Int J Clin Pharm (2013) 35:113120 DOI 10.

1007/s11096-012-9715-2

RESEARCH ARTICLE

Association between parental attitudes and self-medication of their children

Sanna Siponen Riitta Ahonen Vesa Kiviniemi meen-Anttila Katri Ha

Received: 12 June 2012 / Accepted: 8 October 2012 / Published online: 26 October 2012 Springer Science+Business Media Dordrecht 2012

Abstract Background The association between parental attitudes and medication administered to their children has been studied mainly regarding specic diseases and ailments, e.g. asthma, fever and pain. Little is known about how parental attitudes toward medicines in general are associated with how they medicate their children using selfmedication. Objective The aim of this study was to identify how parental attitudes toward medicines are associated with how they medicate their children with self-medication including the use of over-the-counter (OTC) medicines and complementary and alternative medicines (CAMs). Setting A cross-sectional population-based study was conducted in the spring of 2007. The study sample consisted of a random sample of Finnish children under 12 years of age (n = 6,000). Method A questionnaire was sent to parents, s and the parent who usually takes responsibility for the child medication was instructed to answer the questionnaire. Main outcome measure The responding parent was asked to report the childs use of OTC medicines and CAMs during the preceding 2 days. The parents attitude toward medicines was measured by 18 statements using a 5-item Likert scale. Results CAM use was least likely among children whose parent had a positive view of prescription medicines. In contrast, a positive attitude toward OTC medicines by a

parent was associated with both, OTC medicine and CAM use among children, whereas, parental worry about the risks of medicines predicted the use of CAMs among children. Conclusion This study showed that parental attitudes toward medicines have an impact on how they medicate their children, especially with CAMs. This nding highlights the fact that health care professionals should negotiate a childs treatment, taking into account parental views toward medicines, and previous use of self-medication. Keywords Children Complementary and alternative medicine (CAM) Finland Over-the-counter (OTC), medicine Parental attitudes Population-based survey

Impact of ndings on practice To ensure proper use of prescription medicines or selfmedication, consultation with parents about medicines should also cover the views of the parent concerning medication use in children. Since CAMs may be used in conjunction with conventional care, to avoid the risks of interactions, the use of CAMs among children should be discussed with parents when prescribing medicines or recommending self-medication. The boundary between CAMs and OTC medicine may be unclear to some parents, since CAMs may be sold in pharmacies, as well. This should be taken into account by health care professionals, especially in pharmacies. Consultation between health care professionals and parents should also include the safety of CAMs, since one of the predictive factors for CAM use among children was worry about the risks of medicines.

S. Siponen (&) R. Ahonen School of Pharmacy, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland e-mail: sanna.siponen@uef. meen-Anttila V. Kiviniemi K. Ha Finnish Medicines Agency Fimea, P.O. Box 55, 00301 Helsinki, Finland

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Introduction Self-medication is usually a rst course of action in mild or moderate conditions before contacting medical care [1, 2]. Over-the-counter (OTC) medicines are usually used for this purpose, but complementary and alternative medicines (CAMs) may also be used [38]. Complementary and alternative medicines (CAMs) are products that are not usually regarded as medicines, and may be used as supplements or alternatives to conventional care [9]. People hold various thoughts concerning medicine use. It has been shown that attitudes toward medicines have an important role in how an individual medicates him/herself [1012]. Those who are positively oriented toward medicines are usually more willing to follow their prescribed medication or use self-medication [10, 12]. On the other hand, concerns about the risks of medicines may be the reason for problems of adherence [13]. Concerns about the safety of medicines may also be the reason for using CAMs [4, 14], since they are often regarded as natural and safe [1517]. Parents are usually the main caregivers in their childrens medication management. Previous studies have shown that parental views and attitudes toward medicines inuence how they assess the need for medication for their children in different health conditions [1822]. For example, it has been shown that parents with a positive attitudes toward medicines are more willing to medicate their childs pain than are those who have negative thoughts [19, 23]. Parents with a positive view also give pain medication to their child at an earlier stage than do parents with negative views about medicines [19]. Earlier studies show that parents give CAMs to their child after they have tried conventional medicines without success [14, 24]. Sometimes they are used together with conventional medicines [16, 24]. In addition, CAMs are usually regarded as safe to use [1517]; the reason for CAM use may also be the opportunity to have more options in the health care of children and increase the likelihood that something would be helpful for the child [7, 17, 25]. Parental attitudes toward childrens medication have been studied quite widely. However, most of the studies have concerned management of specic ailments, such as asthma [2628], fever and pain [18, 19, 2123] or decisionmaking process in OTC medicines use [20], or they have described parental views toward medicines [2931] or CAMs [7, 17]. Little is known about how parental attitudes are associated with the self-medication of their children in general. This topic is important, since it has been shown that parental attitudes have an impact on management of childrens health conditions, and may lead to under medication or improper medication in the case of negative or incorrect views [23].

Aim of the study The aim of this study was to identify how parental attitudes toward medicines are associated with how they use self-medication, including OTC medicines and CAMs, for their children.

Method Data collection This study was part of a cross-sectional population survey, carried out in the spring (FebruaryApril) of 2007 by the University of Eastern Finland, School of Pharmacy. The survey was designed to measure childrens use of medicines and, thus, children under 12 -years -old were selected as the study population. Based on a previous study in Finland, a total of 6,000 children was calculated to be a sufcient study population [32] if a response rate of 70 % were achieved (n = 4,200). The children were randomly selected from the database of the Finnish National Register Centre, which covers all citizens permanently living in Finland. Children in institutional care were excluded. Data were collected by sending a questionnaire to a parent of each child (primarily the mother), but the parent who usually takes care of the childs medication, was instructed to answer the questionnaire. The questionnaire included the following sections: background of the child and parent, medicine use of the child and sources of information concerning the childs medication and parental attitude toward medicines. The questionnaire was available in Finnish and Swedish which are both ofcial languages in Finland. Two reminders were sent. The childs name was printed on the questionnaire to identify the child that was selected for the survey in families with two or more children. After the questionnaire was returned the childs name was removed from the questionnaire and a random number was given to ensure the anonymity of the respondent. The study setting and research process was in accordance with the guidelines by the Finnish National Advisory Board on Research Ethics (http://www. tenk./ENG/function.html). Data management and disposal of all personal data were conducted in accordance with national privacy protection laws. Main outcome measures In this article, term self-medication refers to OTC medicines and CAMs use by children. It should be noted that in most of the cases, the children were not self-medicating, but actually were medicated by their parent. Use of OTC medicines was measured by asking the parent to write down the names of medicines given to the child during the preceding 2 days, which were classied according

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115 Table 1 The ve principal components and the statements they include [31] Component Component 1: general attitude toward medicine Fever, a natural means of defence of the childs body, should not be lowered articially with medicines The child needs to learn how to bear pain I try to take care of my childs ailments by some other means than using medicines I try to avoid giving medicines to my child I usually give less analgesics to the child than recommended in the instructions Medicines can disturb the bodys own capability to heal illnesses Medicines are unnatural to the human body Component 2: attitude toward prescription medicines Prescription medicines are effective Prescription medicines are safe Medicines that a doctor has prescribed for the child are necessary Medicines are necessary in treating illnesses Component 3: attitude toward OTC medicines OTC medicines are effective I take care of my childs minor ailments by using OTC medicines Over-the-counter (OTC) medicines are safe Component 4: attitude toward the risks medicines Interactions between medicines worry me Side effects of childrens medicines worry me Component 5: attitude toward the long-term use of pain-killers Long-term use of analgesics reduces the pain threshold The more you need to use analgesics the less effective they are against pain

to the Anatomical Therapeutic Chemical (ATC) classication system. Use of CAMs during the preceding 2 days was also measured by asking the parent to write down the names of any medicinal herbs, botanicals or homeopathic remedies given to the child. The short recall period of 2 days was chosen based on a previous population-based study in Finland [33] to obtain comparable results and decrease recall bias, and, thus, increase the reliability of the results. The reported CAM products were further classied as sh oils, probiotics, homeopathics and other CAMs (including products for stomach function and a common cold, for example). Vitamins were excluded from the analysis, since the daily use of vitamin D is recommended for children in Finland, especially under 3 years of age [34]. According to our previous study [8], the use of vitamin D was in fact the most common vitamin children had used in the preceding 2 days. Parental attitudes toward medicines were measured by an 18-item list of statements concerning medicine use in general and giving medicines to a child. Parents were directed to answer the statements using a 5-item Likerts scale (1 = I disagree completely, 2 = I disagree, 3 = I dont agree or disagree/no opinion, 4 = I agree, 5 = I agree completely). A Principal Components Analysis with oblimin rotationdescribed elsewhere [31]was used to discover dimensions in parental attitudes. Based on the analysis, ve principal components were formed and named as follows: General attitude toward medicines, Attitude toward prescription medicines, Attitude toward OTC medicines, Attitude toward the risks of medicines and Attitude toward long-term use of pain killers (Table 1). The reliability of the Principal Component Analysis was satisfactory (Cronbachs alpha between 0.566 and 0.754). Scale scores were created by computing the averages of the original responses to the items in each scale, and they were afterwards categorized into three classes as follows. Scale score values 12.4 were dened as negative regard, 2.53.4 as neutral regard and 3.55 aspositive regard in terms of Attitude toward prescription medicines and Attitudes toward OTC medicines. For General attitude toward medicines, Attitude toward the risks of medicines and Attitude toward long-term use of pain killers, scale score values 12.4 were dened as positive regard, 2.53.4 as neutral regard, and 3.55 as negative regard. Consequently, positive regard actually indicates positive and negative regard indicates negative. Statistical analysis The Statistical Package for Social Sciences, version 17.0 (SPSS Inc., Chigaco, IL, USA) was used to analyse the data. For univariate analysis, cross-tabulation and Pearsons Chi-squaretest and univariate logistic regression analysis were used to analyse the association between parental attitudes and childrens OTC medicines and CAMs use. Multivariate logistic regression analysis was used to measure this association when adjusted for

other explanatory variables which are shown in Table 2. A p value of \0.05 was considered statistically signicant. The discriminating ability of the analyses was measured by receiver operating characteristic (ROC) curve analysis, which indicated that the discriminating ability was good for use of OTC medicines (area under the ROC curve (AUROC) value 0.75) and CAMs (AUROC- value 0.78). The Nagelkerke R-square values were 0.18 for use of OTC medicines and 0.23 for use of CAMs among children. Study description In total, 4,121 questionnaires were obtained. However, in 89 of the cases, the parent had lled in the questionnaire on behalf of a child other than the one selected for the study sample, and these were excluded from the study. Thus, the nal study sample was 4,032 with a response rate of 67 %. Of the parents, the mother was mainly the one who answered the questionnaire (in 95 % of the cases), and secondly the father (4 %). We have previously analysed the

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116 Table 2 Characteristics of the study population (n = 4,032) Characteristic Child Gender Boy Girl Age, years 02 36 711 Use of OTC medicines No Yes Use of CAMs No Yes Childs illness diagnosed by a physician No Yes Number of symptoms of a child 0 1 2B Childs health described by the parent Good Fairly good Moderate, fairly poor or poor Number of children in the family 1 2 3B Parent Prescribed medicine use by the parent No Yes OTC medicine use by the parent No Yes CAM use by the parent No Yes Parental age, years C30 3145 46B Education Junior high school or less (B9 years) Senior high school/vocational school (1113 years) Polytechnic, college, or university degree (C15 years) 252 (6.3) 2,456 (61.4) 1,291 (32.3) 862 (21.6) 2,866 (71.9) 256 (6.4) 3,206 (80.8) 761 (19.2) 2,853 (71.8) 1,118 (28.2) 2,409 (60.2) 1,591 (39.8) 673 (16.8) 1655 (41.3) 1679 (41.9) 1,353 (34.0) 1,298 (32.6) 1,334 (33.5) 3,249 (80.9) 631 (15.7) 135 (3.4) 3,268 (81.5) 741 (18.5) 3,506 (88.6) 452 (11.4) 3,287 (83.4) 655 (16.6) 1,004 (24.9) 1,287 (31.9) 1,741 (43.2) 2,106 (52.2) 1,926 (47.8) n (% of the responses) Table 2 continued Characteristic

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n (% of the responses)

Working status Working or studying Home with children Not working (including persons on sick leave, retired, or unemployed) Monthly net income of the household in euros B1999 20002999 30003999 400010,000 2,698 (67.3) 1,119 (27.9) 194 (4.8)

797 (20.7) 1,292 (33.5) 1,419 (36.8) 347 (9.0)

representativeness of the study sample [8]. That analysis showed that the study sample was representative of the target population in terms of age and gender. Furthermore, analysis of the non-respondents showed no differences compared with the target population in terms of age, sex or regional distribution. In total, 17 % of the children had used some OTC medicine during the preceding 2 days, and 11 % had used some CAM (Table 2) [8]. The most commonly used OTC medicines were analgesics, including non-steroidal antiinammatory drugs (7 % of children), mainly paracetamol, and the most commonly used CAMs were sh oils and fatty acids (6 %) and probiotics (4 %). Homeopathic remedies had been used by 1 % of the children. In Finland, OTC medicines are available only in pharmacies, while CAM products may be sold both in pharmacies and, for example, in grocery stores or health food shops. A more specic description of the use of OTC medicines and CAMs and of legislation concerning OTC medicines and CAMs has been given earlier [8].

Results The association between parental attitudes and self-medication of their children Two of the ve components were found to be related to use of OTC medicines among children and four of the components were associated with use of CAMs (Table 3). According to the univariate analyses, parents positive attitude toward medicines in general was found to predict use of OTC medicines among children, whereas, in the case of CAM use, this association was reversed (Table 3). Complementary and alternative medicines (CAM) use was also least likely among children whose parent had a positive view of prescription medicines. Attitude toward OTC medicines was

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117

Table 3 A cross-tabulation and an univariate logistic regression analysis of the association of parental attitudes with childrens use of OTC medicines and CAMs The use of OTC medicines by children n (%) General attitude toward medicine Negative regard Neutral regard Positive regard Attitude toward prescription medicines Negative regard Neutral regard Positive regard Attitude toward OTC medicines Negative regard Neutral regard Positive regard Attitude toward the risks medicines Negative regard Neutral regard Positive regard Attitude toward the long-term use of pain-killers Negative regard Neutral regard Positive regard p = 0.007 77/603 (12.8) 306/1,882 (16.3) 263/1,431 (18.4) p = 0.33 6/62 (9.7) 90/558 (16.1) 550/3,296 (16.7) p \ 0.001 59/431 (13.7) 221/1,545 (14.3) 365/1939 (18.8) p = 0.47 435/2,718 (16.0) 157/904 (17.4) 53/293 (18.1) p = 0.98 300/1,821 (16.5) 230/1,387 (16.6) 115/707 (16.3) 1.00 1.01 (0.841.22) 0.99 (0.781.25) 1.00 1.10 (0.901.35) 1.16 (0.851.59) 1.00 1.05 (0.771.43) 1.46 (1.091.97) 1.00 1.80 (0.754.29) 1.87 (0.804.36) 1.00 1.33 (1.011.74) 1.54 (1.172.02) OR (95 % CI) The use of CAMs by children n (%) p = 0.002 92/605 (15.2) 216/1,887 (11.4) 141/1,439 (9.8) p \ 0.001 24/62 (38.7) 91/561 (16.2) 334/3,308 (10.1) p = 0.03 33/433 (7.6) 180/1,550 (11.6) 236/1,947 (12.1) p \ 0.001 353/2,735 (12.9) 80/900 (8.9) 16/295 (5.4) p = 0.99 209/1,833 (11.4) 160/1,388 (11.5) 80/709 (11.3) 1.00 1.01 (0.811.26) 0.99 (0.751.30) 1.00 0.658 (0.510.85) 0.39 (0.230.65) 1.00 1.59 (1.082.35) 1.67 (1.142.45) 1.00 0.31 (0.180.54) 0.18 (0.110.30) 1.00 0.72 (0.550.94) 0.61 (0.460.80) OR (95 % CI)

signicantly associated with both OTC medicine and CAM use among children: OTC medicine and CAM use were both most common among children whose parents had positive thoughts about OTC medicines. Attitude toward the risks of medicines was signicantly associated only with CAM use among children, and parents who were worried about the risks of medicines had most commonly given CAMs to their children. In the multivariate analysis, only Attitude toward OTC medicines remained signicantly associated with the use of OTC medicines when adjusted for other variables (Table 4). In addition, three, not four, of the components were signicantly associated with the use of CAMs according to the multivariate analysis: Attitude toward prescription medicines, Attitude toward OTC medicines, and Attitude toward the risks of medicines. There were overall differences in the risks between categories of parental attitudes toward OTC medicines among children that had used some OTC medicine (Table 4). However, no specic differences between categories and in the use of OTC medicines among these children were found. Children, whose parent had a positive view toward prescription

medicines were less likely to use CAMs (OR = 0.24, 95 % CI 0.120.46) than children with parents having a negative regard toward prescription medicines. In contrast, children whose parents had a positive regard toward OTC medicines, were more likely to use CAMs (OR = 1.78, 95 % CI 1.162.72) than children with parents with a negative view of OTC medicines. Worry about the risks of medicines by the parent also predicted use of CAMs among children (OR = 0.43, 95 % CI 0.240.77 among children with a parent who had a positive regard toward the risks of medicines compared with those with a negative regard). According to the multivariate analysis, several explanatory factors were found to be associated with use of OTC medicines and CAMs among children. Factors that were found to predict use of OTC medicines among children were the young age of the child (OR = 0.66, 95 % CI 0.510.86 for 36-year-old children, OR = 0.48, 95 % CI 0.360.63 for 711-year-old children), the childs poorer health status reported by the parent (OR = 1.87, 95 % CI 1.472.37 for fairly good and OR = 2.53, 95 % CI 1.633.92 for moderate, fairly poor or poor health), the child having one or more symptoms (OR = 2.82, 95 % CI

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118 Table 4 A multivariate logistic regression analysis of an association of parental attitudes with childrens use of OTC medicines and CAMs adjusted with other variables The users of OTC medicines by childrena OR (95 %CI) General attitude toward medicine Negative regard Neutral regard Positive regard Attitude toward prescription medicines Negative regard Neutral regard Positive regard Attitude toward OTC medicines Negative regard Neutral regard Positive regard Attitude toward the risks medicines Negative regard Neutral regard Positive regard Attitude toward the longterm use of pain-killers Negative regard Neutral regard Positive regard
a

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more children). These explanatory factors seem to predict use of OTC medicines and CAMs more than attitudes toward medicines.

The users of CAMs by childrena OR (95 %CI) p = 0.86 1.00 0.92 (0.671.27) 0.96 (0.661.38) p \ 0.001 1.00 0.46 (0.230.92) 0.24 (0.120.46) p = 0.02 1.00 1.49 (0.972.30) 1.78 (1.162.72) p = 0.01 1.00 0.82 (0.611.10) 0.43 (0.240.77) p = 0.72 1.00 1.08 (0.831.39) 1.14 (0.821.58)

Discussion This study showed that parental attitudes have an association with how parents medicate their children, especially with CAMs. The nding that parental reservations toward medicines and the risks of medicines predicted use of CAMs among children support the earlier ndings [4, 14]. In addition, our study was in accordance with previous ndings on the association between parental attitudes and childrens pain medication [19, 23]. We also found that CAM use among children was more common if the parent had a positive attitude toward OTC medicines compared with those whose parents had a negative regard towards OTC medicines. This association was interesting, since CAMs are not regarded as medicines. One reason for this association may be that people may regard OTC medicines safer than prescription medicines, since they can be bought over-the-counter [35]. It is known that people regard CAMs as natural and safe [1517]. Responding parents may have also been positively oriented toward self-medication in general, since the difference between medicines and CAMs may be unclear to some consumers [36]. Our results showed that not only parental attitudes towards medicines explain the use of OTC medicines and CAMs among children, but also other factors have an impact on this association. We found that several of the childs health variables, such as the childs illness, the number of symptoms, and the childs age were associated with use of OTC medicines among children. The childs illness and/or the young age of the child have been found to be related to use of OTC medicines also according to previous studies [32, 33, 37, 38]. However, in our study, OTC medicine use was more common among children with no illnesses diagnosed by a physician, which may be due to the fact that children with a diagnosed illness mainly use prescription medicines in treating the current disease. In addition, childrens health conditions [6], and especially parental use of CAMs have been a strong predictor of a childrens CAM use also according to the literature, which was also shown in our study [4, 6, 14, 39, 40]. A point of interest in our results is that the attitude toward long-term use of pain medication was not associated with use of OTC medicines, even though analgesics were the OTC medicines most commonly given to the children in our study. This may be explained by the OTC medication possibly having been used only as a short course instead of regular use, which may not cause such worries about the

p = 0.19 1.00 1.23 (0.911.67) 1.36 (0.981.91) p = 0.10 1.00 2.68 (0.898.09) 3.03 (1.038.98) p = 0.04 1.00 1.00 (0.711.40) 1.28 (0.931.78) p = 0.61 1.00 1.03 (0.821.31) 1.20 (0.841.73) p = 0.76 1.00 1.03 (0.831.29) 0.93 (0.701.23)

adjusted for childs age, childs gender, childs illness diagnosed by a physician, number of symptoms of a child, childs health described by the parent, number of children in the family, prescribed medicine use by the parent, OTC medicine use by the parent, CAM use by the parent, parental age, parents highest level of education, households net income/month(), working status of a parent

2.103.83 for one symptom and OR = 6.54, 95 % CI 4.848.84 for two or more symptoms), and parental use of OTC medicines (OR = 1.27, 95 % CI 1.041.55). If the child had an illness diagnosed by a physician, use of OTC medicines was less likely (OR = 0.70, 95 % CI 0.540.90) than among children with no diseases diagnosed by a physician. On the other hand, parental use of CAMs (OR = 7.25, 95 % CI 5.759.13) and the child having one or more symptoms (OR = 1.33, 95 % CI 0.981.80 for one symptom, OR = 1.88, 95 % CI 1.392.55 for two or more symptoms) were associated with use of CAMs, respectively. If there were three or more children in the family, the use of CAMs was less likely than among children in families with one child (OR = 0.81, 95 % CI 0.591.11 for two children, OR = 0.62, 95 % CI 0.440.88 for three or

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119 2. World Health Organization (WHO) [internet]. The role of the pharmacist in self-care and self-medication. Report of the 4th WHO consultative group on the role of the pharmacist. Hague, The Neterlands, 2628 August, 1998. Department of Essencial Drugs and Other Medicines, World Health Organization. 2012. Available from: http://www.opas.org.br/medicamentos/site/Upload Arq/who-dap-98-13.pdf. 3. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 19901997. Results of a follow-up national survey. JAMA. 1998;280(18):156975. 4. Menniti-Ippolito F, Gargiulo L, Bologna E, Forcella E, Raschetti R. Use of unconventional medicine in Italy: a nation-wide survey. Eur J Clin Pharmacol. 2002;58:614. 5. Reinstein JA. Worldwide trend in self-medication. Dosis. 2005;21(2):8896. 6. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007 national health statistics reports; no 12. Hyattsville: National Center for Health Statistics; 2008. 7. OKeefe M, Coat S. Increasing health-care options: the perspectives of parents who use complementary and alternative medicines. J Paediatr Child Health. 2010;46(6):296300. meen-Anttila K, Sepponen K, Lindblad AK, Ahonen 8. Ylinen S, Ha R. The use of prescription medicines and self-medication among children- a population-based study in Finland. Pharmacoepidemiol Drug Saf. 2010;19(10):10008. 9. National Centre for Complementary and Alternative Medicine (NCCAM) [internet]. What is complementary and alternative medicine? c2011. 2012. Available from: http://nccam.nih.gov/ health/whatiscam/. 10. Isacson D, Bingefors K. Attitudes towards drugsa survey in the general population. Pharm World Sci. 2002;24(2):10410. 11. Dolovich L, Nair K, Sellors C, Lohfeld L, Lee A, Levine M. Do patients expectations inuence their use of medications? Can Fam Physician. 2008;54:38493. 12. Britten N. Patients ideas about medicines: a qualitative study in general practice population. Br J Gen Pract. 1994;44(387):4658. 13. Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm. 2009;66(7):65764. 14. Simpson N, Roman K. Complementary medicine use in children: extent and reasons. A population-based study. Br J Gen Pract. 2001;51:9146. 15. Lynch N, Berry D. Differences in perceived risks and benets of herbal, over-the-counter conventional, and prescribed conventional, medicines, and the implications of this for the safe and effective use of herbal products. Complement Ther Med. 2007;15:8491. 16. Huillet A, Erdie-Lalena C, Norvell D, Davis BE. Complementary and alternative medicine used by children in military pediatric clinics. J Altern Complement Med. 2011;17(6):5317. 17. Nichol J, Thompson EA, Shaw A. Beliefs, decision-making, and dialogue about complementary and alternative medicine (CAM) within families using CAM: a qualitative study. J Altern Complement Med. 2011;17(2):11725. 18. Finley GA, McGrath PJ, Forward SP, McNeill G, Fitzgerald P. Parents management of childrens pain followingminor surgery. Pain. 1996;64:837. 19. Forward SP, Brown TL, McGrath PJ. Mothers attitudes and behavior toward medicating childrens pain. Pain. 1996;67:46974. 20. Ecklund CR, Ross MC. Over-the-counter medication use in preschool children. J Pediatr Health Care. 2001;15:16872. inen-Julkunen KM, Pietila AMK, Kokki 21. Kankkunen PM, Vehvila H, Grey M, Kain ZN, et al. A tale of two countries: comparison of the perceptions of analgesics among nnish and American parents. Pain Manag Nurs. 2008;9(3):1139.

risks of OTC medicine use as does regular use. In addition, most of the parents were quite well-educated, and it has been shown in previous studies that parents with high level of education have a more positive attitude toward medicines and are more willing to administer medicines to their child [20, 29]. Such parents may also be more aware of treating childrens minor ailments with OTC medicines. The study population was a representative sample taken on the basis of children. Thus, this study is not a representative sample of all Finnish parents. Furthermore, most of the respondents were mothers, and thus, these results mainly describe the attitudes of mothers, not fathers. The strengths of this study are the short recall period of 2 days which decreases recall bias, and also that it provided information on how parental attitudes are associated with both OTC medicine and CAM use among children, which have been quite often investigated separately. However, the attitudinal statements used did not include statements concerning of CAM use among children in specic. Since this study measured self-medication among children in general, it raises an interesting topic for further studies: to investigate how parents perceive OTC medicine use compared with CAM use in specic symptoms of children.

Conclusion This study showed that parental attitudes toward medicines have an impact on how they medicate their children, especially with CAMs. Parents positive attitude toward OTC medicines on the one hand, and worries about the risks of medicines on the other, were found to predict use of CAMs among children. These ndings highlight the fact that health care professionals should negotiate a childs treatment, taking also into account parental views toward medicines and previous use of self-medication for their child.
Acknowledgments We want to thank research assistants Paula sa nen and Seija Pirhonen for their valuable help during the data Ra collection process. Funding No external funding was received for this study. All the costs were covered by the Department of Pharmacy, University of Eastern Finland. Conicts of interest The authors do not have any conicts of interests.

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