EDITORIAL: The Landscape of self-care and SelfCare.


Peter R Noyce


School of Pharmacy and Pharmaceutical Sciences, University of Manchester, UK

Self-care has been defined by the Government Department of Health in England1 as: ‘the care taken by individuals towards their own health and well-being’.

It comprises the actions they take to

•  lead to a healthy lifestyle;
•  meet their social, emotional and psychological needs;
•  care for their long-term conditions; and
•  prevent further illness or accidents.

The policy document considers self-care from the perspective of: maintenance of good health and lifestyle, and prevention of ill health; long-term conditions; and minor ailments. It also profiles the diverse range of products and activities needed to support self-care, including self-diagnostic tools and products, self-monitoring devices and self-care equipment, as well as basic health skills and literacy training.

The city of Portsmouth (pop c200,000) provides one example of population-based leadership in developing self-care by stimulating city-wide support through its “Healthy Living Pharmacy” (HLP) Initiative2. The scheme which involves pharmacy staff being formally trained as Health Trainer Champions has an enviable record in achieving weight loss and quitting smoking to the benefit of Portsmouth citizens, providing consultations on, for example, improving asthma control and emergency hormonal contraception, as well as participating in health education campaigns on alcohol and bowel cancer awareness. Following the success of this local scheme, the Department of Health is cascading the model nationally, and establishing pathfinder sites in 20 other areas3.

The comprehensive and extensive definition of self-care provided in Self Care – A Real Choice; Self Care Support – A Practical Option embraces public health and social care, as well as healthcare1. The literature on self-care is correspondingly broad and is scattered throughout a variety of journals covering policy, clinical practice, risk and safety, information communication and technology, patient perspectives, and the medical, nursing, pharmaceutical and therapy professions.

So where does the journal SelfCare fit and contribute to the self-care agenda?

SelfCare has a primary interest in the healthcare aspects of self-care, particularly the products to support self-care together with the relevant services provided by professional and support staff. The products may be preventative, diagnostic, therapeutic or supportive including medicines, medical devices, diagnostic kits, dietary products, disability aids and web-based support programs. Services might range from advice on the management of diarrhoea by a pharmacist, through exercise routines for stroke patients from a physiotherapist or immunosuppressant adherence reinforcement from a transplant team, to training in cognitive behavioural techniques from a mental health worker, among others.

SelfCare is particularly interested in publishing robust evaluative studies that demonstrate the impact or outcomes of products, interventions or services to support self-care (e.g., an RCT of self-help interventions in patients with a primary care diagnosis of irritable bowel syndrome4) and in other rigorous studies that inform and improve self-care practices (e.g., patient/medication safety issues with a product or service).

Long-term conditions (LTCs)

For the management of long-term conditions (LTCs) in low-risk patients, self-care is realistically the only affordable option and so supporting self-care is a contemporary component of healthcare policy in developed countries5.  However the engineering of chronic illness self-management can be a complex process6,7. It necessitates health professionals acquiring a thorough appreciation of patients’ agendas in the self-management of LTCs8, in order to devise strategies and interventions to support self-care.

Essentially health professionals need to develop and maintain partnerships with patients to ensure they understand: their rights and responsibilities for self-care, the nature and purpose of their therapeutic regimens, and the consequences of not persisting with them. Encouraging and training patients to ensure safe and effective medicine-taking is a key feature in facilitating self-care in LTCs, since the use of medicines is the most common intervention in healthcare.

When patients cross care boundaries, e.g. through referral to secondary care, or admission to, or discharge from, hospital, both priorities in medical treatment and the health professionals responsible for care may change.  Ensuring that individuals’ drug regimens remains appropriate, in terms of efficacy and safety, throughout their care pathways is challenging, particularly in patients with multiple LTCs. Unfortunately the quality of healthcare may be compromised by systematic failings e.g. incomplete records, poor communication, errors, and misunderstandings. A recent systematic review suggests approximately 5.3% of hospital admissions are associated with adverse drug reactions, some of which may be preventable, with much higher rates reported for elderly patients in which drugs for the treatment of cardiovascular disorders are the main culprits9.

Patients – who may have competently self-managed medication for their LTCs – may also become disorientated by their changing care settings, and by changes to their medication arising from therapeutic or generic substitution10.

The widespread implementation of pharmacist-led medicines management initiatives in UK and medicines therapy management (MTM) programmes in US is designed to rationalise and clarify individual patients’ medicines regimens, and to empower them to self-manage the medicines needed to treat their LTCs.

From October 2011, community pharmacists across England will be expected under the National Health Service (NHS) to provide 2 new services to support the self-management of medicines11. The “New Medicine” service is designed to ensure patients understand the purpose, use and likely experience of using a newly prescribed medicine and encourage their engagement in using the new therapy. The “Targeted Medicines Use Review” service will be provided to patients newly discharged from hospital to clarify their current medicines regimens and support their adoption of them.

SelfCare welcomes original studies on aspects of self-care of LTCs, including the challenges of self-managing complex medication. The journal is particularly interested in well designed studies on products and professional services that demonstrate improvements in the adoption, effectiveness, efficiency and quality of self-care.

Minor Ailments

The treatment of minor ailments and self-medication with over-the-counter (OTC) products is the traditional heartland of self-care.

For the treatment of a minor ailment that is familiar to an individual then she – and it is often an adult female who takes the lead in the treatment of minor ailments in a household12 – will commonly purchase and use an OTC product that she knows well. She is confident through her experience and very much acts in a consumer mode, choosing products on the basis of presentation, price and comparable products, influenced by personal recommendation and particularly television advertising, but not actively seeking professional support for self-care13.

The treatment of minor ailments, however, are often influenced by a variety of circumstantial factors, such as

•  existing prescribed medication for LTCs, infections or contraception.
• terms and conditions of benefits (i.e., co-payment and pharmaceutical benefit arrangements, of medical insurance and healthcare provision) and  out-of-pocket costs.
•  marketing practices.
•  health professional recommendations.
•  professional intervention at the point of sale which depends on classification of medicines (e.g., P vs GSL in UK).

In some countries (e.g. Denmark) medicines (prescription and OTC) are available only through pharmacies. In others (e.g. UK) there may be two or three classes of OTC medicines, reflecting a regulated graduation of consumer access and with some products available in retail outlets other than pharmacies, whilst in the US, prescription medicines are limited to pharmacies (i.e., retail or mail order) and OTC products are generally available through a variety of retail outlets including pharmacies.

The deregulation of medicines determines the extent of their availability for self-care, and their branding, strength and clinical indications obviously affect their uptake by consumers. The public view prescription medicines as “stronger”, i.e. more powerful and risky, than OTC medicines14. However effectiveness is the key factor in the choice by the consumer of an OTC product, yet this is judged more on the basis of perception or previous experience, rather than the need for hard scientific evidence15.

Whilst the effectiveness of products is the priority for OTC consumers in seeking advice from pharmacies, the focus of pharmacy staff is on product safety16,17. Consumers are not overly concerned with the safety of OTC medicines and are surprised when serious risks arise with their use, as in the case of terfenadine18. To ensure safe and effective self-care, patients need to be alert to the risks of interactions between prescribed and OTC medicines19.

The availability of OTC products on prescription from a preferred healthcare provider, and the respective costs of the products through this route compared with direct OTC purchase, often determine how patients source medication for the treatment of minor ailments, e.g. hay fever20. In UK, for many patients it is cheaper to get general medical practitioners (GPs) to prescribe for minor ailments than purchase OTC medicines21. However 10 years ago a study was undertaken to explore the transfer of the management of 12 self-limiting conditions from GPs to community pharmacies22. Following the success of the “Care at the Chemist” scheme, the NHS across Scotland23 and  in many areas of England  has contracted community pharmacies to provide “Minor Ailment Schemes”, i.e. the supply of OTC products and advice for an agreed range of minor ailments24.

SelfCare welcomes studies from all perspectives on the determination of outcomes in the treatment of minor ailments and the evaluation of products used for self-medication. Both quantitative and qualitative research is of interest which provides insights on the self-care of minor ailments, including for example, information sources used by mothers and carers, aspects of health literacy, and impact of age, ethnicity, wealth and poverty on the recognition of minor ailments and decision-making in self-medication.

Correspondence to: Professor P R Noyce  Peter.Noyce@manchester.ac.uk


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