Chapter 1: Self-Care and Nonprescription
Pharmacotherapy
This chapter introduces the concept of self-care, delineates characteristics of today’s self-care consumer, and examines the growing importance of self-care in modern health care systems. Self-care, as defined by the Global Self-Care Federation, is “[t]he practice of individuals looking after their own health using the knowledge and information available to them. It is a decisionmaking process that empowers individuals to look after their own health efficiently and conveniently, in collaboration with health and social care professionals as
needed.”
1 As discussed in this chapter, the pharmacist has a key role in providing assistance, advice, and information to address self-care needs. An overview of the self-care marketplace, as well as the legislative and regulatory environment, is presented first, with a brief perspective on future changes expected for expansion of self-care and related health care technology.
Broad public education has been shown to be a key factor in advancing the consumer’s role in prevention of illness and general health management; accordingly, several public education programs are reviewed in this chapter to illustrate pharmacists’ role in supporting this effort. The chapter concludes by reviewing the roles of the pharmacist and student pharmacist in assisting
patients with their self-care needs, while emphasizing the key elements of safety and efficacy in the management of self-care conditions.
The Expanding Definition of Self-Care
A simple definition of self-care is as the independent act of preventing, diagnosing, and treating one’s illnesses with or without seeking professional advice. However, self-care definitions can vary according to one’s perspective, with health care professionals’ definition frequently differing from that of the general public. Health care providers (e.g., doctors, pharmacists, nurses) typically consider self-care to include the clinical management of self-care conditions and use of relevant self-care products available to patients without
a prescription. Health care providers who wish to acknowledge the expanded role for today’s pharmacists would add that self-care should include assistance in determining whether a patient’s condition is appropriate for self-care.
Pharmacists are accessible to patients when most self-care decisions are made and are valuable experts in this area. A pharmacist can help the patient improve by recommending the best nonprescription product for treatment of the condition and/or identifying beneficial nonpharmacologic measures (e.g., dietary or lifestyle changes). Such measures also may be helpful to prevent further occurrences of the condition. In this context, the process becomes “pharmacist-assisted self-care.” The primary focus of this book is the
pharmacist’s role in this process but also introduces roles that student pharmacists can assume as they develop their patient care skills for selftreatable conditions. Other health care providers (e.g., nurse practitioners, physician assistants) who also may be involved in advising patients on self-care will find significant applications of the concepts, content, and processes provided in this book. Consumers’ perspective and their definitions of selfcare can differ considerably from those of health care providers. When consumers were asked to describe what self-care involves, their responses went far beyond the use of nonprescription medications.2 The consumers listed healthy habits,
such as diet and exercise, but they also noted other important aspects of selfcare: screenings and wellness check-ups, preventive care, consultations with doctors, and their own participation in deciding how to deal with a health problem. All of these factors represent consumers’ increasing interest in and expectation to be accountable for their own health and wellness. In the United States, “personal accountability” to manage and improve health is expanding the general public’s definition of self-care.
The engagement of a health care provider easily differentiates pharmacistassisted self-care from self-care. However, when does pharmacist-assisted selfcare undergo transition to primary care in a more contemporary health care
system? Many people who are not health care professionals turn to Wikipedia to find common definitions. Wikipedia defines primary care as “the day-to-day health care given by a health care provider. Typically, this provider acts as the first contact and principal point of continuing care for patients within a health care system, and coordinates other specialist care that the patient may need.”
3 Is the pharmacist considered a health care provider under this definition? Is the pharmacist serving as the first point of contact and a principal point of ongoing care for the patient? Many would answer “yes” to these questions, in recognition of pharmacists’ evolving role in providing patient care services and medication therapy management (MTM) in their practice settings. In addition,
state and federal legislation to secure pharmacists’ recognition as “health care providers” is further advancing this belief.
4 Continued delivery of patient care services, such as immunizations and point-of-care testing, also will advance the public’s recognition of pharmacists as primary care providers. In the future, these efforts will contribute to further blurring of the distinguishable differences between pharmacist-assisted self-care and primary care delivery by pharmacists.
The patient-centered care model of health care delivery is gaining popularity as part of ongoing health care reform in the United States. The Institute of Medicine defines patient-centered care as “providing care that is respectful of
and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”
5 This definition implies that patients and their team of health care providers must have a strong partnership and make decisions together based on the patient’s desires and priorities for his or her health goals. As John Gans, former chief executive officer of the American Pharmacists Association (APhA), often said, “All care is self-care!” His point was that the patient is always in charge and will make the final decision on implementing any actions to try to improve his or her health.
A key area of emphasis in the patient–provider partnership is the recognition and integration of cultural beliefs, values, and traditions, because these also
play an important role in a patient’s personal health care decisions. (See Chapter 3 for further discussion of cultural competency in health care.)
Furthering advancements in patient-centered, teambased care will involve an interprofessional team of providers who honor the health care priorities of the patient. It also is important to note that self-care involves the full spectrum of care, including prevention and wellness strategies, diagnosis and screening, and measures for treatment of or relief from symptoms.
Preventive self-care involves maintaining well-being and appearance, both subjective and objective, through a healthy lifestyle. For many people, a healthy lifestyle includes controlling the diet; taking vitamins, minerals, and herbal
supplements; participating in regular exercise and keeping fit; and maintaining physical appearance with use of dental, skin, and hair care products. By contrast, self-care for persons who are ill involves identifying (diagnosing) the responsible condition and then obtaining products for mitigating illness and relieving symptoms. Examples of selfcare measures in illness are dietary options (e.g., consuming hot soup for a cold); utilization of certain medical devices for both disease assessment (e.g., home blood glucose meters, cholesterol tests) and treatment (e.g., ice packs, first aid bandages, vaporizers, nasal strips); and use of nonprescription medications (e.g., pain relievers, cold medicines). The use of self-care products typically is limited to
cases involving mild illness or short-term management of more acute conditions, and most products warn users to contact a health care provider if improvement is not obtained within a short period of time. In some instances, however, self-care involves long-term management of ongoing symptoms or chronic conditions with nonprescription medications, even when such regimens are recommended by a physician. For example, acetaminophen may be used for the ongoing management of arthritis pain. Figure 1–1 provides a depiction of the self-care continuum, extending from “pure self-care with individual responsibility” to “pure medical care with professional responsibility,” as described by the Self Care Forum.6
Figure 1–1 Self-care continuum developed by the Self Care Forum. (Source:
Adapted from reference 6 with the permission of the Self Care Forum.
Copyright © 2015.)
Globally, both the importance of self-care in the overall health care spectrum and the role of the pharmacist are gaining additional visibility. In 2017, the International Pharmaceutical Federation (FIP) released both a reference paper and a policy statement on self-care.7,8 The reference paper provides a global view of the growing role of pharmacists in self-care and improvement of population health around the world. The policy statement provides recommendations to government agencies and insurers, pharmacy
organizations, and pharmacists to advance the adoption of selfcare in health systems around the world. These documents serve as position statements and educational tools for promoting the growing role of pharmacists in self-care to improve global health.
The FIP reference paper refers to an earlier 2005 report from the London Department of Health that highlighted the large role that self-care plays in the total health care model (Figure 1–2).9 For professional care, Figure 1–2 includes primary health care as basic medical care, along with secondary and tertiary health care as more complex medical care services (e.g., specialist physicians, intensive hospitalization care). Self-care, when compared with professional care, is shown to be a much larger component in the individual patient’s
overall health care experience. The FIP paper also references the same London Department of Health report for promoting the importance and supporting the value of self-care behaviors for improved population health, as shown in
Figure 1–3.
9 Professional care for treatment of minor ailments, acute illness, and long-term conditions is depicted in the crescentshaped area of the oval section on the right of the model. The patient’s selfmanagement of these same minor, acute and long-term health conditions is depicted as a larger component of the oval. To the left in the model, preventive self-care measures, important for good health and illness prevention, are depicted as a large component of self-care that does not involve professional care. Again, this
model conveys visually the important concept of the very significant role of self-care within the overall health care spectrum. The lower section of the model identifies many important elements for supporting patients’ self-care measures. Pharmacists would use most of these elements as tools and processes to assist their patients in implementing self-care approaches.
Figure 1–2 Role of self-care in the total health care model. Key: 1ry = Primary; 2ry = secondary; 3ry = tertiary. (Source: Adapted from reference 9 with the permission of the Department of Health, UK.GOV; contains public sector information licensed under the Open Government License v1.0.)
Figure 1–3 Self-care and self-care support. (Source: Adapted from reference 9
with the permission of the Department of Health, UK.GOV; contains public sector information licensed under the Open Government Licence v1.0.)
The International Self-Care Foundation offers additional evidence of the broad scope of self-care, as illustrated by their seven pillars of self-care, shown in photograph 1 of the Color Plates and outlined in Table 1–1.
10 Clearly, self-care is significant to global health care to manage or treat active conditions and to address preventive health and wellness.
Table 1–1 Seven Pillars of Self-Care as Defined by the International Self-Care Foundation
Self-Care Component Description Health literacy
Includes the capacity of people to obtain, process, and understand basic health information and services needed to make appropriate health decisions
Self-awareness of physical and mental condition
Includes knowing one’s BMI, cholesterol level, and blood pressure; engaging in health screening
Physical activity Practicing moderate intensity physical activity, such as walking
Self-Care Component Description or cycling, or participating in sports at a desirable frequency
Healthy eating Includes eating a nutritious, balanced diet with appropriate
level of caloric intake
Risk avoidance or mitigation Includes quitting tobacco use, limiting alcohol use, being vaccinated, practicing safer sex, and using sunscreen
Good hygiene Includes washing hands regularly, brushing teeth, and washing food before consumption
Rational and responsible use of products, services, diagnostics, and medications
Includes being aware of dangers, using responsibly when necessary key: BMI = Body mass index.
Source: Adapted from reference
Understanding Today’s Self-Care Consumer
Consumers today are motivated and empowered by their ability to use selfcare to manage their health. They feel less dependent on physicians and want more control over their health care. Consumers appreciate the availability and convenience of nonprescription medications that enable them to self-treat minor illnesses or injuries, thus avoiding unnecessary inconvenience and copays for treatment from a medical provider.
A survey by the Consumer Healthcare Products Association (CHPA) asked consumers for their perspectives on the role of nonprescription medications in
their self-care.11 A key finding was that consumers trust nonprescription medications, when they are available, for health care management for themselves and their children. Key drivers of trust were effectiveness, adverse effects, and doctor recommendation. Consumers also prefer using a nonprescription over a prescription medication for first-line therapy and for certain ailments such as pain, cough and colds, acid reflux, and upset stomach.
Additional data collected in the survey “Your Health at Hand:
Perceptions of
Over-the-Counter Medicine in the U.S.” support the view that both consumers and physicians recognize the role of nonprescription medications in self-care.
Key survey results include the following 12:
• 93% of physicians believe that medications for minor ailments should be available over the counter.
• 96% of consumers believe that nonprescription medications make it easy to care for minor medical ailments.
• 87% of physicians and 89% of consumers believe that use of nonprescription medications is an important part of overall and family health care.
• 93% of adults prefer to treat minor ailments with nonprescription medications before seeking professional care.
• 88% of physicians recommend that patients address minor ailments with self-care, including the use of nonprescription medications, before seeking professional care.
Today’s consumers also are much more knowledgeable about health care
products and health care in general. In addition, consumers are more motivated to focus on their health and wellness. For example, consumers are making lifestyle changes, such as drinking more water, taking supplements and vitamins, and eating and exercising more responsibly. Employers, through employee wellness programs, also are offering incentives to improve health. Nearly 90% of employers now offer wellness incentives, such as financial rewards or prizes, to employees who work toward becoming healthier.
13
The CHPA survey also showed that one in four respondents self-identified as a “family health influencer” based on being knowledgeable about nonprescription medications and playing a role in educating others in the
family about their self-care options.10 These influencers report that they are knowledgeable about different nonprescription medications, they avoid going to the doctor unless they absolutely have to, and they choose a medication on the basis of the symptoms it will treat. The family health influencer is more likely to be female, and many are mothers in the family unit. In addition, the survey found that multigenerational households, Hispanic households, and households that provide care for an adult outside the home place a high value on a pharmacist’s or other in-store health care provider’s recommendations.
Health care providers must acknowledge and partner with this family health influencer in their caregiver role for the family. Other influencers also may be involved in decision making, as depicted in Figure 1–4.
Figure 1–4 Influencers of consumers’ self-treatment decisions. (Source: Reference 11.)
Internet sources of health information have become increasingly popular across all age groups and demographic populations. Web-based health information is easily and rapidly accessed in the privacy and comfort of one’s home. According to a 2013 Pew Internet and American Life Project report, 59% of U.S. adults searched for online health information in the previous year.
14 Most health information seekers, 77%, begin with a major search engine, such as Google, Yahoo, or Bing, whereas another 13% use a more health-specific site
such as WebMD. The report has identified approximately one third of adults (35%) as “online diagnosers” because they have gone online to diagnose their own or someone else’s medical condition. Consumers who were most likely to search for health information online were white adult women with higher levels of education and income. Dependence on the internet for self-care information can be problematic. No single organization is accountable for the quality or accuracy of health-related information available on websites. The sheer number and diversity of internet sources increase the likelihood that patients may unknowingly view biased or outdated information. When asked if the information found online led them to think they needed the attention of a medical professional, 46% of online
diagnosers answered “yes,” demonstrating the potential role for a pharmacist to provide accurate information and answer questions. All health care providers, including pharmacists, should assist their patients in identifying credible resources for health information. A number of valid internet sources are available to provide information on nonprescription drugs; these include the National Institutes of Health (www.nlm.nih.gov/medlineplus) and websites such as those for the Cleveland Clinic (www.clevelandclinicmeded.com), WebMD (www.webmd.com), the Mayo Clinic (www.mayoclinic.com), and the CHPA Educational Foundation (www.knowyourOTCs.org).
In addition to increased access to health care information, consumers need to be able to understand basic health information to make appropriate health
decisions. Health literacy is the umbrella term that refers to “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
15 Health literacy includes numeracy skills, for example, understanding laboratory values, selecting the proper dose of a medication, and reviewing medical bills. The National Assessment of Adult Literacy showed that only 12% of adults have proficient health literacy and 30% of adults have below-basic levels of health literacy.
15 Health literacy affects people’s ability to
navigate the health care system in a variety of areas: filling out forms, locating physicians and services, discussing their health information, and selecting a community pharmacy and pharmacist to support their engagement in selfcare. Low-level literacy has been linked to poor health outcomes, such as higher rates of hospitalization and less frequent use of preventive services.15
Health care providers need to be aware that health literacy varies across the population they serve and that they may need to tailor their own language to try to match the patient’s skill level. One approach is to use “plain language”—that is, communication that patients can understand the first time they read or hear it. Key components of plain language include putting the
most important points first, breaking complex concepts into chunks (small bits of information), adhering to simple wording, defining technical or medical terms, and using the active voice in which the subject performs the action.
Resources for more information include Plain Language.gov (www.plainlanguage.gov) and the Centers for Disease Control and Prevention (CDC) health literacy training module (www.cdc.gov/healthliteracy/training).
The changing demographics of this country’s population also are changing the profile of the self-care consumer. The growth of the older population, whose members are heavy users of nonprescription medications, will continue to expand the self-care consumer base. The results of the 2017 National Projections by the U.S. Census Bureau found that by 2030, all baby boomers
will be older than 65 years of age.16 The average life expectancy for Americans has increased, with people who attain 65 years expected to live an additional 16–22 years, depending on gender and race. The fastest growing segment of the elderly population is that consisting of persons older than 85 years. The racial and ethnic diversity of the older population also will change as the populations of Hispanic and non-White groups increase. These specific groups will have a significant impact on the future of U.S. health care policy and the health care system as their individual members deal with illness and disability and need longterm care and other resources. The growth in minority populations in the United States will drive a need for cultural considerations in self-care recommendations. Chapter 3 provides
details on cultural considerations in self-care. Chapter 2 provides additional details on self-care for special populations, including geriatric patients, infants and children, and pregnant and breastfeeding patients.
In summary, today’s consumer is more empowered and more likely than ever before to take charge of his or her health, often turning to nonprescription medications as first-line therapy options for a variety of conditions. In the decades ahead, the older population will continue to expand and will need information and health care resources, including pharmacists, to manage their health.