Effect of "Time Famine" on Women's Self-Care and Household Health Care.
By Nancy Vuckovic, PhD

The experience of "time famine" in contemporary American culture affects women's decisions about self-care and their use of pharmaceutical agents for self-medication. This paper examines the manner in which time demands shape women's interpretations of medicine efficacy and drive increases in medication use for themselves as well as for their children. Like other timesaving commodities, medicines appear to shift the time-power differential in favor of individuals, placing them in control of how time is spent. When there is "no time to be sick," allopathic medicines become timesaving devices that enable women to fulfill responsibilities at work or at home while attending to sick children or while being ill themselves. Medicines are used to "beat the clock" by increasing women's capacity to be productive.

Introduction
Lack of time is a plague of industrialized, prosperous societies. It manifests as the acceleration of activities in all facets of life^1-4 and as a reorientation of time sense that places ever-increasing emphasis on the present and on the short-term future.^4-6 This chronic shortage of time, which I refer to as "time famine," is endemic in the contemporary United States. Americans are acutely aware of time pressures in their lives and have become preoccupied with time, its passage, and the lack of it.^7-10

Time as a Scarce Resource
In the United States, economic well-being and social status are linked to temporal notions of speed. Americans have long been characterized as a restless, hurried people driven toward achieving ever-increasing efficiency and progress.¹¹

By enabling people to engage in a wider range of activities, modern technology accelerates the pace at which people live. In turn, this more hectic pace acts as a catalyst for social changes that encourage Americans to believe that they should be engaged in productive activity every moment of the day. The vicious cycle is thus completed: The efficiency enabled by new products places new and greater pressure on consumers to become more efficient. Access to high-speed computers, e-mail, and fax machines means that lack of productivity can no longer be blamed on slow equipment or on the postal service. Pagers and cellular phones allow individuals to be contacted almost anywhere at any time, and fax machines and electronic mail discourages people from claiming that they "didn't get the message in time." Even for employees who do not have as much flexibility in how or where they do their work, changes in the marketplace have increased the demand for overtime labor; consequently, work time is increasingly being extended into personal time.^7,10

Time Famine
Time famine adversely affects quality of life not only by reducing leisure time but also by attacking physical health. By increasing the level of "stress" in people's daily lives, scarcity of time has been implicated as a causal agent in acute and chronic illnesses, including gastric ulcers, headache, and even cancer.^1,12-14 Studies of household health indicate that time shortage may negatively affect health when preventive health behaviors, such as adequate rest or proper nutrition and sanitation, are foregone.^15-19

Less has been written about the ways in which time pressure or time allocation affects household response to illness. This paper examines how time famine in contemporary United States culture affects women's decisions about self-care and about use of pharmaceutical agents for self-medication. In this respect, by altering the timing of professional care and the magnitude of self-treatment, time famine directly affects the frequency and severity of symptoms that ultimately prompt women to visit their physicians.

Qualitative Research Methodology
Forty households residing in and near a midsized city in the southwestern United States (Table 1) were studied for 18 months to observe actions and interactions of family members, who were formally and informally interviewed about their beliefs and practices concerning use of medications and to ascertain the families' domestic response to illness. Questionnaires, self-care diaries, and medicine inventories were also used to learn about household self-medication practices in each participating household.²⁰ The University of Arizona Institutional Review Board approved the project, and informed consent was obtained from all participants.

All interviews were audiotaped and transcribed for analysis. Codes were inserted into the transcript by The Ethnograph text-analysis software program (Scolari/Sage, Thousand Oaks, California) to identify responses to specific questions and to flag themes that emerged from analysis of multiple responses. Segments of text coded for a given topic were reviewed to identify response patterns. Assumptions drawn from this process were tested in consultation with a group of colleagues who read a sample of the transcripts. Participants were assigned pseudonyms for this report.

Qualitative methods (eg, in-depth interviews) allowed participants to describe beliefs and experiences in their own words and to make associations they felt were relevant as they described events and experiences. Because qualitative methods effectively elicit the participant's perspective, these methods are particularly useful for defining the range and variability of beliefs, behaviors, and experiences of study populations as well as the natural language people use to discuss these issues.

Although this type of in-depth ethnographic research is generally incompatible with large sample sizes, it offers richness of information that cannot usually be obtained by more superficial inquiries, whether qualitative or quantitative. Extended study "in the field" enables researchers to gather data by various means and to corroborate findings by comparing data from multiple on-site sources. In addition, when data are collected through repeated contacts over time, participants also may feel less need to "impress the researcher" and may thus offer information that more accurately reflects reality.

To learn about households' health care behavior, this inquiry primarily observed women in recognition
of their role as primary agents in the household production of health and as principal providers of domestic health care.^21-24 Research in the United States indicates that despite changes in gender roles related to wage and domestic labor, women are still the primary decision-makers regarding purchase and administration of medicine and are usually the adults responsible for the care of sick children.^7,25 The women studied were all mothers of young children and had an acute sense of time famine. Making arrangements to meet with these informants opened my eyes to the importance of time and timing in American culture. I had to be prompt, andat least initiallymy visits needed to be scheduled and to the point. Even after I established relationships with these women, dropping in for visits or spending time together beyond the interview was problematic because of their work and family schedules. I soon became aware that time pressures also played a salient role in their self-medication decisions. Having "no time to be sick" emerged as an issue early in my research on pharmaceutical practice in US households and remained an issue of repeated discussion for the subsequent months of field work.

This paper describes the lives and reports words of women who were my principal informants in this study of self-medication practices. Nonetheless, evidence suggests that the experiences of the women in this study are representative of more pervasive time famine that also affects male parents as well as persons of either gender who do not have children.⁷

Results
Impatience with Illness
An outcome of the American cultural ideal of progress and productivity is impatience with illness^26,27not merely reluctance to be uncomfortable, but a practical need to keep the household and workplace running that fuels this expectation of productivity. Multiple responsibilitiesjobs, child care, home management, and social commitmentsallow women little time to "give in" to illness.^19,28 The women in the present study measured their own productivity by activity in their household as well as in their workplace. Summarizing the feelings of other women, Gloria said: "I don't enjoy being sick. I don't like it slowing me down. It takes a lot to keep me home from work. Because of guilt. I don't ever want to be in a situation where I'm wondering 'Well, I can be at work. I know I could.' I want to know that when I'm in bed, I really belong there. And that no one can question that and that I'm not questioning it. You know I'll go to work until I really can't. Until it becomes just physically insane to be there."

Another woman, Karen, explained her situation with a laughand with a phrase I often heard during my conversations with her and other women: "I don't have time to be sicknot with three kids!" She continued: "No, I don't do much of that [ie, being sick]. There's always something to be done. There is. If I'm really feeling bad, I'll go to bed early. But it's a rare day that I would actually sit down and do nothing."

Primary Care Physician Commentary: Women's Health Choices Today's American women are frequently caught between competing priorities of home, family care, and the workplace, leaving little time for personal needsespecially when illness strikes, as this article illustrates. By direct linkage of "time famine" and women's health choices, Nancy Vuckovic leaves open many implications for health care. Women tend to postpone their own health care and are prone to burnout in caring for chronically ill family members. As clinicians, we may be able to positively affect the whole family unit by seizing the opportunity to speak to these caregivers as they accompany ill family to clinic and by encouraging them to attend to needs for personal time and health care. This article can help us to be more understanding when confronted with expectations for quick fixes such as inappropriate antibiotics so we can address the whole problem. We should consider whether our clinical behavior ameliorates time famine or reinforces women's sense of the "clock as enemy" by our prescribing practices, compressed appointment schedules, and long waiting room times. One can speculate whether much use of alcohol, tobacco, and even caffeine is also a manifestation of time famine as women fortify themselves for what can feel like a treadmill into a dark tunnel. – Donna Strain, MD Internal Medicine, NWP

Women who have jobs outside the home often feel that they cannot afford to take time off from work when they are sick because time off for illness means lost incomeand sometimes jeopardizes job security. If a woman takes time off for her own illness, less sick leave remains available for when her children are sick and need to be cared for at home. As a result of these pressures, women continue to go to work unless their symptoms are debilitating.

Maureen's story is one example of such behavior. She told me, "If I call in sick to work, man I'm sick! I'm really sickand I've only ever called in, well, when I had that food poisoning. I thought I was going to die. And then, yeah, I called in sick."

Increased Use of Medications
When women "have no time to be sick," medicines provide a way to keep them going. As Teresa said, "If I have a headache, I'll go get a Tylenol because I got to keep going. I've got to fix dinner and clean the house and take care of the kids and do laundry. I don't have time to sit on the couch and go, 'Oh, I really feel bad.'"

Response to illness becomes more aggressive when time demands create pressures to keep going. Women reach for medicinal solutions to alleviate symptoms quickly and to prevent them from becoming worse. This practice results in increased medicine use over all, even among women who voice a preference to avoid medicines as much as possible.²⁰ Claire explained: "I don't think I got sick less often [before I had children], but when I got sick, I got really sick. Because I would probably not treat it. And now I know I can't afford that. There are three other people depending on me in my house, plus my job. It affects my household, my husband, my children. Just more responsibility. So I treat my symptoms sooner."

Women acknowledged that they relied more on medical solutions to treat symptoms when time commitments prohibited rest or relaxation. Penny talked about consciously assessing her day before deciding whether to take a pain reliever or allergy medicine. She explained that on a work day, she might reason that "I've got a lot of stuff to do" and consequently take medicine to relieve symptoms quickly. Other informants described a similar thought process. Gloria said: "If it was a weekend and I was feeling bad and I knew I was just going to be able to just basically hang around and maybe cook a few meals and what not, I'm less apt to take something than if I've got to be at work and be on top of it, you know. That's when I'll start taking the Dristan or, you know, carry the Pepto-Bismol with me if my stomach's a little upset. Yeah, [I] definitely [take] more [medications] when I'm working."

Other researchers have noted a higher incidence of medicine use among women than among men²⁹ but often look for answers in different morbidity rates between genders³⁰ or in gender difference in perception of illness.³¹ Such reports indicate that women may be more aware of bodily symptoms because they generally have more experience with hormonal changes (in addition to the extensive changes they experience during pregnancy) and that women therefore may identify symptoms and signs of health problems before men do.³² However, the present study suggests that feeling a lack of time to be ill leads women to downplay their illnesses and to "keep going" despite having minorand sometimes majorphysical symptoms. The study shows that this tendency to downplay illness does not reduce women's consumption of medicine and in fact may increase it.

Primary Care Physician Commentary: A Lure and a Snare Expansion of workplace opportunities for women since World War II has proved a lure and a snare. Alhough attracted to the promise of satisfying jobs and of gaining parity with men in professional status and income, women with occupations have mostly retained their traditional domestic roles. They go to work but remain caregivers and what some call "CEOs of the home." Particularly when households become dependent on double incomes, women can be trapped by economics. Finding sufficient time to run a household and to be a mother and spouse can seem impossible even without the additional role in the workplace. In this article, Nancy Vuckovic introduces her concept of "time famine" and ties together two elements of contemporary culture: time pressure and pill-taking. From interviews with women done in the course of preparing a doctoral dissertation, she finds evidence that one effect of time pressure is increased use of medicines. Her subjects attribute this to attempts to save time three ways: 1) avoid time-consuming office visits; 2) shorten the course of illness; and 3) treat symptoms that threaten to interfere with performance of job or household activities. Moreover, use of medicine in children is described as a way to keep them in daycare when they might otherwise be home with a parent forced to miss work. Vuckovic's discovery that many women feel hounded by demands for their time is familiar to those of us practicing primary care. Among our patients are many whose disease seems broadly related to time-pressure, loss of personal time, and work/home life imbalance, or whose dedication to work leads to neglect of personal health. Clinicians of both genders contend with similar time pressures in our own lives. Vuckovic's article helps us complete our picture of the dilemma by describing medicine use among women who generally seek to avoid office treatment. Readers will gain empathy for these women. The bibliography contains references that contribute more fully to understanding the impact of time pressure in contemporary culture. What are some ways this article can help us in Permanente practice? Explain the motivation for some medicine-seeking behavior Remind us that loss of time constitutes a significant burden of illness Lead us to directly address time pressure and time management with patients Encourage us to streamline our processes to reduce the time members invest in obtaining medical care – Arthur D. Hayward, MD Internal Medicine, NWP

Entitlement to Health Care
Anthropological studies of entitlement to health care show that women often forego medical care for themselves when scarce household resources are allocated preferentially to the care of children or male wage earners.^19,33 These findings hold true for the women in this study, for whom time as well as money can be in short supply.

For example, when Claire's husband and children suffered from a round of intestinal "flu" during the winter, they stayed at home to recuperate. Claire therefore stayed home to care for them, missing two days of work. Later, when Claire herself had the upset stomach and diarrhea which had caused her other family members to stay home, she took two doses of an antidiarrheal agent and went to work. She explained, "I just didn't want to miss any more work." By saying that they "do not have time" to be ill, women not only forfeit medical care but also relinquish the sick role³⁴ as a legitimate way to refrain from productive labor.

No Time for Professional Care
When their ability to meet responsibilities became threatened by physical symptoms, women quickly responded to these symptoms by taking medicines that can relieve symptomsor, at least, that can mask them. However, the demands of their lives sometimes caused women to postpone curative therapy, such a seeing a doctor, until the illness became severe. One woman explained that she postponed treatment of her urinary tract infection because "I was so busy taking care of the family that I couldn't allow myself to be sick."

The motivations for choosing self-medication in preference to seeing a health care practitioner are complex and may include lack of money, conflicting medical ideology, negative experiences, or fear.²⁰ Another important factor driving women's decisions to avoid clinic visits for themselves is unwillingness to invest the time necessary to obtain professional care.³⁵ Although willing to take their children to the doctor when necessary, women are reluctant to go to the doctor themselves because "it's just too time-consuming." Often this time is not willingly spent, especially when other options are available to alleviate symptoms. Thus, self-medication is popular in part because it is less time-consuming than professional care. A multitude of medicines are available from stores that are nearer to home than the doctor's office and that are open at all hours. Many women feel that if their self-medication efforts solve a medical problem and thereby avoid a visit to the doctor, then the relatively small time and money invested are worthwhile.

Time Regulation and Children's Illness

When conflicts arose between the need to care for a sick child and the need to go to work, some women medicated their children to make them comfortable and to mask symptoms so that the children could continue to attend school or daycare. Claire explained the decision-making process she used when one of her children became ill during the workweek:

"I'm responsible for what I do at my work, and I like
what I do, and if they [ie, my children] are sick and I feel like I have to be away from work, I feel guilty about leaving my work there for other people to do....So, if they [ie, the children] wake up with a temp[erature], I give them some Tylenol and then we go to school and we pray that the temperature doesn't go up during the day and that they don't call me."

Daycare workers confirmed that parents commonly use medicines to mask symptoms such as cough or high fever in an attempt to keep the child in attendance. High rates of disease prevalence in some daycare facilities may be due in part to this practice.^36-38

Parental aggressiveness in treating children's illness with medications may vary by day of the week. For example, if the child becomes ill on Wednesday, his or her parents may try to keep the child in daycare or school until the weekend by using medications that mask the symptoms. Over the weekend, medication use may be reduced in response to the increased time available for rest and home care. If both strategies fail to produce a cure by Monday, a doctor's visit may be scheduled.²⁴

Expectations that Medications Must Act Quickly
Their quickened pace of life causes Americans to favor commodities (people as well as products) that respond quickly to the demands of a given situation and that work efficiently to optimize productivity. A mentality of time famine alters expectations such that punctuality and the ability to "get to the point" become valued traits not only of employees, but also of family, friends, and even inanimate products. The same reasoning that leads people to expect punctuality from people leads them to expect promptness from medicines. When applied to medications, expectations of punctuality and quick access manifest as demand for rapid transformation from illness to health. If "instant gratification" (ie, fast relief) is not forthcoming, individuals may consume greater amounts and varieties of medications.

For example, Lydia routinely doubled the dosage of ibuprofen that she took for headaches. She said, "If it says one tablet, I take two ... I want pain relief immediately." Other women also reported that they became impatient when medicines failed to achieve a desired effect after a short time. Mercy said, "I should feel better in about ten minutes. And if not, I'll just take more."

Fast-acting medicines and those which treat several symptoms in a single dose are valued for their efficiency. Product efficiency was the reason Mercy gave: "I like the Contact best. It takes care of about 50,000 symptoms." Multisymptom drugs are an encapsulation of Linder's simultaneous consumption, ie, consumption of more than one product simultaneously in an effort to achieve maximum use of time.¹ In this way, multisymptom medications represent a single product opportunity to engage in polypharmacy. Preparations that treat a variety of symptoms are valued for their ability to adapt to the situation at hand because they can be used at one time for one illness and at another time to treat a different illness. Multisymptom products promote time efficiency by eliminating the need to buy specific medicines each time a family member gets sick.

Sleeping Efficiently
The side effects of allergy and cold medicines containing antihistamines can be both undesired and desired. When productivity is important, the sleepiness these medicines produce is experienced as a negative side effect. The same sleep-enhancing quality becomes a positive side effect at night, when sleep is desirable. Because sleep is viewed as a time when the body rejuvenates and heals itself, women in the study expressed their belief that sleeping well could help a person overcome illness more quickly. On occasion, the sleep-inducing effect of cold and allergy medicines was so desired that women took products with antihistamines even when they did not have symptoms that generally indicate use of these products. Women recognized that they could regulate side effects through deliberate choice of particular medicines at particular times of the day. Teresa said, "When I go to bed is when I usually notice my back has hurt all day ... It's real tight, and it's hard to relax to get it to stop hurting. And everybody else is snoring and you're just like, 'I've go to get to sleep or I won't be able to function tomorrow.' I'll get up and pop a couple of Tylenol."

Efficiency and the need to be productive at all times has been extended to the most leisurely of leisure times: sleep. A daytime filled with efficient productivity leads to the expectation that sleep must also come efficiently. This "colonization" of sleep time as productive time leads Americans to medically overcome the insomnia which threatens to make their nights unproductive.¹ People resort to drugs in order to avoid losing time because of an uncooperative body.

Medicines as Timesaving Devices
Products and services designed to save time and improve time management dominate the market and captivate the minds and wallets of Americans.³⁹ These commodities of efficiencyranging from microwave ovens to drive-through pharmacies, day planners to disposable diapersall share one attribute: By buying them, consumers hope to also buy time. Commodities offer consumers the illusion of buying time, not only because the products permit users to do things faster but also because these products enable individuals to do several tasks at the same timea phenomenon described as "multitasking." In this way, equipped with car phone and fax machine, an executive can begin the workday while driving to her office. A parent at home can wash clothes and cook dinner while helping her child download information from a local library.

Medicines possess such time-management attributes in that they enable consumers to increase their productive time by eliminating the "downtime" caused by illness, behavioral difficulties, or "bothersome" biological functions. Certain products, such as "non-drowsy" formulations of medicines, allow a person to treat symptoms and still care for children or function on the job. In yet another way, products formulated to care for multiple symptoms promise to simultaneously accomplish more than one task by treating several symptoms at once. Medicines have become commodities that make consumers more efficient; and in doing so, medicines have joined the ranks of other time-management products.

Women's participation in the labor force often results in increased medicine use, both by women and by their children.⁷ Increased demands on women's time cause them to treat illness sooner or to take medications for symptoms that she might not otherwise treat. Similarly, the need to get to work prompts women to medicate their children's symptoms more aggressively so that the children can remain in daycare or school. Limits on maternal time also lead mothers to rely on medicines in lieu of spending time comforting a sick child. Taking time off work because of a child's illness is often frowned upon by employers, and this disapproval threatens women's job security and ultimately the welfare of their families. In this kind of environment, it is financial necessitynot lack of concern for childrenthat motivates aggressive use of medicines.

Implications for Clinical Practice
In addition to creating and exacerbating illness, time-induced stress drives impatience with symptoms and desire for fast-acting treatment. The need for quick relief prompts greater and more frequent use of medicine and thus raises the risk of overmedication, adverse drug reactions, and a tendency for people to self-medicate for nonpathological conditions. Lowered tolerance for discomfort can also lead people to rely on medications instead of seeking longer-term, behaviorally oriented strategies. Use of vitamins, laxatives, and antacids to counteract poor eating habits is one example of this strategy.

The self-care practices described in this paper may affect the timing of professional care as well as the stage at which patients are initially seen for their illness. As described above, patients may view self-medication as more expedient than seeking professional care. This behavior may be appropriate for self-limiting illnesses but can be harmful when applied to more serious conditions. Further, these self-medication strategies can mask symptoms and thus complicate diagnosis when patients finally seek medical care.

Because use of over-the-counter (OTC) medications for symptomatic relief is so common, patients may not remember whether they used some products or may not consider them to be "medication." Health care professionals must therefore query patients about their use of specific drugs so that patients report their medication use as accurately as possible. In addition, some patients are reluctant to report their self-care activities, because they fear being ridiculed or chastised for taking inappropriate action. A nonjudgmental approach to asking questions about medication use may help alleviate these patients' concerns.

A final consideration for clinical practice: Desire for fast relief may prompt some patients to ask for particular pharmaceuticals even when use of that medication is clinically inappropriate. More than one participant in the present study told me about having demanded antibiotics to speed relief from a cold.

Conclusion
In our current cultural environment, use of medicine becomes one way to make the best of what is perceived to be the unchangeable, taken-for-granted phenomenon of time famine. When women have "no time to be sick," medications act as time-saving devices that enable women to fulfill responsibilities at work or at home while attending to sick children or while being ill themselves. Over-the-counter and prescription drugs are used to "beat the clock" by
increasing a person's capacity to be productive. Like other timesaving commodities, consumers find medications appealing because they seem to shift the time-power differential in favor of individuals, placing them in control of how time is spent.

A related version of this article was published as: Vuckovic N. Fast relief: buying time with medications. Med Anthropol Q 1999;13(1):51-68.

Acknowledgments: I would like to thank Louise Williams, PhD, for her enthusiasm, encouragement, and generous editorial contributions to the revision of this manuscript.

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