Contextual and individual aspects of use of medication : Mutilevel studies on anxiolytic-hypnotic drug use, social context, adherence to medication, and disability pension

Abstract: Aims Study I: to estimate an influence of the neighborhood on women's AHD (anxiolytichypnotic drug) use, and to analyze whether neighborhood social participation is associated with use of these medicines. Study II: to investigate whether women living in the same neighborhood have similar propensity for disability pension that relates to neighborhood social participation, and whether there is an association between AHD use and disability pension in women that is modified by the neighborhood context. Study III: to investigate whether the contextual component of the miniaturization of community concept is associated with AHD use, and whether people living in the same area share a similar probability of AHD use Study IV: to investigate whether age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary nonconcordance with medication (i.e., non-redemption of prescription), and whether people living in the same area have similar probability of primary nonconcordance with medication that relates to area social participation. Study V: to examine whether individual low social participation is associated with low adherence to antihypertensive medication, and whether this possible association is modified by the municipality of residence. Methods We used multilevel logistic regression analysis with individuals at the first level and areas (neighborhoods) at the second level. Both fixed effects (measures of association) and random effects (measures of variation) were investigated. In Study I (n=1 5 456) and Study II (n=12 156), we used data from The Malmö Diet and Cancer Study, Sweden. The women, aged 45-73 years, who participated in the cohort lived in Malmö during the baseline period 1991-1996. In Study III (n=20 319 women and 17 850 men) and Study IV (n=9 070 women and 6 795 men), we used data from the Life & Health year 2000 survey, a postal questionnaire sent out to a random sample aged 1879 years in central Sweden. In Study V (n = 1288), we used data from The Health Survey in Scania 2000, a postal questionnaire sent out to a random sample of people aged 18-80 years in Scania, Sweden. Results Study I: A small proportion of the differences in AHD use were explained by the neighborhood level. A low level of social participation in the neighborhood was associated with higher probability of AHD use, after adjustment for socioeconomic status. Study II: Both AHD use and neighborhood social participation were associated with higher propensity for disability pension, after adjustment for individual factors. The association between AHD use and disability pension was not modified by the neighborhood context. There was variation in disability pension between the neighborhoods. Study III: The contextual component of the miniaturization of community concept was associated with AHD use, after adjustment for socioeconomic status. The variation in AHD use between the areas was fairly small. Study IV: Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. Area social participation was, however, not related, and the variation in primary nonconcordance between the areas was small. Study V: Individual low social participation was associated with low adherence to antihypertensives, independently of educational level. The association between low social participation and low adherence to antihypertensives varied among municipalities in Scania. Conclusions In the Swedish setting, the social context seems to influence use of AHD and disability pension. However, administrative area boundaries seem to play a minor role in understanding AHD use, but matters more for disability pension. People with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence-as defined by administrative boundaries-seems to play a minor role for primary non-concordance. Also, individual low social participation seems to be associated with low adherence to antihypertensives, and this association may vary between different municipalities.