) hand. In February, 1991, SOBRAVIME
(Sociedade Brasileira de Vigilancia de Medicamentos), was
created as the first civilian organization to be concerned
with pharmaceutical quality control. Its self-purported
role is to denounce irregularities in the production,
licensing, propraganda, and sale or use of pharmaceuticals.
SOBRAVIME, while comprised principally of physicians and
pharmacists, is guided by the principals of the recently
published Consumer Defense Code (Cdico de Defesa do
Consumidor) which represented the efforts of an incipient,
broad-based consumer movement.
These organizations are interested in monitoring not
only the price of medications, but also the medications that
are marketed. Some experts estimate that more than 50% of
the medications sold in Brazil have no proven therapeutic
value, and the number of products on the Brazilian market
that are known to be dangerous or inappropriate is large.
In 1990, Health Action International, the Berne Declaration
Group, and BUKO-Pharmakampagne denounced the sale of
products in the Third World, including combination drugs
which nave no pharmacologic justification, products with an
inappropriate dosage or with "inadequate" (subtherapeutic)


102
In Brazil, it is highly unusual for a health insurance
program to pay for medications. In addition, because in Rio
de Janeiro CEME products were relatively scarce at the time
of this study, patients were generally required to purchase
their own medications, even if entitled to free medicines.
In the sample for this study, the majority of elders
purchase their own medications: 75.4% in Copacabana, 64.6%
in Mier, and 56.3% in Santa Cruz (see Table 4.6). Area
associations were significant (X2=36.60, df=6, p<.001). A
relative pays for their medication expenses for 23.2% of the
sample in Copacabana, 32.6% in Mier, and 29.8% in Santa
Cruz. Only in Santa Cruz did any elder have their
medication expenses paid for by a public institution
(11.3%).
Household income information was successfully obtained
for only a portion of the total sample (73.6%).
Nonetheless, it is an important measure, and some
observations can be made about health care expenses and
household income. As shown in Table 4.7, the proportion of
the household income as health expenditure was greatest for
elders in the middle class area, Mier (20%), and similar in
the other two areas (12% and 13% in Copacabana and Santa
Cruz, respectively). An analyis of the area differences of
the proportion of monthly household income as medical
expense, however, revealed no statistically significant
differences (F=1.12, df=2, p=.30). In all three areas,


35
employees and 50.4 of all self-employed individuals were
covered to some extent by 1980, with the highest proportion
residing in the more industrialized southern regions (IBGE,
1980) .
There has been a direct cost associated with this trend
which has become the nemesis of the system. As mentioned
previously, the curative, hospital-based care INAMPS
provides is expensive. However, INAMPS also pays for
services rendered in non-INAMPS facilities on a fee-for-
service basis. Patients with a choice of facilities tended
to select the higher cost private care, invoking a version
of the "moral hazard" associated with certain health
insurance schemes. Since insurance lowers the price of care
to individuals, they will consume more care than if they had
to pay the entire price themselves, and "too much" medical
care is consumed (Feldstein, 1988:128-129).
The physicians also had a direct role in promoting this
behavior by means of what Brazilians call "dupla
militancia". referring to a conflict of interest that arises
when physicians work as part-time employees at several jobs,
as many do, in both public and private facilities. Under
dupla militancia. physicians recruit patients from the
public facility, where they are salaried and work with
patient quotas, into the private facility where (it is
assumed) the physician believes s/he can offer better
quality services. This is also a lucrative business move


51
Although the price of medications in general has been a
matter of public concern, at least since the early 1970s,
the current economic crisis, marked by both hyper-inflation
and recession, has brought the issue back in full force. In
a 17 month interval, from January 1987 to May of 1988, the
price of medications increased on the average 5,297%,
although the rate of inflation during this period was
943.7%. Among the medications experiencing the greatest
increase were those commonly used for chronic diseases like
Higroton and Atenol, both antihypertensives (medications
frequently used by elderly patients), which increased 1,952%
and 2,969% respectively during this period (Caldas, 1988).
After the steps were taken to deregulate the economy in
1990, further price increases were the result of hikes in
the commercial dollar exchange rates for imports and
exports. Since 42% of the value of the primary materials
used in production is imported, this increase (approximately
30% between October and November, 1990) was transferred to
the price of medications. Although the industry argued that
price increases reflected the increases in cost of
production, as well as mark-ups to cover the cost of
producing products whose prices were still controlled, new
prices generally outstripped these increased costs and
general inflation ("A indstria farmacutica...", 1990;
"Remdios tero...", 1990).


108
should be careful about prescriptions, and 7.6% reported
that one should rarely trust the prescription (see Table
4.11). Of those that were the most skeptical, the greatest
proportion was in Mier. However, the elders in Mier were
also the most likely to always trust the prescription
(Xz=20.60, df=4, p<.000).
Table 4.11 Should you always trust the physician's
prescription?
Copacabana Mier Sta. Cruz
(n=138) (n=147) (n=151)
% % %
Always 57.5 64.2 54.1
Sometimes, but not always 38.8 21.9 40.5
Rarely 3.7 13.9 5.3
Xz=2 0.60, df=4, p<.000
The Role of the Pharmacy
Nearly 90% of the elderly in this sample obtained their
medications from community retail allopathic pharmacies (see
Table 4.12). The popular notion that the elderly are heavy
users of homeopathic remedies was not supported in this
study. Homeopathy has become an accepted alternative, even
within the INAMPS system. Despite the growing interest and
popularity of homeopathy among the general population in Rio
over the last decade (Soares, 1987), only 3.2% of the
elderly in this study reported using homeopathy.


175
patient group that merits special attention with respect to
medication use precisely because of their increased
vulnerability to various types of drug related problems.
Although similar therapeutic classes of medications are
used, their rankings differ considerably in Brazil from that
in the United States. This may be due to underlying
epidemiological differences (morbidities, including culture-
bound syndromes) between the elderly populations, differing
prescribing habits, or other sociocultural factors.
The finding of a low frequency of self-medication in
this sample was unexpected, although it is suspected that,
technically, more people were probably self-medicating than
were reported. Some elderly clearly had received a
prescription at some point, but were never given a treatment
endpoint (or they forgot, etc.). They consider themselves
to be using prescribed medications, and not self-initiating
drug treatment. These results suggest that, in the absence
of precautionary measures in community pharmacies,
physicians should be sensitive to the possibility of the
unnecessary continuation of old prescriptions among their
elderly patients.
The converse (patient's prematurely discontinuing
treatment) may also be a problem for this population,
although not specifically addressed in this study. In the
absence of patient-specific dosage packaging of medications,
it is conceivable that once the patient finishes the last


205
29. 0(a) Sr(a). acha que o pessoal que trabalha na farmacia bem dirigido por um farmacutico
qualificado?
1. mu ito bem dirigido.
2. bem dirigido.
3. mal dirigido.
4. nada dirigido.
5. NS
30.
Na sua opinio, em geral, os balconistas que atendem a gente na farmcia sabem
1. tudo sobre remedios.
2. muito sobre remdios.
3. alguna coisa sobre remdios.
4. pouco sobre remdios.
5. nada sobre remdios.
9. NS
31.Se o(a) Sr(a). precisar do pessoal da farmcia, o(a) Sr(a). poderia falar com ele(a), a qualquer
hora,
1. sem nenhuma dificuldade.
2. com alguna dificuldade.
3. com bastante dificuldade.
4. com muita dificuldade.
9. NS
32. 0(a) Sr(a). acha que h bastante farmacuticos formados neste bairro?
1. h bastante
2. falta
9. NS
33. 0(a) Sr(a). acha que h bastante farmcias neste bairro?
1.
h bastante
2.
falta
9.
NS
farmcia
, o pessoal sabe dar
injego e tomar presso?
1.
sabe os dois.
2.
sabe dar injego, mas nao tomar presso.
3.
sabe tomar presso.
mas no dar injego
4.
nao sabe nem um nem
outro
9.
NS


40
As with many other businesses, these corporations are
having difficulties in dealing with the vagaries of the
contemporary Brazilian economy. Within the last few years,
the tension between the actual health care providers and the
contractors for their services has run high. Conflicts
revolve around the inadequacies of the payment structure,
(primarily reimbursement schedules), in the wake of the
prevailing inflation rates. With run-away inflation, the
more time that elapses between charging for a service and
receiving payment, the greater the devaluation of the
remuneration.
Similarly, salaries had to be constantly reajusted for
inflation. In June, 1990, the national organization for
health care corporations presented a new payment scheme for
their physicians in response to the new rates previously set
by the Brazilian Medical Association (BMA). The medical
corporations argued that they could not afford to pay their
physcians according to the BMA rates because the
corporations were not permitted to adjust the fees they
charged their clients. Unsatisfied physicians went on
strike (crippling both public and private health care
services) and began to charge for private services using the
BM rates. It was not until nearly three months later, in
September, that a judge ruled against using the BMs rates
as mandatory rates, and sent all parties to the negotiating
table.


100
item, area differences in Rio de Janeiro were significant
(see Table 4.5). A posteriori comparisons (Scheff)
indicated that the mean number of symptoms reported in
Copacabana was significantly lower than that reported for
Mier and Santa Cruz.
Table 4.5 Mean number of symptoms reported for areas.
Copacabana Mier Sta. Cruz
(n=138) (n=147) (n=151)
Mean no. symptoms reported 5.15 6.84 6.79
(SD) (3.05) (3.79) (4.18)
F=9.42, df=2, pc.0001
Mean no. symptoms believed
to be caused by a medication
being used 0.24
(SD) (0.53)
F=0.42, df=2, p=.66
Overall, the particpants reported that relatively few
symptoms were caused by any medication being used. The
symptom most often attributed to medication use was dry
mouth (7.3%): 13% of those with dry mouth in Copacabana,
6.1% in Mier, and 3.3% in Santa Cruz, believed that their
dry mouth was due to a medication. Overall, 2.9% of the
sample reported that their symptom of drowsiness was due to
a medication being used, 1.1% reported that their
incontinence was due to a medication, and 1.1% reported that
their vision problem was related to a medication being used.
0.27 0.31
(0.64) (0.81)


168
In Mier (where medication expenses were
proportionately the greatest of the three study areas),
together with health status and symptoms, the perception of
drugs being more affordable is related to a decreased
likelihood of self-medicating. There was no effect with
prescribed medication use. Patients may be less willing to
spend "additional" money on medications that a physician
does not recommend. The inverse of this relationship (the
perception of medications being less affordable is related
to an increased probability of self-medication, all else
being equal) is compelling. This may actually be reflecting
the resort to the use of home remedies rather than to the
purchase pharmaceuticals without a prescription.
The perceived acceptability of medical services was a
significant predictor of PP medication use in both Meier and
Santa Cruz, confirming the notion that patients who are more
satisfied with the care they receive are more likely to use
them. In Santa Cruz, however, this included a control for
the perceived affordability of medical services. In Santa
Cruz, after controlling for age, gender, income, need
variables, and acceptability of medical services, the
perceived affordability of medical services was a negative
predictor of PP medication use. This is likely to reflect
an interaction effect with health status, implicit in the
measure of affordability. Those who perceived care to be
more costly included patients who delayed seeking care when


215
67. Se o mdico recomendar um tratamento mdico, o(a) Sr(a). teria
1. total confianga de que seria o melhor tratamento para o(a) Sr(a).
2. bastante confianga de que seria o melhor para o(a) Sr(a).
3. pouca confianga de que seria o melhor para o{a) Sr(a).
8. NR
9. NS
68.
Na sua opinao, seu mdico acompanha de perto as ltimas descobertas mdicas
1. sempre acompanha.
2. nem sempre acompanha.
3. nunca acompanha.
9. NS
69.
Quando o(a) Sr(a). consulta o mdico, as perguntas que ele(a) faz sobre seu problema sao
1. em geral, boas perguntas.
2. perguntas que nao tern muito a ver.
3. em geral, pergunta pouco ou nada.
9. NS
70. Na consulta, o seu mdico deixa a(o) Sr(a). falar tudo que importante
1. sempre ou quase sempre deixa a gente falar.
2. muitas vezes deixa a gente falar.
3. s vezes deixa a gente falar.
4. nunca ou quase nunca deixa a gente falar.
71. Falando com o mdico, o(a) Sr(a). acha que ele(a)
1.
2.
3.
9.
presta atengao.
nem sempre presta atengao.
nunca presta atengao
NS
72. Em geral, os mdicos sao cuidadosos quando fazem exame mdico. Na sua opinao, o seu
mdico

1.
muito cuidadoso.
2.
bastante cuidadoso
3.
un pouco cuidadoso
4.
nada cuidadoso.
9. NS
73. As vezes demora muito tempo para os doentes serem atendidos pelo mdico. Na sua experiencia, os
pacientes esperam muito tempo no consultorio?
1. Sempre sempre
2. muitas vezes
3. s vezes
4. nunca
9. NS
74.
0(a) Sr(a). acha que o pessoal que trabalha no consultorio (recepcionistas, atendentes,


147
between availability of pharmacy services and use of NPP
medications (r=.16) and the negative relationship between PP
and NPP drugs (r=-.16).
Perceived health status was significantly correlated
with NPP medication use only in Meier (r=.18), suggesting
that some NPP medication use may be for health maintenance
rather than for strictly curative purposes. Willingness to
accept lay advice about medicines was positively associated
with NPP medication use in Santa Cruz (r=.22), Meier (r=.18)
and Copacabana (r=.18). Larger households are significantly
associated with use of more NPP medications in Santa Cruz
(r=.2 4) .
None of the access to care variables, medical and
pharmacy related, was significantly correlated with NPP
medication use in Copacabana. However, Avail_Pharm_Serv is
associated with NPP medication use in Meier (r=.16),
suggesting that self-medication may be spurred on by the
relative easy access to medications through the pharmacy.
In Santa Cruz, where NPP medication is the most frequent,
Avail_Med_Serv is negatively associated with NPP medication
use (r=-.23), suggesting a possible substitution effect of
self-medication when medical services are not available.
The relationships between income, education, and gender
are similar for the three areas. In Santa Cruz, however,
there is a significant negative relationship between age and
education (r=-.22), a relationship which not significant in


233
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235
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70
prescribed and nonprescribed medicine use, has been found to
decrease as household size increases. This is generally
considered a function of income (Rabin, 1977). However, a
larger household increases the opportunity for and may thus
increase the likelihood of the sharing and lay prescribing
of medications among household members. Therefore, a
positive association may be expected between increase in
household size and number of nonprescribed medicines
actually used.
Education; The influence of formal education on
medication use in Western societies is not clear. One
difficulty in assessing it is that, together with income and
occupation, education is one of the indicators of social
class, a variable frequently used in many medication use
studies in lieu of education. Education is associated with
a greater ability to manipulate the socio-political system,
to excert control over one's environment and to mobilize
resources needed for health-related needs (Wood and
Carvalho, 1988:90). Generally, educational achievement and,
hence, social class, is thought to imply greater health
knowledge. According to Blum and Kreitman,
"health knowledge, including information about
medicines, is but one instance of that general
sophistication which is predictable on the basis
of economic, social, political and personal
factors which affect the availability of, access
to, interest in, and capacity to utilize knowledge
sources" (1981:134-135).


153
Table 4.31 Logistic Regression Model for Non-Physician
Prescribed Medication Use for Elderly, Rio de
Janeiro, by Area.
Variable
Regression Coefficients
Beta
Std. Error
Std. Beta
Area: Copacabana
Intercept
2.015
PP med. use
.290
. 775
. 038
Att_Lay_Advice
1.018
.608
. 174
Concordant pairs=
51.2%
Somers'
D =
.18
Discordant pairs =
33.6%
Tied pairs = 15.1%
(3995 pairs)
Area: Meier
Intercept
5.737
PP med. use
.355
.498
.077
Afford Drugs
- .432
.235
- .222
Health status
- .395**
. 153
- .362
No. symptoms
-1.108*
.432
- .376
Concordant pairs=
70.0%
Somers'
D =
.41
Discordant pairs =
29.0%
Tied pairs = 0.9%
(3952 pairs)
Area: Santa Cruz
Intercept
1.255
PP med. use
1.432
.466
.380
Household size
.247**
.088
.338
Att Lay Advice
1.712**
.618
. 381
Accept Pharm Serv
. 066
.035
.234
No. symptoms
- .855*
.384
- .302
Concordant pairs=
74.2%
Somers'
D =
.48
Discordant pairs =
25.6%
Tied pairs = 0.2%
(5096 pairs)
*px2 < .05
**px2 < .01
***px2 < .001


195
c. The clerks do not seem to care if I don't get
better.
d. Clerks often keep the patrons waiting to be
served.
e. My pharmacy takes the feelings of his patrons into
consideration.
f. My pharmacist does his best to keep his patrons
from worrying.
9. COURTESY/RESPECT
a. The people who work in the pharmacy are always
courteous and friendly.
b. My pharmacist always treats his/her patrons with
respect.
c. Sometimes I think that my pharmacist acts like
he/she is doing me a favor by selling me a drug.
d. Clerks usually treat their patrons with respect.
e. Sometimes, pharmacy clerks act as though they are
doing me a favor by selling me a drug.
G. AVAILABILITY OP PHARMACY SERVICES
1. ACCESSIBILITY
a. There are several pharmacies I could go to.
b. I can reach my pharmacy to ask questions at any
time.
c. If I can't reach my pharmacist, I can reach
another pharmacist to ask questions.
d. If the pharmacist is not available, I can count on
the clerks to help me.
e. If I have a health problem, I know I can get the
drug I need at my pharmacy.
f. If I have a problem with a drug, I can get the
help I need from the pharmacy.


188
c.The medical care available to me should be more
complete
2.FOLLOW-UP CARE (using information)
a. My doctor has ignored things about my medical
history when trying to make a diagnosis.
b. When I see my doctor for something new, he usually
checks up on the problems I've had before.
c. I think that my doctor often forgets to look at my
records.
3. INFORMATION GIVING
a. Doctors should be more careful to communicate to
the patient about illness and treatments.
b. My doctor is careful to explain what I am expected
to do.
c. My doctor seldom explains why he orders lab tests
and x-rays.
d. My doctor never tells me when and how to take the
medicine that is prescribed.
e. My doctor is careful to explain the side effects
of the medicines he/she prescribes for me even
when I don't ask.
f. My doctor does not always explain the medical
treatment choices open to me.
g. My doctor always explains the nature of my illness
so that I can understand the problem.
4. PREVENTIVE MEASURES
a. My doctor has asked about what foods I eat and
explains what foods are best for me.
b. My doctor has told me what I should do to avoid
illness.
5. PRUDENCE/DISCRETION
a. When my doctor is unsure about what is wrong with
a patient, he/she would refer to a specialist.


228
PERCEIVED AFFORDABILITY OF MEDICAL SERVICES (.32)
Seekincr Care
When
Needed
1.60
0.81
a.
I have never had to delay seeking
medical attention when I needed because
I could not pay for it.
Price
of Medical Exams
3.35
1.01
a.
The price of medical exams and X-rays is
reasonable.
PERCEIVED ACCEPTABILITY OF PHARMACY SERVICES (.75)
Completeness
2.21
0.75
a.
The selection of medications in the
pharmacy is complete.
Competence (
. 64)
2.28
1.23
a.
The pharmacy personnel are well
supervised by a qualified pharmacist.
3.00
1.29
b.
The pharmacy personnel know a lot about
drugs.
1.57
1.13
c.
When I ask for advice at the pharmacy,
the questions they ask me are usually
good questions.
2.95
1.18
d.
There is always someone who works in the
pharmacy that I trust.
Prudence
2.58
1.20
a.
The pharmacy personnel never recommend
medications that are not necessary.
Considerateness (
.63)
1.90
1.11
a.
The pharmacy personnel really want me to
be healthy (get better).
1.97
1.10
b.
The pharmacy personnel worry that I not
take the wrong medications.
1.40
0.99
c.
There is someone in the pharmacy who is
concerned about my health problems.
2.32
1.13
d.
The pharmacy personnel will tell me when
I have options with my medications.
Givina
Information
to Client (.58)
1.52
0.87
a.
I often ask for information about my
medications at the pharmacy.
2.03
1.11
b.
The pharmacy personnel will explain to
me how to use my medications even if I
don't ask.


Ill
(56.1%). Unlike the other two areas, the trustworthiness of
the pharmacist was mentioned relatively frequently in this
Table 4.14 Proportion
aspects of
of elders identifying
their pharmacy(ies)
positive
Copacabana
(n=131)
%
Mier
(n=129)
%
Sta. Cruz
(n=139)
%
Physician
0.0
2.0
0.0
Nothing special
3.8
5.4
10.1
Location
75.6
62.0
56.1
The pharmacist is
trustworthy
22.1
30.2
45.3
The prices are good/
discount is offered
67.9
76.7
60.4
The clerks are
trustworthy
38.2
39.5
36.7
The inventory of
drugs is good
50.4
40.3
41.7
The quality of the
drugs sold is good
51.9
34.1
30.2
The pharmacy sells other
useful merchandise
47.3
25.6
19.4
I can order by telephone
40.5
16.3
6.5
I can pay the pharmacy
in installments (credit)
0.8
3.1
9.4
Other
17.6
10.9
12.9


158
As in studies elsewhere, analgesics comprised a significant
portion of NPP medications used by the Brazilian elderly.
However, in contrast with the United States, where there
would appear to be a "vitamin/mineral supplement culture"
(one of the most common therapeutic classes in self-
medication) use of "industrialized" vitamins in the study
population was found to be relatively infrequent. Among the
elderly in this study there was a great concern for
maintaining a good appetite, and having a diet with plenty
of fresh fruits and vegetables1 (many participants were not
aware that some of the medications prescribed by their
physician contained some vitamins). Similarly, many of the
home remedies that the elderly in this sample used were for
the purposes of digestive aids and have choleretic
properties.
In the few cases where more potent drugs were used
without a physician's prescription, the patients were
confident that a physician would have prescribed the same
medication. For example:
A 76 year old employed machine operator (in
Mier), began to self-medicate after consulting
with a balconista about what medications other
people use for symptoms he had been experiencing.
For more than four years, this gentleman had been
using methyldopa (.25 mg) on an "as needed" basis
to treat his (undiagnosed) high blood pressure,
1 Many of the elders interviewed by the principal
investigator mentioned that they had relatives who had died
from tuberculosis, and they were particularly concerned about
being too thin and weight loss, symptoms they associate with
TB.


ACKNOWLEDGEMENTS
Several individuals and institutions are responsible
for the successful completion of this project. This project
would not have been possible without the support of the
Institute of Social Medicine at the State University of Rio
de Janeiro (IMS/UERJ). A special debt of gratitude is owed
to Dr. Renato P. Veras, coordinator of the Brazilian Old Age
Survey (BOAS), the first comprehensive survey of physical
and mental health of the Brazilian elderly, for his
generosity and encouragement. The present project on
medication use in the elderly was able to take advantage of
the extensive preliminary work of the BOAS team of
identifying the sample and training interviewers.
Especially appreciated are the efforts of Sidney Dutra
Silva, field coordinator on both projects. The continuity
provided by this was of immeasurable benefit.
Also at IMS/UERJ, special thanks are extended to Gerson
Noronha Filho, M.D., Ph.D., Director of the Department of
Planning, Antonio Cesar Lemme, M.D., and other members of
the Study Group on Quality of Care and Patient Satisfaction.
The receptivity and vitality of this group provided for a
stimulating intellectual exchange of ideas and research
experiences.


138
future investigation. Although access and perceived health
status variables are technically ordinal measures, they are
treated as interval. All appropriate diagnostic tests were
performed on residuals and for detecting multicollinearity,
and no gross violations of the assumptions for the
appropriateness of linear regression analysis were
discovered. Fifteen observations were omitted due to
missing values for the income variable (N=421).
The backward elimination procedure (using the SAS
Stepwise Procedure) was used to select significant
predictors. This procedure starts with all the variables in
the model. It removes variables one at a time, according to
which one gives the smallest partial F-value, given all the
rest, provided that this partial F-value is not significant.
The procedure terminates when all partial F-values are
significant at the significance level for staying in. For
the purposes of "theory trimming", an alpha level of 0.10
was chosen for the procedure (Pedhazur, 1982). This level
is liberal enough to allow for the inclusion of useful
determinants while excluding the less meaningful ones. Area
was controlled for by creating two dummy variables: a=l for
Copacabana, b=l for Meier. Santa Cruz is the reference
area. The model that resulted is presented in Tabel 4.25.


32
rivals that of the more developing countries. Indeed, the
costs of care also approximate those of some of the more
developed countries: in 1987, total public plus private
expenditures on health care in Brazil exceeded US$10 billion
per annum, more than 5% of the Gross Domestic Product, which
is approximately the same percent as the United Kingdom
(World Bank, 1988a:19). However, health care in Brazil is
marked by sharp disparities on the regional and local levels
such that the "marginal", poorer populations have limited
access to even the most basic of public health services,
including medications.
The health care system is also constantly evolving.
Health care is provided by public institutions (federal,
state, and municipal) and private institutions. These are
not totally independent, but they are not well coordinated
either. Decades of bureaucratic reforms gave rise to a
large centralized public sector which became notorious for
its inefficiencies in service delivery at all levels. More
recent reforms, however, call for the decentralization of
the system.
The Public Sector
The Brazilian public health care sector consists of two
major agencies: the Ministry of Health and INAMPS (Instituto
Nacional de Assistncia Mdica), the social security
institution. The Ministry of Health, which is financed
through general government revenues, is responsible for the


Table 2.2
Types of health services used in Brazil and
Rio de Janeiro, 1986.
45
Type of Service
Brazil
Rio de
Janeiro
%
Urban
%
Rural
%
Public health post or
health center
20.8
12.2
16.9
Hospital
36.9
34.5
35.6
Clinic, Polyclinic,
or physician's office
36.2
49.2
39.3
Union or employer's
infirmary
4.1
2.9
6.9
Other
2.0
1.2
1.3
Total
100.0
100.0
100.0
Source: IBGE (1989), table 9, p. 11 and p. 329.
Table 2.3 Utilization of health care serivces in Rio de
Janeiro by household income per capita, 1986.
Income Group Type of Service
(Minimum salary) Public health
Hospital
Clinic,
Other
post/center
MD office
%
(1)
(2)
(3)
(4)
Urban
No income
100.0
17.7
50.6
28.0
3.7
<= 1/4
100.0
14.9
41.0
42.6
1.5
1/4 to 1/2
100.0
21.2
38.4
34.4
6.0
1/2 to 1
100.0
17.7
41.5
37.1
3.7
1 to 2
100.0
10.8
36.0
49.7
3.5
+ 2
100.0
5.3
26.7
64.2
3.8
Rural
No income
100.0
100.0
<= 1/4
100.0
28.3
45.3
14.7
11.7
1/4 to 1/2
100.0
22.4
35.0
33.0
9.6
1/2 to 1
100.0
12.2
38.4
39.7
9.7
1 to 2
100.0
8.3
16.6
75.1

+2
100.0

37.2
62.8

Source: IBGE
(1989) ,
table 11, p.
331.


159
and digoxin (.25 mg) for his (undiagnosed) heart
condition, once a day, for three years. He
reported no current illness symptoms and
considered himself to be in good health.
A 68 year old man (Copacabana) reported that he
had been using Stugeron (cinnarizine), ever since
he had participated in the original clinical
trials for the medication some 20 years ago. He
was convinced that since it appeared to do him no
harm, and it is a relatively inexpensive
medication, there was no reason to stop.
In general, the attitudes of the elderly toward their
medications were of respect for their role in treating
serious illnesses, and of respect for being potentially
dangerous if used incorrectly. These attitudes, together
with a great faith in the physician7s ability to diagnose
correctly and prescribe appropriately, was reflected not
only in the relatively low rate of NPP medication use, but
also in the tenacity with which some people kept
prescriptions active. There were several examples of how
drug regimens were made potentially dangerous by continuing
a prescription that was no longer needed. The following are
some examples:
A 74 year old woman (Santa Cruz) had been taking a
daily dose of chloroquine (180 mg.) for nearly
eight years, since a physician last prescribed it
to treat malaria.
A 70 year old man (Mier) continued to take the
brand Delacoron (verapamil), prescribed for him 17
years ago, even after a different physician
prescribed the generic verapamil 12 years ago. No
one told him to discontinue the Delacoron.
An 83 year old woman (Copacabana) received a
prescription for flurazepam (.30 mg.) to help her
get to sleep after she became widowed, more than
10 years ago. She continues use it daily, but has


41. (cont. 2)
Nota: OPM=outra pessoa mdica (veja o manual)
a. Nome do remdio
b. Dosaqom
(exemplo)
a. LANOXIN
b. ,25 mg
Razio por
usar
(especif icat )
Receitado ou
recomendado por
1. Mdico/OPM
2. Farmacutico
3. Amigo/familiar
l>. Outro (espec.)
5. Ninguem
(auto-receitado)
8. NS (nao iembra)
9. NR
Cono usa
(frequncia)
1. todos os das,
x vezes por dia
2. <7 vezes/semana
4. <3 vez/semana
5. so quando precisa
6. parou de tomar
7. outro
8. NS 9. NR
OuragSo
(# meses)
98. NS
99. NR
r
Toma
1. regularmente
2. se esquece de
tomar de vez
em quando
8. NS 9. NR
0 remdio
Serve?
0. Nao
1. Sim
8. NS
9. NR
Percebe problema
com o remdio?
0. Nao
1. Sim
(especifique)
8. NS
9. NR
5. a.
b.
6. a.
b.
7. a.
b.
B. a.
b.
|Entrevistador:
Leia a lista dos remdios ao entrevistado para verificar os nomes e para que Bao usados.
IMPORTANTE: Pergunte sobre os remdios que o entrevistado tomou as ltimas duas semanas ma que nao
tem na casa atualmente. Se o entrevistado disser todos os remdios, marque "NA" na primeira coluna.
209


Igun, U.A. 1987. "Why we Seek Treatment Here: Retail
Pharmcay and Clinical Practice in Maiduguri, Nigeria."
Social Science and Medicine 24 (8):689-695.
237
"INAMPS afasta 1,524 Mdicos em Todo o Pais." 1990. Jornal
do Brasil August 16.
"A Industria Farmacutica Congela os Pregos dos Remdios por
45 dias." 1990. Folha de Sao Paulo December 27.
Isuani, Ernesto A., 1984. "Universalizacin de la Seguridad
Social em America Latina: limites Estructurales y Cambios
Necessarios," Revista Paraguaya de Sociologa 21(61):189-
205.
Jenkins, Rhys. 1984. Transnational Corporations and
Industrial Transformation in Latin America. New York: St.
Martin's Press.
Johnson, Richard E. and Clyde R. Pope. 1983. "Health Status
and Social Factors in Nonprescribed Drug Use." Medical Care
21(2):225-233.
Joseph, A. E. and D. R. Reynolds. 1984. Accessibility and
Utilization: Geographical Perspectives on Health Care
Delivery. New York: Harper and Row.
Kalache, Alexandre, Renato Veras, and Luiz Roberto Ramos.
1987. "O Envelhecimento da Populago Mundial: um Desafio
Novo". Rev. Sade Pblica 21(3):200-210.
Kinsella, Kevin. 1988. Aging in the Third World.
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Washington, DC: US Department of Commerce, Bureau of the
Census.
Kleinman, Arthur. 1980. Patients and Healers in the Context
of Culture. Berkeley: University of California Press.
Kloos, Helmut, Tsegaye Chama, Dawit Abemo, Kefalo Gebre
Tsadik, and Solomon Belay. 1986. "Utilization of Pharmacies
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Knoben, J. E. and Albert Wertheimer. 1976. "Physician
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Koos, Earl. 1954. The Health of Regionville. New York:
Columbia University Press.


103
medications accounted for the greatest proportion of health
expenditures. Paired comparison anlaysis (Scheffe')
indicate significant area effects, with Meier having a
significantly greater proportion of household income as
medication expense than in the other two areas (F=5.79,
df=2, pc.005).
Table 4.7 Proportion of monthly household income as
medical and drug expense.
Copacabana
%
Mier
%
Sta. Cruz
%
Monthly household income
as medical expense
4.8
6.3
4.1
Monthly household income
as drug expense
7.0
13.5
8.9
N=
92
103
126
In an open-ended question, although over one half of
the sample (53%) reported having no problems obtaining their
medications, 30.9% reported that financial difficulty was
the most important problem in obtaining their medications.
Financial difficulty was clearly related to socio-economic
status (see Table 4.8). Elders in Copacabana were less
likely to report financial difficulty in obtaining their
medications, and more likely to report problems finding the
medications they needed. Half of the respondents from Santa
Cruz reported financial difficulty as the most important
problem.


130
Cruz were significantly more likely to have delayed buying a
needed medication and skipping or lowering a medication dose
in order to economize.
The patterns that emerge from this analysis suggest
that it is useful to analyze access to care in its separate
dimensions for the different socioeconomic strata. In all
dimensions other than availability of both medical and
pharmacy services, Copacabana and Mier, the high and middle
SES areas, were more similar than different. However, with
respect to the perceived availability of services, Mier was
more similar to Santa Cruz, the lower SES area.
Attitude Measures
The measure for attitudes toward formal medical care
(Att_Med_Care) included the summated scores on seven items
referring to skepticism of the ability of modern medicine to
cure serious illnesses, reluctance to accept medical care,
and the belief that the individual understands his/her
health better than the doctor. Attitudes toward lay advice
about medicines (Att_Lay_Advice) was measured by the
summated scores on three items reflecting the willingness to
accept non-medical advice about medicines. Item and
descriptive statistics are also presented in Appendix D.
There were no significant differences in the means
between the three areas on the measure of attitudes toward
medical care (F=1.59, df=2, p>.20), but there were
differences on the measure of willingness to accept lay


169
needed due to financial constraints. A healthy person would
not have delayed seeking care, for whatever reason, if there
was no need.
The perceived acceptability of pharmacy services was a
significant predictor of NPP medication use in only in Santa
Cruz, after controlling for attitudes towards accepting lay
advice about drugs and household size and including
prescription drug use. This is consistent with previous
studies in Brazil that depict the pharmacy as having a
central role in popular medicine as an acceptable
alternative source for care in health seeking, particularly
in more deprived or remote areas, both urban and rural
(Loyola, 1983; Haak, 1988).
Need characteristics were found to be important
determinants of PP medication use in all three areas. As
mentioned previously, there are some limitations with resect
to the interpretation of the relationship between need
characteristics, access to services, and utilization
measures of the HSU model. For example, Wolinsky et al.
(1989), in their study of ethnic differences in physician
and hospital utilization, found that need was more important
in predicting the demand for physician7s services among
minority elderly than among majority elderly. The
researchers suggest that equivalent coefficients (both
standardized regression and multiple correlation
coefficients) would indicate equitable access between


125
interpreted as a measure of the unidimensionality, but
rather as the lower bound of the proportion of variance in
the composite scores that is explained by common factors.
Access Measures
The results of the analysis for the summated items of
the final access measures, are presented in Table 4.21.
Table 4.21 Access to medical and pharmacy services
measures.
Label No. Items Cronbach's
alpha
Acceptability of Medical Services
(Accept_Med_Serv)
15
. 84
Availability of Medical Services
(Avail_Med_Serv)
11
. 69
Affordability of Medical Services
(Afford_Med_Serv)
2
. 32
Acceptability of Pharmacy Services
(Accept_Pharm_Serv)
15
.75
Availability of Pharmacy Services
(Avail_Pharm_Serv)
11
.56
Affordability of Drugs
(Afford_Drugs)
2
. 61
The results indicate that the internal consistencies of
the items are fairly strong on some of the measures, and
weaker on others. Notably, the measure of affordability of
medical care attained a very low coefficient (.32). This
measure included only two items and there was little
variance in the responses. This is likely reflective of the
presence of national health care services which are


99
Table 4.4 Symptoms Reported by Area
Copacabana
Symptom3 %
Mier
%
Sta. Cruz
%
Total
%
Breathless
14.5
21.8
27.8
21.6
Palpitations
18.8
32.7
29.8
27.3
Constipation
22.5
29.9
33.8
28.9
Diarrhea
4.4
8.2
6.6
6.4
Feeling sick, being sick
20.3
37.4
39.1
32.6
Indigestion
4.4
9.5
12.6
8.9
Lack of appetite
13.8
21.1
22.5
19.2
Dry mouth
27.5
42.2
33.8
34.6
Headache
18.1
23.1
31.8
24.5
Backache, other pains in
arms, legs, or joints
60.1
67.4
69.5
65.8
Faintness, dizziness
19.6
25.9
32.5
26.1
Insomnia
39.1
37.4
37.1
37.8
Drowsiness
15.9
29.9
23.2
23.2
Nervousness
44.9
48.3
45.7
46.3
Depressed
31.2
34.7
35.8
33.9
Forgetfulness
40.6
55.1
39.7
45.2
Incontinent
9.4
10.9
13.3
11.2
Confused
10.1
16.3
16.6
14.4
Rash, itching
7.9
23.8
26.5
19.7
Hearing problem
31.9
31.3
25.2
29.4
Vision problem
52.2
70.8
62.3
61.9
Other
11.6
15.0
19.9
15.6
N=
138
147
151
436
a Symtpom list adapted from Cartwright and Smith (1988).


52
Those hardest hit by the impact of these events were
the consumers, particularly chronic medication users. The
following testimonies from letters to the editor of the
major newspaper in Rio de Janeiro, Jornal do Brasil, are
examples of the experiences consumers encountered:
(...) I went to the Drogaria Popular on Rosario
Street, downtown, to buy a box of Antak, which I
take regularly for ulcer problems. Upon arriving
home I compared the price with the last one I
bought and almost flipped. On December 5, I paid
Cr$689, and on December 14, only nine days later,
they charged me Cr$l,886, a 173.68% increase
(...). Paulo Sergio Pereira (RJ) (Dec. 28,
1990).
(...) On January 8, 1991, I had to buy a box of
Frontal, that was purchased by a third party, at
the Drogaria Mexico, Ltda., on Mexico Street,
downtown, upon receiving the medication I was
surprised by the price of Cr$l,375, because not
long before I bought the same medication at the
same pharmacy for a much lower price. Upon
examining the package, I noticed that the price
sticker was placed on top of others. I took it
upon myself to lift off, one by one, the old
stickers and verified that the original price,
according to the first sticker, was Cr$612, on the
second it was Cr$642, on the third Cr$919, and,
finally, on the last one, it had been changed to
Cr$1,375 a 124% increase in a month and half!
(...). Theo de Castro Drummond (RJ) (Jan. 1,
1991).
(...) I am a heart patient, having survived a
triple by-pass surgery. I am required to take the
prescription drug Ancoron. There are 20 pills per
package. For me, a package lasts 40 days, and 40
days ago I paid Cr$505 for one box. On January 5,
I went to buy the medication at the same pharmacy
and I paid Cr$960, or, an increase of 90% in 40
days. This is scandalous (...) Leno Cunha
(Petrpolis, RJ) (Jan. 19, 1991).
(...) I am nearly 80 years old and have had two
by-pass surgeries (...). Early December, 1990,
among the many medications that I am obliged to
purchase, I bought at the Drogaria Popular, on


PROJETO
REMEDIOS NA TERCEIRA IDADE
1990
Rio de Janeiro, Rio de Janeiro
Brasil
5 de Outubro, 1990
Prezado Sr(a).:
No ano passado, o(a) Sr(a). participou, com mais 730
outras pessoas idosas, de urna pesquisa coordenada pelo
Departamento de Epidemiologa do Instituto de Medicina
Social da UERJ Universidade do Estado do Rio de Janeiro.
Naquela poca, o(a) Sr(a). respondeu a um questionrio
sobre vrios aspectos da sua sade, cujos resultados esto
sendo analisados pela equipe da UERJ. Grapas sua
colaborago, estamos conhecendo melhor a populago idosa
brasileira e seus problemas e assim fornecendo subsidios
para o planejamento de servigos.
Este ano, o Departamento de Farmcia da Universidade
da Florida, est fazendo urna segunda pesquisa a respeito do
consumo de remdios da populago idosa brasileira. Os
temas de intersse desta segunda pesquisa sao:
1) quais os remdios mais usados pelos idosos, e
2) qual o uso, por parte dos idosos, dos servigos
de atendimento mdico e dos servigos
f armacuticos.
Em cooperago com o Projeto da Terceira Idade do
Instituto de Medicina Social, foram escolhidas
aleatoriamente 450 pessoas que foram entrevistadas no
primeiro estudo. assim que o Sr(a). foi selecionado(a)
para participar neste segundo estudo.
A coleta dos dados para o Projeto Remdios na Terceira
Idade est programada para os meses de Outubro, Novembro e
Dezembro. As entrevistas duram urna hora. Um membro
credenciado da equipe de entrevistadores, (nome, #ID) ,
entrar em contato com o(a) Sr(a). com antecedncia para
marcar urna hora para a entrevista. As opinioes das pessoas
entrevistadas nesta pesquisa, como na anterior, sao
confidenciais.
Agradego a sua colaborago,
Maria Andrea Miralles
Coordenadora
Ra Anbal de Mendonga 16, Rio de Janeiro, RJ 22241 239-7027
224


196
2. CONVENIENCE
a. My pharmacy's hours are good for me.
b. My pharmacy is in a very convenient location.
c. Getting to the pharmacy is a problem.
d. My pharmacy will deliver to my house if I ask.
e. It takes a long time to get to my pharmacy.
3. CONTINUITY OF CARE
a. I hardly ever go to the same pharmacy for all my
medications.
b. I have had the same pharmacist for several years.
c. My pharmacist knows (treats) others in my family.
d. If more than one person in the family needs
medicine, we have to go to different pharmacies
(i.e., this in the event that some members are
covered by a medical plan to receive medications
at a particular dispensary, but others not).
e. I see the same pharmacist every time I go for a
consultation or prescription renewal.
5. EMERGENCY CARE
a. In an emergency, I can always get a pharmacist.
b. In case of emergency, I can always count on the
pharmacy.
6. SUPPLY OF PHARMACISTS
a. There are enough pharmacists in this area.
7. SUPPLY OF PHARMACIES/DISPENSARIES
a. More pharmacies are needed in this area.
H. AFFORDABILITY OF CARE
I. COST OF CARE:
a. Sometimes I delay getting a prescription filled
until I can pay.



PAGE 1

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5
Background;Medication Use in the Third World
Both the restricted access to essential medications and
the unsupervised access to legend medications in developing
countries have provoked a great deal of controversy world
wide, at least since the 1970s (Silverman, 1976, 1977;
Melrose, 1982; Silverman et al., 1982, 1986; Landmann,
1982). Over-medication, under-medication, use of the wrong
drug, and unnecessary medication use are always important
considerations in promoting effective drug therapy anywhere,
anytime. However, these considerations acquire a greater
prominence in many developing countries, especially for the
case of self-medication.
Whereas in the more developed countries self-medication
may be considered a luxury, in many developing countries,
self-medication may be a necessity (Van de Geest and Hardon,
1990). The tendency to by-pass a physician's prescription
may be considered a necessary adaptation to a situation
characterized by an ineffective or non-functioning official
drug distribution system and the relative dearth of medical
personnel. The lack of control over the distribution and
use of medications gives multinational pharmaceutical
corporations greater latitude, especially for the marketing
of suspect medications, thereby exacerbating the already
precarious conditions for self-medication. The types of
medications made available to these populations, and the
undue expense of inappropriate treatment for impoverished


8
the backbone to profits in the industry. This, together
with new regulatory restraints regarding the marketing of
pharmaceuticals (especially in the United States with the
passing of the 1962 Kefauver-Harris Amendment), encouraged
pharmaceutical firms to look to developing countries without
such rigid controls, either de facto or de jure, as
potential markets. This is particularly true for unapproved
new and old products (CEPAL, 1987:17-29).
The pharmaceutical industry typically creates a demand
for products through intensive drug promotion. Both the
real medical need and popular demand for modern medicines in
Third World countries can be easily exploited. Drug
promotion has been documented to include deceptive and
misleading practices which involve some form of
misinformation and/or error (Silverman, 1977; Silverman et
al., 1982, 1986). Errors of omission include neglecting to
mention potential adverse reactions and other warnings, and
errors of commission include listing inappropriate
indications for use and providing fictitious clinical data
on drug effectiveness and other forms of "statistical
malpractice" (Victora, 1982). Physicians, influenced by the
information presented to them, become "irrational"
prescribers (Melrose, 1982).
The capability to monitor the quality of products and
their marketing is generally beyond the means of many
developing countries. As such, government agencies must


83
were discovered.2 Although interviewers were forewarned of
a reinterview schedule for the purpose of quality control,
they were not informed of the actual schedule. Every third
questionnaire completed and returned by each interviewer was
selected for review. A follow-up call or visit with the
subjects who had been interviewed included an explanation to
the subject of the purpose of the reinterview. A selected
subset of questions with high stability coefficients was
repeated to the subject to verify the answers obtained in
the interview. This also afforded the principal
investigator an opportunity to ask other questions of the
subject that would help to clarify responses, as well as to
collect any missing data.
The Sample
The sample for this study consisted of a randomly
selected subsample of all surviving and consenting
participants of the 1989/90 Brazilian Old Age Survey (BOAS).
The BOAS survey was developed and conducted by the Institute
of Social Medicine of the State University of Rio de Janeiro
(IMS/UERJ). The sample consisted of 738 respondents aged
60 years or more, selected to be representative of municipio
of Rio de Janeiro.
2 Two interviewers turned in completed questionnaires
without having actually conducted the interviews. All of the
questionnaires provided by these interviewers were
disqualified, and their behavior reported to relevant
authorities. The respondents were later interviewed in order
to recuperate the sample.


80.
0(a)
Sr(a). consulta sempre o mesmo mdico?
1.
Sim
2.
Nao
81.
Para
o(a) Sr(a). se consultar sempre com o mesmo mdico
1.
fci 1
2.
un pouco difci1
3.
difcil
4.
muito difci1 9.
NS
82.
Em caso de emergencia, o(a) Sr(a). procura atendimento mdico
logo
1.
fcilmente
2.
com alguma dificuldade.
3.
com dificuldade.
4.
com muita dificuldade. 9.
NS
83.
0(a)
Sr(a). acha que h bastante mdicos em seu bairro?
1.
Nao, falta
2.
Sim 9.
NS
84.
0(a)
Sr(a). acha que h bastante hospitais/cllnicas em seu bairro?
1.
No, falta
2.
Sim 9.
NS
85.
Na sua opino, h bastante laboratrios em seu bairro?
1.
No, falta
2.
Sim 9.
NS
86.
0(a)
Sr(a). acha que os custos dos exames de laboratorio e raio X sao
1.
bastante razoveis
2.
razoveis.
3.
pouco razoveis 9.
NS
87.
0(a)
Sr(a). demorou em procurar atendimento mdico at poder pagar
1.
muitas vezes.
2.
algunas vezes.
3.
poucas vezes.
4.
nunca.
88.
0(a)
Sr(a). teve que esperar para comprar um remdio at poder pagar?
1.
muitas vezes
2.
algunas vezes
3.
nunca


238
. 1958. "Metropolis What People Think about their
Medical Services." In Patients. Physicians and Illness. Ed.
E. G. Jaco. Glencoe, IL: Free Press. 113-119.
Knox, Paul. 1979. "Medical Deprivation, Area Deprivation and
Public Policy." Social Science and Medicine 13D:111-121.
. 1981. "Retail Geography and Social Well-being: a Note
on the Changing Distribution of Pharmacies in Scotland."
Geoforum 12:255-264.
Kroeger, Axel. 1983. "Anthropological and Socio-Medical
Health Care Research in Developing Countries." Social
Science and Medicine 17(3):147-161.
Landmann, Jayme. 1982. Evitando a Sade e Promovendo a
Doenca. 2nd ed. Rio de Janeiro: Ediges Achiame.
Lapa, Ronaldo. 1991. "Guerra no Mercado Farmacutico
Laboratorios Acusem Farmcias de Margens Abusivas." Folha
de Sao Paulo January 25.
Ledogar, R. J. 1975. Hungry for Profits. New York: IDOC.
Lilja, John. 1983. "Indigenous and Multinational
Pharmaceutical Companies." Social Science and Medicine
17(16):1171-1189.
Lipton, Helene L. and Philip R. Lee. 1988. Drugs and the
Elderly: Clinical. Social and Policy Perspectives. Stanford,
CA:Stanford University Press.
Logan, Kathleen. 1983. "The Role of Pharmacist and Over the
Counter Medications in the Health Care System of a Mexican
city." Medical Anthropology 3:68-87.
Low, Setha M. 1981. "The Urban Patient: Health-Seeking
Behavior in the Health Care System of San Jose, Costa Rica."
Urban Anthropology 10(l):27-52.
. 1983. "Patient Satisfaction in Costa Rica: A
Comparative Study." In Third World Medicine and Social
Change. Ed. J. Morgan. Landham, MD: University Press.
Loyola, Maria Andrea. 1983. Mdicos e Curanderos: Conflito
Social e Sade. Sao Paulo: Difel.
Luz, Madel. 1986. As Instituces Mdicas no Brasil. 3rd ed.
Rio de Janeiro: Ediges Graal.
MacKeigan, Linda D. and Lon N. Larson. 1989. "Development
and Validation of an Instrument to Measure Patient


Area 78
Instrument Development 78
Item Selection 78
Interviewer Training and Instrument Pilot 80
The Sample 8 3
Study Areas 86
Copacabana 8 6
Meier 89
Santa Cruz 89
Analysis Strategy 91
Summary 92
4 RESULTS 94
Sample Characteristics 94
Descriptive Results 97
Health Status 97
Medical and Medical Expenses 101
The Role of the Physician 104
The Role of the Pharmacy 108
The Role of the Pharmacist 114
Medication Use 119
Measures 124
Access Measures 125
Attitude Measures 130
Correlates of Medication Use 131
Modeling Medication Use 137
Prescription Medication Use 137
Non-Physician Prescribed Medication Use 140
Correlates of Medication Use for Areas 142
Modeling Medication Use for Areas 149
Prescription Medication Use for Areas 149
Non-Physician Prescribed Medication for
Areas 151
Summary 154
5 DISCUSSION AND CONCLUSION 156
Medication Use Among the Brazilian Elderly 156
Health Services Utilization and Medication
Use 161
Patient Population Characterisitcs
and Medication Use 162
Access to Care and Medication Use 164
Limitations 166
Policy Implications 170
Health Care and Medication Use among the
Elderly 173
Pharmacy Health Care 177
Conclusion 181
Vll


121
uses. An analysis was done to determine the number and
percentage of participants receiving at least one ingredient
of a given therapeutic class. If a participant was
receiving more than one drug of a given class, it was
counted only once. Results are presented in Table 4.19.
The most common types of drugs reported to be
prescribed by physicians included antihypertensive drugs
(29.5%), diuretics (26.9%), and congestive heart failure
drugs (22.5%). For non-physician prescribed medications,
the most common included analgesics/antipyretics (15.5%),
antirheumatic drugs (13.5%), digestants (10.1%) and
diuretics (9.4%). Overall, 24% of the elderly used at least
one antihypertensive drug and 24% used at least one diuretig
followed by congestive heart failure drugs (17.9%),
antirheumatic drugs (14.2%) and analgesics/antipyretics
(13.9%). The ranking of the combined prescription and
nonprescription medication use for this sample varies from
the typical ranking reported for the elderly in the United
States (Stewart, 1988:55). For example, in one study of
Florida elderly, the top five rankings include vitamins
(including vitamin and mineral combinations),
anithypertensive drugs, analgesics (non-narcotic),
antirheumatics, and coronary vasodilators (Hale et al.,
1987) .


187
b. Drugs requiring a physician's prescription are
dangerous.
c. There are some drugs that can make you worse than
the illness itself.
e. Medicines you can buy in a store without seeing a
doctor are not dangerous.
4. BELIEF THAT EXPENSIVE MEDICINES ARE BETTER
a. Less costly drugs are worthless (do nothing).
b. If you want to get a drug that really works, you
will probably have to pay dearly for it.
c. Drugs that cost more than others are made with
better quality (or, "fresh") ingredients.
d. Name brand products are generally better than
generic drugs.
e. Generic drugs are not always made with "fresh"
ingredients.
C. ACCEPTABILITY OF MEDICAL CARE
GENERAL:
a. For the most part, I am satisfied with the medical
care I receive.
b. Most people in this area receive medical care that
could be much better.
c. There are many things about the medical care I
receive that could be much better.
SPECIFIC:
1. COMPLETE FACILITIES
a. I think that my doctor's office is has all the
necessary equipment and facilities to provide
complete medical care.
b. My doctor's office it adequately equipped to
provide the kind of care I need.


80
number of alternatives. For example, rather than requiring
a respondent to "agree" or "disagree" with the statement,
"The pharmacy is always open when I need", the question was
posed as, "Is the pharmacy always open when you need?" and
possible responses included "Always", "Sometimes", and
"Never". The format also encouraged the respondent to
clarify or expound on their responses and recount specific
relevant experiences. Interviewers were instructed to make
note of these experiences in the questionnaire. The
instrument is included as Appendix B.
Interviewer Training and Instrument Pilot
Interviews were conducted by a team of twelve
individuals in addition to the principal investigator,
selected on the basis of personal or professional interest
in the subject matter. Interviewers were identified by the
field coordinator of the BOAS project. The interview team
included a social worker, a pharmacist, a medical student, a
physical therapist, a sociologist, a journalist, and five
senior university students from the School of Social
Sciences at the State University of Rio de Janeiro (UERJ).
Three training sessions were held. The first session
briefed 15 potential interviewers on the nature of the
project. Printed background material on aging in Brazil and
related health care concerns distributed prior to the first
meeting were reviewed in conjunction with the specific
objectives of the project. Basic survey logistics and the


10
the 1970s, the notion of "rational drug systems" was
developed (WHO, 1975). Developing countries have been
encouraged, with the assistance of the World Health
Organization, to design national formularies that would
guide the public sector procurement of so-called "essential"
low-priced products considered appropriate for the
particular health needs of individual countries. Emphasis is
also placed on developing or expanding the role of the state
and local private pharmaceutical industries to produce these
products so as to break the cycle of dependency on MNCs (Von
Wartensleben, 1983).
The Social and Cultural Context
The relationship between the presence of a national
essential drugs formulary, physician prescribing, and self-
medication is not irrelevant. Because regulations regarding
the sale of legend medications are either very relaxed or
not well enforced in many situations, consumers can purchase
almost any medication without presenting a prescription from
a physician. Nonetheless, self-medication in many
developing countries appears to parallel the prescribing
habits of physicians, especially in the preference for brand
name products (cf., Hardon, 1987; Fergusen, 1981; Loyola,
1983; Logan, 1983). Drug merchants and consumers learn what
medications are prescribed for various conditions from
previous prescriptions (their own or others7), or drug
promotion literature and package inserts. In Brazil, for


16
measures of availability and cost of services as proxies for
access to care. Service characteristics (enabling
variables) typically include measures of hospital bed
supply, physician supply, and so on, for a given area.
While these are practical measures for many policy
development concerns, it has been suggested that they may
not be best suited for the elderly and that a more
psychosocial approach to conceptualizing and measuring these
constructs may be more appropriate for this population
(Wolinsky and Arnold, 1988; Wolinsky, et al., 1990). Such
an approach would acknowledge the role of other important
aspects of care seeking among the elderly, such as social
networks and other emotive aspects of illness behavior
(Stoller, 1988). Furthermore, there is an implicit
assumption of a close correspondence of "actual"
availability and cost of services with perceived
availability and cost. Such assumptions may not always be
valid, particularly under abnormal situations, as in the
case of illness and other physical and psychological
impairments. They also do not take into considerations the
availability of alternative sources of care .
Conceptualizing Access to Care
In its broadest sense, the health services utilization
model addresses the relationship between the accessibility
and use or non-use of health care services. As a general
model, it serves as a guide for the development of more


150
Table 4.30 Regression Models for Prescribed Medication
Use for Elderly, Rio de Janeiro, by Area.
Regression Coefficients
Variable
Beta
Std. Error
Std. Beta
Area: Copacabana
Intercept
- .934
Age
.066**
.023
.220
Att Med Care
.200**
.070
.220
No. Symptoms
1.213***
.346
.279
R2 = .16 N=138;
df=137
Area: Meier
Intercept
5.310
Household Size
- .143
. 099
-.113
Accept Med Serv
.210**
.338
.210
Avail Pharm Serv
- .074
.042
-.139
No. Symptoms
.974***
.276
.283
R2 = .15 N=147;
df=146
Area: Santa Cruz
Intercept
1.843
Gender
1.106**
. 342
.231
Age
.075**
.022
.212
Income
.874
.560
. 109
Accept Med Serv
1.326***
.294
.287
Afford Med Serv
- .188
.097
-.134
Health Status
- .551***
.083
-.417
No. Symptoms
.572***
.276
. 156
R2 = .45 N=151;
df=150
*p < .05 **p < .01
***E < .001,
all others
significant
at e <= *10.


Table 4.22 Comparison of mean access
scores by area.
Access
Copacabana
Mier
Santa Cruz
Pr > F
Label (Range)
(n=138)
(n=147)
(n=151)
Accept_Med_Serv (19-50)
43.78
42.22
43.25
n. s.
Avail_Med_Serv (13-31)
26.41
24.97
24.48
0.0001
Afford_Med_Serv (2-7)
5.12
5.33
4.56
0.0001
Accept_Pharm_Serv (18-51)
31.12
32.23
37.22
0.0001
Avail_Pharm_Serv (13-33)
26.48
23.73
23.46
0.0001
Afford_Drugs (2-5)
4.68
4.54
4.17
0.0001
Significance levels of 0.05 or less reported.
127


157
for the US (Simonson, 1984:14-15). Use of homeopathic
medications, which were all reported to be prescribed by a
homeopathic physician in this sample, was also less than
expected, given conventional wisdom and reports of
increasing use among the general population of all socio
economic levels (Soares, 1987).
There are various possible explanations for the low
rate of NPP medication use among this elderly sample.
Younger, working adults with less time to go to a physician,
for example, may be more likely to self-medicate, especially
for apparently minor and transient ailments and those
associated with the medicalization of "daily living
problems" (Temporao, 1986:140-146, 157). Mothers are also
likely to medicate their ill children with products obtained
without a prescription (Greenhalgh, 1987; Hardon, 1987;
Haak, 1988). The elderly in this study, especially the
retired, had few time constraints. In addition, 86% of the
elderly had at least one regular physician, and 80% had at
least one prescriber. In addition, symptom experiences were
more likely to be attributed to normal aging, and not
"illnesses" per se. Those elderly who were taking
medications for chronic and/or degenerative conditions were
particularly cautious about deviating from their physician's
recommendations.
Most of the medicines that were used without a
prescription were for relatively mundane or banal purposes.


203
22. Em geral, quern paga a maior parte da despesa com remdios do(a) Sr(a)?
1. instituigo pblica paga todas as despesas (ou d remedio).
2. o entrevistado.
3. a familia ou prente (ex. marido, filho, sobrinho, cunhado etc.)
4. seguro/plano mdico particular/privado
5. outro (especifique)
8. NS 9. NR
23. Quando o(a) Sr(a). tem alguma pergunta sobre um remedio, onde ou a quem o(a) Sr(a). normalmente
pergunta primeiro?
00. o entrevistado nao procura ningum
01. o mdico da instituigo pblica que o entrevistado tem direito de utilizar
02. mdico particular
03. mdico de instituigo privada
04. mdico em urna instituigo de caridade
05. enferme ira
06. farmacutico ou balconista de farmcia
07. conselho de um leigo
08. outros (especificar)
98. NS 99. NR
24. Em geral, qual o problema (dificuldade) mais importante que o(a) Sr(a). tem para obter
os remdios que usa (toma) regularmente?
(Entrevistador: NAO lea a lista de alternativas)
01. o entrevistado no tem problemas para obter os remdios
02. problema financeiro
03. remdio que nao fcil de ser encontrado
04. dificuldade em obter receita
05. difcil acesso farmcia (falta de transporte)
06. problema em obter algum para ir farmcia
07. outro problema (especifique)
97. NA (no usa remdio) 98. NS 99. NR
25. Em geral, quando o(a) Sr(a). tem um remdio que no precisa mais, o que que faz com
ele? (Entrevistador: NAO leia a lista)
1. fica com ele para possivel uso no futuro
2. joga no lixo
4. d para outra pessoa que precisa
5. outro (especifque)
7. NA 8. NS 9. NR


165
programs designed to reduce financial barriers to care
(Wolinsky and Coe, 1984).
There is some evidence to suggest that self-medication
may be a substitute and/or a supplement for seeking medical
care and for prescription medication use. Patients that
found the quality of their medical care wanting
(Accept_Med_Serv) tended to use more non-physician
prescribed medications. Patients who were more willing to
accept lay advice about medications were also more satisfied
with the pharmacy services they receive, and patients more
willing to accept lay advice about medications were more
likely to self-medicate.
Of the enabling access variables that were evaluated,
only perceived acceptability of medical care was found to be
a significant predictor of prescription medication use for
the aggregate data. When controlling for area and other
significant predisposing (age, gender, income) and need
variables, the more the patient perceived the quality of
medical services to be acceptable and satisfactory, the more
likely s/he was to use prescription medications. Self-
medication, therefore, may be a substitute for formal care
when medical services are considered unsatisfactory in ways
unrelated to their cost to the patient or their
availability. However, without more specific information
regarding illness history (e.g., severity of condition,
seeking alternative treatments, and so on), the nature and


0(a) Sr(a). j diminuiu a dose que deveria tomar de um remdio para economizar?
1. sim
2. nao
Em caso de urgencia, o(a) Sr(a). consegue os remdios necessrios mesmo se nao tiver o dinheiro na
mo
1. sem dificuldade.
2. com alguna dificuldade.
3. com muita dificuldade 9. NS
Na sua experiencia, a farmacia permite pagar mais tarde se a gente nao tem o dinheiro na hora?
1. sempre
2. muitas vezes
3. algunas vezes
4. nunca ou raramente 9. NS
0(a) Sr(a). acha que h algum na farmcia que se preocupa com os problemas de sade dos clientes?
1. Sim
2. N3o
0(a) Sr(a). costuma pedir informages sobre remdios na farmcia, inclusive as bulas dos remdios?
1. sempre pede informages.
2. muitas vezes vezes pede informages.
3. algunas vezes vezes pede informages.
4. nunca pede informages.
Na sua experiencia, o pessoal da farmcia explica como usar os remdios mesmo quando a gente nao
pede?
1. sempre explica.
2. muitas vezes explica.
3. algunas vezes explica.
4. nunca explica.
0(a) Sr(a). acha que os farmacuticos podem explicar sobre os remdios para a gente
1. melhor que um mdico?
2. igual a um mdico?
3. pior que um mdico? 9. NS
0(a) SrCa). acha que os farmacuticos devem explicar quais sao os efeitos dos remdios sobre a
gente?
1. sempre devem explicar.
2. nem sempre devem explicar.
3. nunca devem explicar.
Por qu?
Quando se usa mais de um remdio por dia, aumenta a probabi1idade de misturar ou confundir os
remdios. 0(a) Sr(a). acha que isto um problema grave para


222
114. Algumas pessoas acham que ainda que o farmacutico formado seja muito informado sobre os remdios,
hoje em dia, como todo remdio j vem embalado e com bula, nao se precisa mais do farmacutico na
farmacia particular. 0 que que o(a) Sr(a). acha?
1. Nao se precisa mais do farmacutico formado na farmcia.
2. Ainda se precisa do farmacutico formado na farmcia.
8. NS
9. NR
Por qu?
115. Sem aumentar os gastos do governo com a sade, o(a) Sr(a). acha que o atendimento poderia ser
1. muito melhor.
2. un pouco melhor.
3. n3o poderia ser melhor.
9. NS Por que?
ENTREVISTADOR: Faga um resumo (ex. J terminamos a quarta e ltima sego..).
Anote a hora :
1. Pergunte ao entrevistado se ele(a) tem alguma outra observagao sobre a farmcia onde ele(a) vai que
nao foi discutido neste questionrio mas que importante para ele(a). Faga o favor de escrever as
observagSes no outro lado da pgina.
2. Agradega ao entrevistado. Explique que as primeiras anlises sero enviados pelo correiro em margo,
1991. Se tiver alguma pergunta ou sugesto, pode entrar en contato por telefone (239-7027) ou por escrito
(Ra Anbal de Mendonga 16, #304, Rio de Janeiro, RJ, 22410).
Assinatura do Entrevistador


Table 3.1continued
Variable name
Perc'd acceptability of pharmacy services
(Accept_Pharm_Serv)
Perc'd availability of pharmacy services
(Avail_Pharm_Serv)
Perc'd affordability of Drugs
(Afford_Drugs)
Need variables:
Perc'd health status
Symptom experience
Use variables:
Physician prescribed (PP) medication use
Non-physician prescribed (NPP) medication use
Measurement
Summated score of 15 items
(ordinal measures)
Summated score of 13 items
(ordinal measures)
Summated score of 2 items
(ordinal measures)
Summated score of 2 items
(ordinal measures)
No. of reported symptoms
experienced with frequency
No. of medications used prescribed
(or recommended) by a physician
No. of medications (incl. home
remedies) used recommended by
a lay friend or family member,
pharmacist, nurse, self, or other
lay individual.
CTi
00


Table 4.23 Means and Standard Deviations of Variables in Regression Models.
Mean
SD
Copacabana
Mean SD
Meier
Mean SD
Sta.
Mean
Cruz
SD
Gender (0=male)
*1
0.62
0.48
0.62
0.48
0.58
0.49
0.66
0.47
Age
x2
71.79
6.87
72.53
7.09
72.23
7.04
70.71
6.40
Education
x3
6.39
4.84
10.57
4.87
5.56
3.19
3.45
3.37
House, size
*4
2.44
2.01
1.73
1.33
2.31
1.69
3.22
2.48
Income8
X5
0.54
0.45
0.89
0.48
0.44
0.34
0.32
0.28
Perc'd health
X6
6.67
1.71
6.99
1.39
6.52
1.66
3.53
1.97
No. Symptoms8
x7
1.84
0.59
1.69
0.50
1.91
0.61
1.89
0.64
Att Med Care
*8
13.54
2.80
13.18
2.46
13.83
3.21
13.57
2.64
AttLayAdvice8
x9
1.69
0.59
1.65
0.31
1.59
0.33
1.84
0.40
Accept Med Serv8
X10
2.38
0.44
2.34
0.38
2.45
0.44
2.35
0.49
Avail Med Serv8
Xn
1.76
0.56
1.58
0.52
1.83
0.51
1.85
0.62
AffordMedServ
Xi2
4.99
1.40
5.11
1.17
5.33
1.26
4.56
1.61
Accept Pharm Serv
X*
33.62
6.55
31.06
4.79
32.25
6.47
37.24
6.44
Avail Pharm Serv
24.52
3.81
26.52
2.72
23.81
3.94
23.42
3.85
Afford_Drugsb
X15
0.31
0.95
0.56
0.83
0.37
0.93
0.02
1.00
PP
X16
2.63
2.23
3.35
2.16
2.80
2.11
2.12
0.69
NPP
Xl7
0.59
1.08
0.54
0.91
0.51
1.13
0.69
1.13
% no NPP
66.5
64.4
73.2
61.9
N=
421
132
142
147
a Values represent logged transformations of variables.
b l=some problem with the affordability of drugs, -l=no problem with the affordability of drugs.
132


219
1.
muitas pessoas
idosas.
2.
algunas pessoas
idosas
3.
poucas pessoas
idosas.
95b. 0(a) Sr(a). acha que o pessoal da farmacia deve acompanhar os remdios que a gente usa para evitar
os problemas de misturar ou confundir remdios?
1. Sim
2. Nao 9. NS
Por qu?
96a. 0(a) Sr(a). acha que o pessoal da farmcia deve explicar sobre outros remdios, alm dos que o
mdico receita, que podem ser bons para a gente?
1. sempre deve explicar.
2. nem sempre deve explicar.
3. nunca deve explicar.
Por qu?
96b. Na sua experiencia, o pessoal da farmcia explica para o(a) Sr(a). quando tem opges com os
remdios?
1. sempre
2. multas vezes
3. poucas vezes
4. nunca
97.
0(a) Sr(a). acha que o pessoal da farmcia se preocupa com que a gente tome o remdio errado?
1. sempre se preocupa.
2. muitas vezes se preocupa.
3. poucas vezes se preocupa.
4. nunca se preocupa.
98.
0(a) Sr(a). acha que o pessoal da farmcia recomenda remdios que no so necessrios?
1. muitas vezes recomenda remdios que no so necessrios.
2. s vezes recomenda remdios que no so necessrios.
3. raramente recomenda remdios que no so necessrios.
4. nunca recomenda remdios que no so necessrios.
99.
Se o farmacutico no tiver certeza do problema de um fregus, o(a) Sr(a). acha que ele(a)
100.
1. mandara o fregus para o mdico ou outro especialista.
2. tentara resolver o problema ele(a) mesmo.
9. NS
0(a) Sr(a). acha que o pessoal da farmcia acompanha de perto as ltimas descobertas e pesquisas
sobre medicamentos?
1.
sempre acompanha de perto.


41
The health care organizations were also recently faced
with other changes that directly affected their clientele.
In January, 1991, new federal regulations gave health care
organizations the option of either formally becoming health
insurance corporations, or of maintaining their health
programs as they were, but managing them as if they were
insurance policies. Previously, health plans offered
services similar to health insurance policies, but were not
subject to the price and other quality controls imposed on
insurance policies.1 Golden Cross, with over 700 thousand
clients in its health plan nation-wide, was one of the first
to switch to a formal insurance entity, Golden Cross
Insurance. Although there were no changes in service, the
monthly fees to clients did increase enough to make many
clients very concerned: in Rio de Janeiro, for example,
where more than half of Golden Cross7 clients reside, rates
increased by over 150% (Susep elabora..., 1991).
Health Services Utilization in Rio de Janeiro
In 1986, a national household survey examined health
services utilization in Brazil. The study revealed that 67%
of all Brazilians who had a health problem sought medical
attention. Ninety-seven percent of all urban residents, and
53% of all rural residents with a health problem sought
1 In addition, if the corporations changed their non
profit status to become a private insurance company, the
government could reap an estimated US$80 million per annum in
new tax revenue (Dantas, 1991).


P R O J E T O
REMEDIOS NA TERCEIRA IDADE
RIO DE JANEIRO, RIO DE JANEIRO
BRASIL
E
1990
efo
**a!
?
Maria Andrea Miralles, MA
COORDENADORA
Department of Pharmacy Health Care Administration
College of Pharmacy
University of Florida (USA)
em colaboraco com o
Projeto de Epidemiologa da Terceira Idade
Instituto de Medicina Social, UERJ
Nn ero do Questionrio
rea 1 (CopacaDana) 2 (Meier) 3 (Santa Cruz)
C luster
Nome do entrevistado
E nd e reg
B a irro
Cidade RIO DE JANEIRO Cdigo Postal
Telefone
Nome do entrevistador
Data da entrevista
Hora (Inicio)
/ /
Hora (F im )
199


86
until the target sample size for each area was obtained. In
anticipation of attrition due to mortality and change in
residence, as well as refusal to participate, the remaining
subjects were retained as alternates.
Study Areas
Rio de Janeiro is the capital city of the State of Rio
de Janeiro. Rio de Janeiro, together with its neighbors to
the south (Sao Paulo) and east (Belo Horizonte) make up the
core cities of the Southeast region of Brazil, the
wealthiest and most diversified region of the country. Rio
de Janeiro, in addition to being a major tourist center, is
one of the most important commerical, financial, and
industrial centers in the country. It also harbors the
largest slum (Roginha) in Latin America. The Municipio
(county) of Rio de Janeiro, with a population of more than
5.5 million, encompasses a part of a vast metropolitan area,
several suburban and rural areas. The three study areas
selected for this study are representative of this
diversity. A map of the study areas is presented in Figure
3.1.
Copacabana
Copacabana is the most metropolitan of the areas
studied. Internationaly known for its beaches, night-life
and social clubs, became a haven for the affluent in the
1940s and 1950s, after the construction of tunnels that made
the area more accessible by automobile and increased the


22
offer a reasonable alternative in the absence of complete
data on actual service availability.
The current investigation adopts the perspective that
geographical area is more than a simple measure of location
and spatial discreetness. In this sense, the approach taken
in this study approximates the traditional approach of the
sociology and anthropology of community study (Stein, 1972;
Arensbery and Kimball, 1965). However, in recognition of
the limitations of the usefulness of community studies as a
source of information about broader regional or national
experiences, this study examines a larger geographic unit of
analysis (groups of communities sharing significant
characteristics) in order to enhance the representativeness
of the sample. The investigator concurs with other studies
that recognize the limitations of the distance variable in
assessing access to care (Gesler and Meade, 1988:460). In
addition, the investigator agrees with and builds upon the
work of other health services utilization studies that
acknowledge the possibility of a significant influence of
social structure on perceived access to care for various
subpopulations in a society (Wolinsky, et al., 1989).
Furthermore, she suggests that an independent examination of
smaller geographical areas within the larger areas may
reveal relationships of various predictor variables and
access to care that might otherwise be obscured in studies
of larger aggregate populations. Specifically, in this


200
ENTREVISTADOR: Explique a organizago do questionrio.
SEQO 1 INFORMALES GERAIS
1.Sexo do entrevistado 0. Masculino 1. Feminino
2. Quantos anos o(a) Sr(a). tem? anos
3. Atualmente, qual seu estado conjugal?
1.
nunca casou
2.
casado/morando junto
4.
divorciado
5.
separado
8.
N.S.
9.
N.R.
4. Quantos anos de escola o(a) Sr(a). completou? anos
5.
6.
7.
0(a) Sr(a). est trabalhando atualmente? 0. Nao
Qual /era sua ocupago principal?
1. Sim
horas/semana
Atualmente, quantas pessoas vivem com o(a) Sr(a). nesta casa?
00. o entrevistado mora s pessoas 98. NS 99. NR
8.
Por favor, eu gostaria de saber, qual a sua renda (dinheiro) mensal. Nao preciso saber o valor
exato, diga-me o valor aproximado do rendimento mensal que o(a) Sr(a). percebe regularmente.
Entrevistador: caso baja mais de urna fonte, anote a soma destes valores.Atenpo: valor liquido.
rendimento mensal .0 0
NA 7 0 0 0 0 0 7
NS 8000008
NR 9000009
9. Por favor, agora eu gostaria de saber o total mensal dos rendimentos das pessoas que vivem nesta
residencia. Nao preciso saber o valor exato, diga-me o valor aproximado do rendimento mensal
regularmente percebido pelas pessoas.
Entrevistador: se o entrevistado vive sozinho e tem rendimento, repita o valor informado
na Q.8. Se o entrevistado vive sozinho e nao tem rendimento, marque NA.
rendimento mensal .0 0
NA 7 0 0 0 0 0 7
NS 8000008
NR 9000009
10. Quantas pessoas, incluindo o(a) Sr(a). e os empregados que moram na casa, vivem com esse
rendimento familiar?
pessoas 98. NS 99. NR


152
prescription medications, with a significance level to stay
in of p=0.10.
Cooacabana; The resulting prediction model for
Copacabana yielded a D score of 0.18. Controlling for
prescription medication use, greater willingness to seek
nonmedical advice about medications is associated with
increased probability of self-medication, although the
association is barely significant at the .10 level. The
absence of any access variables suggests again that access
may not be relevant issue for this area for NPP medication
use and that there are perhaps other factors related to NPP
medication use that are not being tapped by this study.
In Meier, controlling for PP medication use, health
status and number of symptoms, greater Afford_Drugs is
associated with decreased likelihood of NPP medication use,
although the association is a weak one. An increase in
number of symptoms, controlling for the other variables, is
Iso associated with a decreased likelihood of NPP medication
use. This model attained a D statistic of .41.
The prediction model for NPP use for Santa Cruz
includes five variables, including the control for PP
medication use, and explained a greater proportion of
variance (D=.48) than did the models for the other two
areas. When controlling for PP medication use and all other
variables, living in a larger household, being more willing
to accept lay advice about medicines, perceiving pharmacy


64
longer mandatory. As pharmaceuticals became more
accessible, the professional pharmacist abandoned community
practice to commercial interests, and a new dimension was
added to the potential hazards of self-medication, relative
to other countries with more controlled environments.
The relationship between the health care system and
care-seeking behaviors in Brazil reflects an historical
process that is deeply rooted in the culture and politics of
the country. Health care services have not been universal
nor uniform for all: some groups have had quite different
experiences and individuals7 expectations regarding services
are bound to be related to their experiences and needs.
With this understanding of the context in which health
services are utilized in Brazil, the question of the
relationship between perceived access to medical care,
perceived access to pharmacy services, and medication use
may be addressed. The following chapter discusses the
methodology that will be employed to examine this question
for elderly residents in three different socio-economic
areas in Municipio of Rio de Janeiro.


19
higher education may actually restrict rather than broaden
the patient's range of health care options (Low, 1981).
Perceived options in health care is also a reflection
of patient preference for, and expectations of, particular
services or treatment modalities. Attitudes towards medical
and pharmaceutical services, as well as alternative healing
strategies, are essentially historical in nature. They are
not only historical with respect to an individual's personal
experiences (so that elderly patients are likely to have
different views about medical care than younger patients),
but encompass a broader social and cultural experience.
The effect of the social distance between client and
professional on patient satisfaction with different forms of
health care has been researched by medical sociologists and
anthropologists for many years, in many situations in
various cultural and multicultural settings (c.f., Simmons,
1958; Koos, 1954, 1958; Clark, 1970; Low, 1983; Loyola,
1983) Patient dissatisfaction may arise from the conflict
between the social equalitarian ideology behind public
services (such as health care) and the realities of
socioeconomic inequalities and cultural conflicts regarding
the interpretation of appropriate therapies and outcomes.
The more overt examples of this interaction include the
reserved attitudes of ethnic enclaves toward "mainstream"
medical care for certain conditions and complaints, but not
others (Clark, 1970). Patients unsatisfied with a given


106
Church (evangelical), God, and Jesus Christ. This
corresponds to the greater proportion of non-Catholics in
these two areas relative to Copacabana. There are a number
of Christian churches (large and small) that practice faith
healing in these areas. Some respondents related stories of
people they knew who had been cured of serious illnesses
(cancer, for example) in this fashion. A Mason (male, 78
years old), reported that he had just participated in a
faith healing (along with other members of his congregation)
of a seriously ill friend. The "treatment" required that he
fast and keep constant vigilance over the patient. Another
respondent, a 76 year old woman (Santa Cruz) discontinued
treatment for high blood pressure with cinnarizine
(prescribed by her physician at the time), because it made
her feel worse rather than better. She began to attend a
new church which practices faith healing (Casa de Bengo)
and reports that she no longer has any health problem.
Summary information on number of different physicians
used and frequency of physician visits is presented in Table
4.10. The average number of physicians consulted on a
regular basis for the aggregate sample is 1.54 (s.d.=1.14).
However, the average number of physicians that an elder
consults on a regular basis in each area varies
significantly (F=20.33, df=2, p<.0001), and the paired
comparison (Scheff) indicated that all areas were
signficiantly different from each other. The number of


78
inquiry, participants were asked to retrieve their medicine
containers, if available. Included in this analysis are
home remedies. This served to enhance the respondent's
recall and to assist the interviewer to correctly identify
the medicines.
Area
The sample was drawn from three socio-economic areas in
the Municipio (county) of Rio de Janeiro. The basis for the
selection of these areas and a description of their salient
characteristics are discussed in a following section on
sampling.
Instrument Development
Instrument development and interviewer training in this
cross-sectional survey were very much intertwined and are
best characterized as a single process. A participatory
approach afforded unique instrument development
opportunities and, in addition, allowed the interviewer to
apply an instrument with which s/he was intimately familiar.
This section will discuss the research procedures, the
survey instrument development, and interviewer training
employed in this study.
Item Selection
Studies of patient satisfaction with medical care
services (Ware and Snyder, 1975) and pharmacy services
(McKeigan and Larson, 1989) provided the basis for item
selection for the instrument in this study. Aspects of