PHARMACEUTICAL CARE 1 GENERAL PRINCIPLES OF HEALTH CARE Pharmaceutical Care: Is the component of pharmacy practice with entails the

e direct interaction of pharmacist with the patient for the purpose of caring for that patients drug related needs Objectives of Pharmaceutical Care: Cure of a disease Elimination or reduction of a patients symptomatology Slowing or arresting of a disease process Preventing a disease/symptomatology

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.

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 mans 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 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

Health care professionals can prevent, control or One of the largest industries in the world One of the leading employers in most
cure hundreds of diseases Has become a part of the health care industry

Has a unique body of knowledge and skills to

contribute in our health care system has the knowledge to assure safe and rational use of drugs EARLY FUNCTIONS OF A PHARMACIST 1. Assisting in the selection of appropriate drug therapy 2. Preparing, compounding and manufacturing drugs for individualized patients 3. Dispensing and packaging the prescribed drug products including proper labeling 4. 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

Dispenses the appropriate drug product and

communities At 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 scarce By the end of the 20th century Medical advances Life expectancy increased to 76 years Today 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

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 patientoriented, better prepared to dispense drug knowledge and drug products PRIMARY AIM To attain success in the goals for therapy, pharmacist must approach the patientcounseling 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

A goal to strive for It is not obtainable No one ever achieves a state of complete mental, physical and social well being CURE

CARE

Latin word cura 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 patients health care

needs

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 pharmacists approach From the health professionalcentered MEDICAL MODEL to the patientcentered HELPING MODEL MEDICAL MODEL Patient is passive Trust is based on expertise and the authority of pharmacist Pharmacist identifies problem and determine solutions Patient is dependent on pharmacist Parentchild relationship PQL HELPING MODEL Patient is actively involved Trust is based on personal relationship developed over time Pharmacist assist patients in exposing problem and possible solution Patient develops selfconfidence to manage problems Equal relationship

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 patients 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 PATIENT Medical Care I care Mental Health Care Geriatric Care Dental Care Pharmaceutical Care Nursing Care Chiro-practice Care Surgical Care Pediatric Care Nutritional Care Eye Care Maternal Care PRIMARY CARE Frontline or first contact care Personcentered Not disease or organ system centered Comprehensive in scope Not limited to illness episodes or by organ systems or disease process involved INTERACTIONS With patients and other health care providers COUNSEL CONSULT EDUCATION 4 Rs OF THE PHILOSOPHY OF PRACTICE I. Rules II. Roles III. Relationship IV. Responsibilities

Patient Quality of Life suffering is the primary concern patients perspective

Welfare of humanity and the relief of human Must learn to view medications use from the

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

PHARMACEUTICAL CARE A responsible provision of therapy for the purpose of achieving definite outcomes that improve the patients quality of life

- Hepler and Strand PHARMACEUTICAL CARE PHARMACIST CARE A practice in which the practitioner takes responsibility for a patients drugrelated 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 disease 2. Elimination or reduction of symptoms 3. Arrest or slowing of a disease process 4. Prevention of disease or symptoms THE PHILOSOPHY OF PHARMACEUTICAL CARE Recognition of a social need Primary Focus Continuit y Strategy Orientatio n Rx order or OTC request Upon demand Obey Drug product

Physicians or other health professional s Discontinuo us Find fault or prevention Process

PATIENT

CONTINOUS ANTICIPATE or IMPROVE 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 not As a rule, seek help to remain well, yet he must take positive steps to maintain good health He 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 action Because 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 misadventuresadverse effects, drug interactions, errors in the use of medication and noncompliance MINIMIZE WASTE and MAXIMIZE BENEFITS of medical treatments REASONS FOR PHARMACISTS INVOLVEMENT Improve Patients Quality of Life (PQL) years High cost of health care today BENEFITS 1. Reduce drugrelated morbidity and its subsequent cost to individual and society 2. Improve PQL 3. Reassures that a medication is safe and effective 4. 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 selfcare (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 CARE OLD PARADIGM NEW PARADIGM Emphasis on acute Emphasis on the patient care continuum of care Emphasis on treating Emphasis on maintaining illness and promoting wellness Responsible for Accountable for the individual patients health of define populations All providers are essentially similar Differentiation based on ability to add value Success achieved by increasing market Success achieved by share of in-patient increasing the number of admissions covered lives and

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

and prevent drug therapy problems THE FOCUS 1. Patientcenteredness 2. Addressing both acute and chronic conditions 3. Emphasizing prevention 4. Implementing documentation systems that continuously record patient need and care provided 5. Being accessible to frontline first contact 6. Ensuring integration of care 7. Being accountable 8. Placing emphasis on ambulatory patient 9. Including education/health promotional intervention PHARMACEUTICAL CARE PRACTICE Patient 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 (patients susceptibility to other factors) DENIALNot me! ANGERWhy me? DEPRESSIONYes, me! BARGAININGYes me, BUT. ACCEPTANCEIm ready VITAL POINTS Dont assume patients had information from the doctor Dont assume patients understand all information given Dont assume patients have resources to comply

Dont assume patients dont care or are stupid Dont assume patients will comply if they
understand

Dont assume others will monitor of followup Dont assume patients will voluntarily seek help
or information if there are problems

TRADITIONA L PHARMACY

CLINICAL PHARMACY

PHARMACEUTIC AL CARE

Goal is to fill beds Hospitals, physicians, and health plans are separate

keeping people well Goal is to provide care at the most appropriate level Integrated health delivery system

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 ones 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 ones own worth Ability to learn Rational thinking

THE ROLE OF THE NEW PHARMACIST Has evolved from being productoriented to a patientoriented 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

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 PHARMACEUTICAL CARE 1 CONCEPTS OF HEALTH Health: 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 NEGATIVE DEFINITION LLL Absence of disease or illness POSITIVE DEFINITION JJJ A state of wellbeing JJJA state of complete physical, mental and social well-being not merely the absence of disease or infirmity (WHO) ENVIRONMENTAL HEALTH Physical environment in which people live Includes o Housing o Transportation o Sanitation and pure water facilities o Pollution Societal Health o Link between health and the way a society is structured o Includes the basic infrastructure necessary for health HOLISTIC WEALTH Is an approach that identifies components of health that function interdependently to influence an individuals health

Old English word for heal (hael)

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 ones self

TRAVIS WELLNESS MODEL

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 smokebelching 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 DISEASE A. 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 palate 3. Metabolic due to disturbance or abnormality in the intricate processes of metabolism Examples: 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 injury Examples: fractures 6. Allergic due to abnormal response of the body to chemical or protein substances or to physical stimuli Examples: asthma, skin allergy 7. Neoplastic due to abnormal or uncontrolled growth of cells Example: cancer 8. Idiopathic cause in unknown; self-originated; of spontaneous origin Example: cancer 9. Degenerative results from the degenerative changes that occur tissue and organs Examples: osteoporosis, osteoarthritis 10. Iatrogenic results from the treatment of a disease Examples: hypothyroidism after thyroid surgery; alopecia (hair Loss) after chemotherapy B. According to Duration or Onset 1. Acute illness usually has a short duration and is severe Example: 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

ILLNESS
Is a personal state in which the person feels unhealthy Is a state in which a persons physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired compared with previous experience Precursor of Illness HEREDITARY family history for diabetes mellitus, hypertension, cancer BEHAVIORAL FACTORS cigarette smoking, alcohol abuse, high animal fat intake

ENVIRONMENTAL FACTORS overcrowding, poor sanitation, poor supply of potable water Stages of Illness 1. SYMPTOM EXPERIENCE Examples: 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 ROLE Examples: Acceptance of the illness Seeks advice, support for decision to give up some activities 3. MEDICAL CARE Examples: Seeks advice of health professionals for the following reasons Validation of real illness Explanation of symptoms Reassurance or prediction of outcome 4. DEPENDENT PATIENT ROLE Examples: The person becomes a client dependent on the health professional for help Accepts/rejects health professionals suggestions Becomes more passive and accepting May regress to an earlier behavioral stage 5. RECOVERY/REHABILITATION Example: 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:

3. Occupational results from factors associated

with the occupation engaged in by the patient Examples: cancer among chemical factory workers Familial occurs in several individuals of the same family Examples: hypertensive, cancer Venereal usually acquired through sexual relation Examples: AIDS, gonorrhea Epidemic attacks a large number of individuals in a community at the same time Examples: SARS Endemic present more or less continuously or recurs in a community Examples: malaria in Palawan, goiter in Mountain Province Pandemic an epidemic disease which is extremely widespread involving an entire country or continent Example: AH1NI Sporadic a disease in which only occasional cases occur Example: Dengue during rainy season, leptospirosis during floods DISEASE, ILLNESS AND ILL HEALTH

Examples: psychiatric illnesses

workers contribute to ill health by taking over peoples responsibility for their health. THE PRACTICE OF MEDICINE LEADS TO IATROGENIC ILL HEALTH caused by doctors and health workers 3 Types: 1. Clinical iatrogenesis - ill health caused by medical intervention. Example: Sideeffects caused by prescribed drugs, dependency on prescribed drugs, and crossinfection in medical settings such as hospitals. 2. Social iatrogenesis - is the loss of coping and the right to selfcare 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 HEALTH Health 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 persons 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 illness Example: diabetes mellitus is a lifelong disease Perceived threat of an illness Example: 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 action Examples: internal: fatigue, uncomfortable symptoms; external: mass media, advice from others Smiths 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 persons potential Leavell and Clarks 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

4. 5. 6. 7.

8.

9.

derived from DESAISE -DISEASE

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

is the health subjective

ILLNESS

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 selfregulation, 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

 Health Promotion Model o Individual perceptions o Modifying factors o 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 health 2.Your values 3.Your social support 4.Your health-related skills 5.Your health-related resources 6.The momentum developed by your healthrelated decisions Indicators of Health Status PERSONAL HEALTH STATUS 1. Satisfaction with life 2. Zest for life 3. Functional level of physical fitness 4. 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 men 3. Middle, high-income than in low-income groups Predisposing, Reinforcing, and Enabling Factors PREDISPOSING FACTORS 1. Life experience 2. Knowledge 3. Cultural and ethnic heritage 4. Beliefs and values ENABLING FACTORS 1. Abilities 2. Mental and Emotional capabilities 3. Resources 4. Facilities REINFORCING FACTORS 1. Support 2. Encouragement and discouragement from people in your life DETERMINANTS an attempt to categorize all things affect health status 1.Lifestyle 2.Heredity 3.Environment 4.Health care Activities to Promote Health and Prevent Illness 1. 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 examination 5. Regular eye examination 6. Exercise regularly (3x/wk for 30 mins.) 7. Do not smoke, avoid second hand smoke 8. Avoid alcohol, recreational drugs 9. Reduce fat and increase fiber in diet 10. Sleep regularly 11. Maintain ideal body weight

PHARMACEUTICAL CARE 1 GENERAL 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 Patients 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 patients perception of well-being Measures of health are changing today. Increasingly, we see writings about recognition of 1) diversity 2) 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

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 populations 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 patients perspective. How can we understand a persons 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 patients cultural view of illness will be helpful in meeting the persons needs. This approach requires a reasonable understanding of the culture as a whole before you can confidently apply this knowledge.

Models of Health Given the breadth of patients 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 patients 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 ones 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 others 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.

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 ones culture using the norms of another, usually your own. Understanding another person through critical culture norms unique to that persons 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 professionals level of competence in the context of each patient.

The model defines the concept as follows: 1. Cultural awareness is the self-understanding of ones 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 patients 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 patients 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 patients need from the context of a cultural framework. How does one become culturally competent? 1. Live with the group 2. 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 providers knowledge, skills and understanding.