PHARMACEUTICAL CARE 1GENERAL PRINCIPLES OF HEALTH CARE

Pharmaceutical Care: Is the component of pharmacy practice with

entails the direct interaction of pharmacist with the patient for the purpose of caring for that patient’s drug related needs

Objectives of Pharmaceutical Care: Cure of a disease Elimination or reduction of a patient’s

symptomatology Slowing or arresting of a disease process Preventing a disease/symptomatology

Many people spend their HEALTH to gain WEALTH, and later on, spend all their WEALTH in a

desperate effort to regain HEALTH”

HEALTH BACKGROUND Sickness has been one of man’s greatest

adversaries In the past 100 years

► Medicine has developed weapons to fight disease effectively

► Drugs► Vaccines► Surgical procedures► Instruments ► Sanitation and nutrition

To identify or diagnose a specific disease or injury► Physicians, pharmacists, and other ► health care professionals utilize clues► Requires scientific knowledge and ► technical skills► Apply these abilities in innovative ways

MEDICINE Latin word “medicus”-physician Science and art of diagnosing, treating and

preventing disease and injury It is a healing art Aims to help people become more active and live

longer and happier lives with less suffering and disability

Constant search ► New drugs► Effective treatments ► More advanced technology

Health care professionals can prevent, control or cure hundreds of diseases

Has become a part of the health care industry One of the largest industries in the world One of the leading employers in most

communitiesAt the turn of the 20th century (1900) Men and women were frail by age 40 Life expectancy was 47.3 years Effective treatment for diseases were so scarceBy the end of the 20th century Medical advances Life expectancy increased to 76 yearsToday People in their 80s and 90s are independent and

physically active Medical expansion has been expensive

HISTORY OF HEALTH CARE Prehistoric medical practice

► Study of ancient pictographs that show medical procedures and surgical tools uncovered from anthropological sites of ancient societies

► Serious diseases were of primary interest to early humans but they were not able to treat them effectively

► Diseases were attributed to the influence of malevolent demons

► Diseases were believed to project an alien spirit, a stone, or a worm into the body of the unsuspecting patient

► Diseases were warded off by incantations, dancing, magic charms and talismans, and various other measures

► Make the body uninhabitable to the demon by beating, torturing and starving the patient

Trepanning► Alien spirits are expelled by potions that

caused violent vomiting, or could be driven out through a hole cut in the skull

► Remedy for insanity, epilepsy and headache

Surgical procedures practiced in ancient societies

► Cleaning and treating wounds by cautery (burning or searing tissue), poultices, and sutures

► Resetting dislocations and fractures, and using splints to support or immobilize broken bones

Additional therapy included laxatives and enemas to treat constipation and their gastrointestinal diseases

Discovery of the narcotic and stimulating properties of certain plant extracts

► Many are still of use today Digitalis, a heart stimulant

extracted from foxglove Systems of medicine, based on magic, folk

remedies, and elementary surgery, existed before the coming of the more advanced Greek medicine about the 6th century B.C.

HEALTH CARE PROFESSIONALS 11.6 million people work in health care in

other countries 778,000 physicians, 2.1 M nurses and

160,000 dentists Work in health care services, involved in the

diagnosis and treatment of patients Research, teaching or administration of

medical facilities

PHARMACIST Has a unique body of knowledge and skills to

contribute in our health care system Dispenses the appropriate drug product and

has the knowledge to assure safe and rational use of drugs

EARLY FUNCTIONS OF A PHARMACIST1. Assisting in the selection of appropriate drug

therapy2. Preparing, compounding and manufacturing

drugs for individualized patients3. Dispensing and packaging the prescribed drug

products including proper labeling4. Advising and educating patients on proper use of

drugs 5. Monitoring the outcome and responses of

patients to the effect of drugs, both beneficial and adverse

6. Serving as a community resource person on drug and health information

THE TEN STAR PHARMACISTS Pharmaceutical Care Giver Researcher Manager Communicator Leader Life-long learner Decision-maker Entrepreneur Teacher Agent of Positive Change

CONCERNS AMONG HEALTH CARE PROVIDERS Potential abuse, misuse and inappropriate

use of drugs Increase in health care cost Patient suffering

THE PATIENT-ORIENTED PROFESSIONAL Able to apply and provide drug knowledge to

improve drug use in the health care system

Pharmacy colleges responded by providing clinical training for the undergraduates

► Clinically and patient–oriented, better prepared to dispense drug knowledge and drug products

PRIMARY AIM To attain success in the goals for therapy,

pharmacist must approach the patient–counseling an encounter as a HELPER and an EDUCATOR

THE TRADITIONAL PHARMACIST Involved in the preparation and dispensing of

medications At the direction of the physician Strongly allied with the medical profession View that the health professional should be in

control of the patient

Pharmaceutical care must be the organizing force for the profession of pharmacy

THE MODEL Shift in the model of pharmacy From focus on the medication to a focus on

the patient Need for a shift in the pharmacist’s approach From the health professional–centered

MEDICAL MODEL to the patient–centered HELPING MODEL

MEDICAL MODEL HELPING MODELPatient is passiveTrust is based on expertise and the authority of

pharmacist Pharmacist identifies problem and determine solutions Patient is dependent on pharmacist Parent–child relationship

Patient is actively involved

Trust is based on personal

relationship developed over time Pharmacist assist patients

in exposing problem and possible solution Patient develops self-

confidence to manage problems Equal relationship

PQL Patient Quality of Life Welfare of humanity and the relief of human

suffering is the primary concern Must learn to view medication’s use from the

patient’s perspective

AN OATH“I will use knowledge and skills to the best of my ability in

serving the public and other health professionals”

DELINEATION“Health is a state of complete physical, mental, and social well-being and not just the absence of disease or infirmity”

-World Health Organization (WHO)

HEALTH A goal to strive for It is not obtainable No one ever achieves a “state of complete

mental, physical and social well being”CURE

► Latin word “cura”► CARE

CARE ► Providing for the welfare of another► Attentive conscientiousness of devotion► Conveys a compassionate state of being and not

merely an attitude► Involves a profound respect for the “otherness” of

the other

THERAPEUTIC RELATIONSHIP Built on dialogue and commitment Alliance between a practitioner and a patient

Formed to meet a patient’s health care needs

CHARACTERISTICS OF A CARING BEHAVIOR: VITAL COMPONENTS OF A THERAPEUTIC RELATIONSHIP

Mutual respect Honesty/Authenticity Open communication Cooperation Collaboration between patient and practitioner Empathy Sensitivity Promotion of patient independence Seeing the patient as a person Exercising patience and understanding Trust Competence Putting the patient first Offering reassurance Confidence Paying attention to the patient’s physical and

emotional comfort Supporting the patient Offering advocacy Assuming responsibility for intervention Being willing to be held accountable for all

decisions made and recommendations given

HEALTH CARE NEEDS OF A PATIENTMedical CareMental Health CareDental CareNursing Care Surgical Care Nutritional CareMaternal Care

I careGeriatric CarePharmaceutical CareChiro-practice CarePediatric CareEye Care

PRIMARY CARE “Front–line” or “first contact” care Person–centered Not disease or organ system centered Comprehensive in scope Not limited to illness episodes or by organ

systems or disease process involvedINTERACTIONS

With patients and other health care providers► COUNSEL► CONSULT► EDUCATION

4 R’s OF THE PHILOSOPHY OF PRACTICEI. RulesII. RolesIII. RelationshipIV. Responsibilities

PHARMACEUTICAL CAREA responsible provision of therapy for the purpose

of achieving definite outcomes that improve the patient’s quality of life

- Hepler and Strand

PHARMACEUTICAL CARE “PHARMACIST CARE” A practice in which the practitioner takes

responsibility for a patient’s drug–related needs, and is held accountable for this commitment

Applying knowledge to promote well-being of others

Requires responsiveness, sensitivity and commitment to others

Generalist practice that emphasizes health, prevention and care

A form of primary health care OUTCOMES

1. Cure of disease2. Elimination or reduction of symptoms3. Arrest or slowing of a disease process4. Prevention of disease or symptoms

THE PHILOSOPHY OF PHARMACEUTICAL CARE Recognition of a social need Patient–centered approach

Caring as a modus operandi Specific responsibilities to identify, resolve,

and prevent drug therapy problems

THE FOCUS1. Patient–centeredness 2. Addressing both acute and chronic conditions3. Emphasizing prevention4. Implementing documentation systems that

continuously record patient need and care provided

5. Being accessible to front–line first contact6. Ensuring integration of care7. Being accountable8. Placing emphasis on ambulatory patient9. Including education/health promotional

intervention

PHARMACEUTICAL CARE PRACTICEPatient is always at the center

PATIENT CARE PROCESS PRACTICE MANAGEMENT SYSTEM PROCESS PHILOSOPHY OF PRACTICE

5 FACTORS TO BE CONSIDERED IN PHARMACEUTICAL CARE PRACTICE

A general understanding of how people feel about being ill, the seriousness of the disease (patient’s susceptibility to other factors)

DENIAL–“Not me!”ANGER–“Why me?”DEPRESSION–“Yes, me!”BARGAINING–“Yes me, BUT….”ACCEPTANCE–“I’m ready”

VITAL POINTS Don’t assume patients had information from the

doctor Don’t assume patients understand all information

given Don’t assume patients have resources to comply Don’t assume patients don’t care or are stupid Don’t assume patients will comply if they

understand Don’t assume others will monitor of follow–up Don’t assume patients will voluntarily seek help

or information if there are problems

TRADITIONAL PHARMACY

CLINICALPHARMACY

PHARMACEUTICAL CARE

Primary Focus

Rx order or OTC request

Physicians or other health professionals

PATIENT

Continuity Upon demand

Discontinuous

CONTINOUS

Strategy Obey Find fault or prevention

ANTICIPATE or IMPROVE

Orientation

Drug product

Process OUTCOMES

HEALTH CARE Concerned with the prevention as well as the

treatment of disease“It is more difficult to convince a person what he must do to

stay well than it is to convince an individual what he must do to get well once he is sick...”

When a person is ill, he will generally seek help When he is well, he will notAs a rule, seek help to remain well, yet he must take positive steps to maintain good healthHe cannot take these steps unless he is aware of them

Even then, he may not take action unless he is educated as to why he must do so and encourage to take actionBecause of his accessibility, professional knowledge and training, the pharmacist is in a premier position to play an important role in maintaining the health of his community by serving as a health educator

WHAT A PHARMACIST CAN DO? Patients on medications experience a lot of “drug

misadventures”–adverse effects, drug interactions, errors in the use of medication and non–compliance

MINIMIZE WASTE and MAXIMIZE BENEFITS of medical treatments

REASONS FOR PHARMACIST’SINVOLVEMENT

Improve Patient’s Quality of Life (PQL) years High cost of health care today

BENEFITS1. Reduce drug–related morbidity and its

subsequent cost to individual and society2. Improve PQL3. Reassures that a medication is safe and effective4. Patient get additional explanation about their

illness and medication that they did not receive from their physicians because they were too rushed, too upset or too embarrassed to ask

5. Assist patients on self–care (the pharmacist is always the first person that a patient will turn to in order to discuss a variety of problems)

6. Assist patients in non-medication related problem

TRANSFORMATION OF HEALTH CAREOLD PARADIGM

Emphasis on acute patient careEmphasis on treating illnessResponsible for individual patientsAll providers are essentially similarSuccess achieved by increasing market share of in-patient admissionsGoal is to fill bedsHospitals, physicians, and health plans are separate

NEW PARADIGM Emphasis on the continuum of careEmphasis on maintaining and promoting wellnessAccountable for the health of define populationsDifferentiation based on ability to add valueSuccess achieved by increasing the number of covered lives and keeping people wellGoal is to provide care at the most appropriate levelIntegrated health delivery system

THE ROLE OF THE NEW PHARMACIST► Has evolved from being product–oriented to a

patient–oriented professional► Extremely healthy for both patient and

pharmacist ► Dispensers of therapy and drug effect

interpretations as well as drugs► In the future, pharmacy services must be

evaluated on patient outcome rather than the number of prescriptions dispensed

► It must evolved towards interpretation and patient consultation, related to the use of medication technologies

PHARMACEUTICAL CARE 1CONCEPTS OF HEALTH

Health: Old English word for “heal” (hael) “WHOLE” Whole person and his or her integrity, soundness,

or well-being Definition:

Is the state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity (WHO)

Is the quality of life involving social, emotional, mental, and biological fitness on the part of the individual, which results in adaptations from the environment

2 COMMON MEANINGS OF HEALTH FOR EVERYDAY USE

THE 6 DIMENSIONS OF HEALTH

PHYSICAL HEALTH The body Sexual Health

► Acceptance and ability to achieve a satisfactory expression of one’s sexuality

Body size and shape Sensory acuity Susceptibility to disease and disorders Bodily functioning Ability to perform certain tasks

MENTAL HEALTH Positive sense of purpose An intellectual underlying belief in one’s own

worth Ability to learn Rational thinking Intellectual capabilities

EMOTIONAL HEALTH Ability to express feeling To develop and sustain relationships Ability to recognize emotions and feel

comfortable expressing them appropriately As well as the ability to not express emotions

when it may be inappropriate to do so

SOCIAL HEALTH Sense of having support available from family

and friends Interactions with others Ability to adapt to various social situations and

daily behaviors Ability to have satisfying social relationships

SPIRITUAL HEALTH Recognition and ability to put into practice moral

or religious principles of beliefs Ability to understand and express a purpose in

life To feel a part of a greater spectrum of existence To care about and respect all living things Involves a belief in higher form of being

ENVIRONMENTAL HEALTH Physical environment in which people live Includes

o Housingo Transportationo Sanitation and pure water facilities o Pollution

Societal Health o Link between health and the way a

society is structuredo Includes the basic infrastructure

necessary for health

HOLISTIC WEALTH Is an approach that identifies components of

health that function interdependently to influence an individual’s health

WELLNESS► No generally accepted definition exists► Often is used interchangeably with health► Usually indicates a holistic approach that

emphasizes personal responsibility toward health► It refers to an ongoing effort to achieve optimal

well-being Wellness is a way of life Wellness is the integration of body, mind and

spirit Wellness is the loving acceptance of one’s self

TRAVI’S WELLNESS MODEL

ILLNESS Is a personal state in which the person feels

unhealthy Is a state in which a person’s physical, emotional,

intellectual, social, developmental or spiritual functioning is diminished or impaired compared with previous experience

Precursor of IllnessHEREDITARY – family history for diabetes

mellitus, hypertension, cancerBEHAVIORAL FACTORS – cigarette smoking,

alcohol abuse, high animal fat intakeENVIRONMENTAL FACTORS – overcrowding,

poor sanitation, poor supply of potable water

Stages of Illness1. SYMPTOM EXPERIENCEExamples:

NEGATIVE DEFINITION POSITIVE DEFINITION

LLL Absence of disease or illness

JJJ A state of well–being

JJJA state of complete physical, mental and social well-being not merely the absence of disease or infirmity (WHO)

Transition stage The person believes something is wrong Experience some symptoms 3 aspects:

• Physical – fever, muscle aches, malaise, headache

• Cognitive – perception of “having Flu”• Emotional (worry on consequences of

illness)2. ASSUMPTION OF SICK ROLEExamples:

Acceptance of the illness Seeks advice, support for decision to give up

some activities 3. MEDICAL CAREExamples:

Seeks advice of health professionals for the following reasons

• Validation of real illness• Explanation of symptoms• Reassurance or prediction of outcome

4. DEPENDENT PATIENT ROLEExamples:

The person becomes a client dependent on the health professional for help

Accepts/rejects health professional’s suggestions Becomes more passive and accepting May regress to an earlier behavioral stage

5. RECOVERY/REHABILITATIONExample:

Gives up the sick role and returns to former roles and functions

DISEASE an alteration in body functions resulting in

reduction of capacities or a shortening of the normal life span

Common Causes of Disease:▼ Biological agents – microorganisms▼ Inherited genetic defects – cleft palate▼ Developmental defects – imperforate anus▼ Physical agents – hot and cold substances,

radiation, ultraviolet rays▼ Chemical agents – lead, emissions from smoke-

belching cars▼ Tissue response to irritation – fever,

inflammation▼ Metabolic process – inadequate iodine causing

goiter, inadequate insulin in diabetes mellitus▼ Emotional/Physical reaction to stress –

anxiety, fear

Risk Factors of a Disease• Genetic and Physiological Factors• Age• Environmental• Lifestyle

CLASSIFICATION OF DISEASEA. According to Etiologic Factors

1. Hereditary – due to defect in the genes of one or other parent which transmitted to the offspring

Examples: diabetes mellitus, hypertension

2. Congenital – due to a defect in the development, hereditary factors, or prenatal infection; present at birth

Examples: cleft lip, cleft palate3. Metabolic – due to disturbance or abnormality in

the intricate processes of metabolismExamples: diabetes mellitus, hyperthyroidism

4. Deficiency – results from inadequate intake or absorption of essential dietary factors

Examples: osteomalacia, which is vitamin D deficiency in adults

5. Traumatic – due to injuryExamples: fractures

6. Allergic – due to abnormal response of the body to chemical or protein substances or to physical stimuli

Examples: asthma, skin allergy7. Neoplastic – due to abnormal or uncontrolled

growth of cells

Example: cancer 8. Idiopathic – cause in unknown; self-originated;

of spontaneous originExample: cancer

9. Degenerative – results from the degenerative changes that occur tissue and organs

Examples: osteoporosis, osteoarthritis10. Iatrogenic – results from the treatment of a

diseaseExamples: hypothyroidism after thyroid surgery; alopecia (hair Loss) after chemotherapy

B. According to Duration or Onset1. Acute illness – usually has a short duration and

is severeExample: appendicitis

2. Chronic illness – usually longer than 6 months and can also affect functioning in any dimension

Example: hypertension Remission – period during which the disease

is controlled and symptoms are not obvious Exacerbation – the disease becomes more

active again at a future time, with recurrence of pronounced symptoms

3. Sub –acute - symptoms are pronounced but more prolonged than in acute disease

Example: sub-acute endocarditis C. Others. Diseases may also be described as:

1. Organic – results from changes in the normal structure, from recognizable anatomical changes in an organ or tissue of the body

2. Functional – no anatomical changes are observed to account for the symptoms present, may result from abnormal responses to stimuli

Examples: psychiatric illnesses 3. Occupational – results from factors associated

with the occupation engaged in by the patientExamples: cancer among chemical factory workers

4. Familial – occurs in several individuals of the same family

Examples: hypertensive, cancer5. Venereal – usually acquired through sexual

relationExamples: AIDS, gonorrhea

6. Epidemic – attacks a large number of individuals in a community at the same time

Examples: SARS7. Endemic – present more or less continuously or

recurs in a communityExamples: malaria in Palawan, goiter in Mountain Province

8. Pandemic – an epidemic disease which is extremely widespread involving an entire country or continent

Example: AH1NI9. Sporadic – a disease in which only occasional

cases occurExample: Dengue during rainy season, leptospirosis during floods

DISEASE, ILLNESS AND ILL HEALTH

DISEASE

derived from “DESAISE” -- uneasiness or discomfort

is the existence of some pathology or abnormality of the body which is capable of detection.

implies an objective state of ill health

ILLNESS

is the health subjective experience of loss of health

this is couched in terms of symptoms

indicate a condition causing harm or pain

ILL HEALTH refers to the experience of disease plus illness

THE VIEW OF HEALTH IS CHARACTERIZED AS:1. Biomedical - health is assumed to be a property

of biological being.2. Reductionist – states of being such as health

and disease may be reduced to smaller and

smaller constitutive components of the biological body.

3. Mechanistic – conceptualizes and treats the body as if it were a machine.

4. Allopathic – it works by a system of opposites. If something is wrong with the body, treatment consists of applying opposite force to correct the sickness.

5. Pathogenic – focuses on why people become ill.

5 BASIC ASSUMPTIONS UNDERPINNING WESTERN SCIENTIFIC MEDICINES

1. The body is like a machine, in which all the parts are interconnected but capable of being separated and treated separately.

2. Health equals some all the parts of the body functioning properly.

3. Illness equals some malfunction of the parts of the body, which is measurable

4. Disease is caused by internal processes such as degeneration through ageing or the failure of self–regulation, or by external processes such as the invasions of pathogens into the body.

5. Medical treatment aims to restore normal functioning or health to the body system.

HEALTH PROBLEM IDENTIFICATION HEALTH is a personal task which people must be

free to pursue autonomously. Doctors and health workers contribute to ill health by taking over people’s responsibility for their health.

THE PRACTICE OF MEDICINE LEADS TO…IATROGENIC ILL HEALTH – caused by doctors and health workers3 Types:

1. Clinical iatrogenesis - ill health caused by medical intervention.

Example: Side–effects caused by prescribed drugs, dependency on prescribed drugs, and cross–infection in medical settings such as hospitals.

2. Social iatrogenesis - is the loss of coping and the right to self–care which has resulted from the medicalization of everyday life.

3. Cultural iatrogenesis - is the loss of the means whereby people cope with pain and suffering, which results from the unrealistic expectations generated by medicines.

4 THEORIES OF HEALTHHealth…

as an ideal state as mental and physical fitness as a commodity as a personal strength

Health Belief Model, Becker, 1975 Describes the relationship between a person’s

belief and behavior Individual perceptions and modifying factors

influence health belief and preventive health behavior

Individual Perception Perceived susceptibility to an illness

Example: Family history to diabetes mellitus increases risk to develop the disease

Perceived seriousness of an illnessExample: diabetes mellitus is a lifelong disease

Perceived threat of an illnessExample: Diabetes mellitus causes damage to the brain, heart, eyes, kidneys, blood vessels

Modifying Factors Demographic variables

Examples: Age, Sex, Race Structural variables

Example: knowledge about the disease Sociopsychologic variables

Examples: social pressure or influence from peers

Cues actionExamples: internal: fatigue, uncomfortable symptoms; external: mass media, advice from others

Smith’s Model of Health CLINICAL Model – absence of signs and

symptoms or injury ROLE PERFORMANCE Model – performing work

well ADAPTIVE Model - ability of the person to

adapt, that is to cope EUDAEMONISTIC Model – actualization or

realization of a person’s potential

Leavell and Clark’s Agent Host-Environment Model

1. AGENT – any factor or stressor that can lead to illness or disease

2. HOST – persons who may or may not be affected by a disease

3. ENVIRONMENT – any factor external to the host that may or may not predispose the person to a certain disease

Health Promotion Modelo Individual perceptionso Modifying factorso Participation in health

HEALTH STYLE the sum of personal health decisions that affect

the individual and the community both very personal and very interpersonal It is described as being influenced by

1.The information you have about your health2.Your values3.Your social support4.Your health-related skills5.Your health-related resources6.The momentum developed by your health-

related decisions

Indicators of Health Status PERSONAL HEALTH STATUS

1. Satisfaction with life2. Zest for life3. Functional level of physical fitness4. Minimum of illness

COMMUNITY HEALTH STATUS 1. MORBIDITY refers to the rate of illness in a

group. MORTALITY refers to the rate of death in a group.

2. LIFE EXPECTANCY refers to the number of years a person is expected to live

FACTORS that affect HEALTH Behaviour and Status Race Sex Income

1. Caucasian American have longer life expectancy than African American

2. Women longer than men3. Middle, high-income than in low-income

groups

Predisposing, Reinforcing, and Enabling Factors• PREDISPOSING FACTORS

1. Life experience2. Knowledge3. Cultural and ethnic heritage4. Beliefs and values

• ENABLING FACTORS1. Abilities2. Mental and Emotional capabilities3. Resources4. Facilities

• REINFORCING FACTORS1. Support

2. Encouragement and discouragement from people in your life

DETERMINANTS an attempt to categorize all things affect health

status1.Lifestyle2.Heredity3.Environment4.Health care

Activities to Promote Health and Prevent Illness1. Have a regular physical examination (yearly)2. Women

•Regular PAP test•Monthly BSE (breast self-examination)

3. Men• Regular testicular self examination

4. Annual dental examination5. Regular eye examination 6. Exercise regularly (3x/wk for 30 mins.)7. Do not smoke, avoid second hand smoke8. Avoid alcohol, “recreational drugs”9. Reduce fat and increase fiber in diet10. Sleep regularly11. Maintain ideal body weight

PHARMACEUTICAL CARE 1GENERAL PRINCIPLES OF HEALTH CARE: THE PATIENT

THE PATIENT AS A PERSON• Who is this person who comes to you as a

patient?• What does this person want?• What does this person need?

The Patient We must understand the patient as someone who

possesses certain Strengths Vulnerabilities Preferences Worries and fears Hopes and joys

By virtue of our humanity, we possess the same fundamental dignity and value as any other human being.

It is this view point that is needed to serve all patients.

The patient is the central reason for your work and the only reason for a health profession.

Our values, beliefs, attitudes, and concepts define us as a people.

These things create our frame of reference about how we approach life and the world around us.

The critical frame determines the patients’ beliefs about their health and health-related needs.

The Patient: A Health Context

The Patient’s Concept of Heath

Begin by understanding the ways that health professionals and patients conceptualize health.

Health thinking, from the health professions’ perspective, has historically been based on a disease concept founded in the traditional biomedical model

Disease Concept Disease is any abnormal condition, affecting

either the whole body or any of its parts, which impairs normal functioning.

Disease is described in terms of negative symptoms combined with the directly related physical pathology that causes those symptoms.

In this model, the concept of health is represented by “the absence of disease”.

Patients on the other hand, come to us with a diverse set of concepts, ideas, beliefs, and values about what health is and what it means.

Many patients understand their health in a way that is considered consistent with Western medicine where body, mind, cognition, emotion, and spirituality are seen as discrete entities.

In contrast, they may also participate in Eastern philosophies of Buddhism, Taoism, or traditional Chinese medicine.

These philosophies adopt a holistic conceptualization of an individual and his or her environment.

In this view, health is a body-mind-spirit concept perceived as a harmonious equilibrium that exists between the interplay of “yin” and “yang”.

Several traditions are practiced within our communities, such as Chinese herbal medicine, indigenous North American medicine, and chiropractic, acupuncture, homeopathy, and naturopathic medicine.

The same patients who use these alternative approaches also participate in the mainstream Western philosophies.

Although we as health professionals may attempt to provide professional care within a singular primary model of health, patients may find no need to actually choose among models.

They sometimes participate in multiple, seemingly inconsistent, health care models.

Differences in these understandings of health have led to a broader examination of the concept and its possible meanings.

Historically, Western measures of health did not include a patient’s perception of well-being

Measures of health are changing today. Increasingly, we see writings about recognition of

1) diversity2) the value of the whole person and the

richness of life,3) broad concern about the person, and 4) the need of inclusion of spirituality

Models of Health Given the breadth of patient’s beliefs and

behaviors, it is better to have a model defined. Models help us frame our ability to serve the

needs of patients by proscribing a context to the care they seek and we provide.

Models help us behaviorally define our actions to be consistent with the beliefs and expectations consistent with the model that represent our patient’s expectations.

Not all concepts of health are represented to our satisfaction.

However, these models recognize the various ways in which patients define health.

If we know the model that best fits our patient, we can offer professional care that meets those needs and acknowledge the

influences that modify one’s expectations of care.

What the Pharmacist will do… Review the definitions of the models of health. Select the one that best represents your own

health beliefs.

Select the one that you think represents most patients’ health beliefs like to be in your care.

If you work in a pharmacy setting, select the one that best represents the concept of health that prevails in that organization, as represented by organizational programs, services, and decisions about care provision.

If you are working with other health professionals, discuss each other’s perceptions about this matter.

What do you think should be done to successfully provide care to the patient when there are differences among these models?

Conceptual Factors How do you know what concept the patient has of

health? Each of us has our own concept, but it is formed

by many factors like, cultural influences, values and beliefs

Cultural Influences Culture is described as a property of society. There is no such thing as a pure culture,

because there is diversity, oven recognizable as subcultures.

Within a large ethnic group, substantial variation may exist in education, socioeconomic status, and practiced religions.- America continues to become a more

ethnically diverse population.- 74% is Caucasian; expected to decrease to

64% by 2010.- Asian 5%- African Americans – 13%- Hispanics – 15%- The population’s average age is rising with:

Female life expectancy averaging 86 years

And male life expectancy averaging 76 years by 2010.

Access to care will continue to be segregated into 3 identifiable groups:

1. Empowered consumers who have resources, use technology, and want to share in health decision making

2. Worried consumers who have health insurance but no choice in plan

3. People who are excluded because they have no form of health insurance or method of payment other than out of pocket

Pharmacists should view health and illness from the patient’s perspective.

How can we understand a person’s culture in a way that helps to meet his or her health care goals and needs?

One way is to learn the values and attitudes considered important enough to pass down from one generation to the next.

Understanding a patient’s cultural view of illness will be helpful in meeting the person’s needs.

This approach requires a reasonable understanding of the culture as a whole before you can confidently apply this knowledge.

Example• In your initial assessment of an African American

woman, you may automatically assume she is from the US.

• As you begin to listen to her, you may realize that her dialect resembles a British accent.

• One of her cultural frames is actually from an area in Britain.

• You realize that you were applying your own cultural bias over hers.

• This example illustrates the problem of ethnocentricity or the interpretation of one’s culture using the norms of another, usually your own.

• Understanding another person through critical culture norms unique to that person’s community is important.

• Competence in cultural interpretation matters and is certainly true of health beliefs that dominate cultures.

• There is a great deal to know about the cultural context of the patients you serve.

• Health professionals should become culturally competent through the on-going process of integrating cultural awareness, knowledge, skill, encounters, and desire.

• Campinha-Bacote described this model of cultural competence in HC delivery as a framework for developing and implementing culturally responsive care.

• The model assumes that culture competence is a process, not an event.

• It recognizes that there is more variation within ethnic groups than across groups

• It assumes that the provision of culturally responsive care is directly related to the health professional’s level of competence in the context of each patient.

The model defines the concept as follows:1. Cultural awareness is the self-understanding of

one’s own cultural and professional background.2. Cultural knowledge is the process of seeking and

obtaining an educational foundation about different cultural and ethnic groups.

3. Cultural skill is described as the ability to collect relevant cultural data about the patient’s problem as well as performing a culturally based physical assessment.

4. Cultural encounter involves the health professional engaging in cross-cultural interactions with individuals from diverse backgrounds. This interaction is almost impossible when the patient and health provider speak different languages, the patient a limited English proficiency, the patient is speaking from a different perspective, or the provider a limited proficiency in the patient’s language. Occasionally, cultural tradition may preclude a patient speaking directly to a provider. For these reasons, an interpreter is sometimes needed.

5. Cultural desire is the motivation of the health care provider to engage in the process of culturally responsive care.

A culturally competent pharmacist will consciously adapt care for the patient in a way that is consistent with the patient’s need from the context of a cultural framework.

How does one become culturally competent?1. Live with the group2. Learning can be accomplished through

• reading• convening focus groups • participating in community

activities It is more important to remain open to learning

from the patient what is culturally important and relevant.

Cultural competence is discovery of the way in which a health care provider can move a relationship with the patient from parallel to mutual through increasing the provider’s knowledge, skills and understanding.