Les pouvoirs publics français, dans un souci de maîtrise des dépenses de santé, encouragent le recours à l’automédication de la population. Les comportements d’auto-soin, qui consistent à consommer de sa propre initiative un médicament sans consulter un médecin, placent ce dernier au cœur d’un antagonisme entre la volonté d’autonomie des usagers confrontée à celle d’encadrement des pouvoirs publics et l’obligent à se positionner face à des pratiques dont par essence il est exclu par le patient. Cette étude cherche à comprendre, par la méthode de contextualisation des discours, l’influence du milieu géographique dans les positionnements et comportements des praticiens vis à vis de l’automédication. Elle a été réalisée à partir d’entretiens semi-directifs, selon des grilles élaborées conjointement avec des sociologues, des médecins et des géographes, auprès de 30 médecins généralistes et 19 pharmaciens des agglomérations nazairienne et nantaise. Les résultats de ce travail suggèrent l’importance de la prise en compte des données territoriales entourant soignant et soigné dans l’analyse des comportements des professionnels de santé et dans de nouvelles perspectives d’approche du recours à l’automédication.
The French public authorities encourage the population to resort to self-medication to control health expenditure. Since risk may occur from this practice, general practitioners and pharmacists have been appointed to be the “guarantors” of a safe use for self-medication. Self-care behaviours, implying the consumption of medication without consultation, put the practitioner in an antagonistic situation between the patients’ will to be self-reliant in care use on the one hand, and the frame imposed by the public authorities on the other. This demands of the professionals that they adopt for themselves a position on such self-care practices in which they are excluded by the patient. This study aims at understanding the influence of the geographical environment on the professionals’ position and behaviour in relation to self-medication examined through the method of contextual speech. Semi-structured interviews have been conducted with 30 practitioners and 19 pharmacists from the Nantes and Saint-Nazaire areas based on questions defined by sociologists, doctors and geographers. The results of this study suggest that spatial data are salient to analyzing health professionals’ behaviour in relation to this concern of patient’s self-medication. The interviews aimed at determining the professionals’ perceptions with respect to the self-medication of their patients in terms of whether they have encouraged or on the contrary, attempted to prevent these behaviours through arguments in favour of the public policies promoting self-medication. The questions deal with the professionals’ career, the socio-economic characteristics of the patients and the motivations for their choice of place of work so as to link practices and behaviours with places. The simultaneous study of two different urban areas enables the analysis to distinguish the effects of context from geographical invariants. The main case study was Saint Nazaire with the case of Nantes used as a mirror to enable the identification of similarities or differences. Both case studies rely on a spatial analysis of data issued of the same program: the ANR Auto-med. The choice of Saint Nazaire as the main case study is based on two observations. First, the patients’ rate of self-medication declared in a survey conducted within the ANR Auto-med program appears to be lower in Saint Nazaire than that of the regional area. Secondly, an investigation of a panel of medical consultations on the frequency of self-medication mentioned by the doctor or the patient again indicates that the area of Saint Nazaire is below the average (tab.1). Local socio-economic conditions, culture and history influence the practices of the health professionals. The socio-economic status of the patients influences the attitude to them of the doctors, for example, in terms of their medical costs. The professionals located in the most deprived districts underline the inequalities in health generated by the de-listing of drugs known as “of comfort” from those whose costs will be reimbursed to the patient. In this context, the pharmacists seem to offer advice according to their customers’ supposed purchasing power. The health professionals located in a district concentrating a large number of poor workers express a certain concern with respect to the inequality of access to care. In this case, self-medication is an essential part of health-care behaviour because even if people provide a prescription, they are not necessarily reimbursed for certain kinds of drugs. The medical and social history of the Saint-Nazaire area has shaped the relations between patients and doctors such that a distinct community of professional practice has appeared in this area. This community is defined by a global approach towards the patient’s health, a broader concern with self-medication, and a significant emphasis given to listening and discussion during the consultations. Thus, the advice on drugs is simply part of the global relations between the patient and the GP or the pharmacist whereas in the mirror area of Nantes, this advice is delivered more as a recommendation of good practice from the “expert” to the non-expert. Interviews with pharmacists in Nantes suggest that self-medication offers a therapeutic alternative in response to a lack of listening that is prevalent among the doctors of the area. The doctors are influenced in their practices by perceived local beliefs about health. If the doctors are also native to their place of work and have always been embedded in such sets of beliefs, they are more tolerant than their fellow-doctors towards these beliefs and indeed will sometimes accept being guided by their patients when writing the prescription (although sometimes they may just add a placebo to seem to concur with the patient). The patients’ resort to self-medication is neither perceived nor accompanied in a homogeneous way from one city to another or from one district to another. In the area of Saint Nazaire, medical and social interventions have been anchored for a long time in a political and social tradition of solidarity, networking and proximity with a population weakened by the roughness and the liability of working conditions. Consequently, this situation strengthens even further the relationship between doctor and patient having thus a strong influence on self-medication. These results suggest the importance of taking into account the territorial context in the analysis of the health professionals’ behaviours opening new opportunities for studying self-medication.
