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Models of pharmacy practice within healthcare systems CHAPTER 2
and fitness to practise of pharmacists and pharmacy
technicians, as well as the procedure for disciplining
or even removing a pharmacist or pharmacy technician
from the register. Thus the legislation in place at any
time in a country will have a direct effect on the ability
ofa person to becomeand remaina pharmacistandtheir
opportunities for employment and career prospects.
These will be explored in more detail.
UK healthcare systems
Pharmacists throughout the world have to operate
within the particular healthcare system of their country. This will have a direct effect on their roles, responsibilities and employment opportunities. In most
countries the aim is that all citizens have access to
health care. This is called universality. However,
how and whether this is achieved will differ between
countries. Most countries have a private healthcare
system running alongside a state or insurance-based
system which will either fully or partially fund treatment. A system of claims and/or benefits may be in
place for certain members of the country – for example the young, the old and the unemployed may receive free treatment.
In the UK, all the population (including visitors)
are provided with a ‘free’ healthcare system provided
by the National Health Service (NHS) which is
funded through taxation. In the primary care sector,
that is in the community, many healthcare professionals are independent but have contracts with the
NHS to provide NHS services. For example doctors
and dentists will have contracts with the NHS so that
access to them is free, although in the case of dentists,
while a dental check up is free, there is a co-payment
scheme in operation for any treatment. In practice
this means that patients can choose to be treated
either as an NHS patient or as a private patient by
their dentist, so the dentist operates in both the private sector and the NHS. Community pharmacists
are similarly independent but most will have a contract
with the NHS to provide dispensing and pharmaceutical services. This situation enables community
pharmacists to dispense both private and NHS prescriptions and to provide private pharmaceutical services if they wish. The NHS also provides the
secondary care structures such as hospitals, health
centres/clinics, etc., and employs a wide range of
healthcare professionals such as pharmacists, nurses,
physiotherapists, nutritionists, social workers and doctors. Access to hospital treatment is free.
While most medicines are available on an NHS prescription, a few medicines, in particular some of the
newer, more expensive drugs with limited long-term
clinical evidence, may not be available. Thus if a person
is financially able to afford these NHS-restricted
medicines then a private prescription can be written
alongside NHS prescriptions. Additionally community
pharmacies, as independent retailers, can offer medicines as well as other goods for sale.
Alongside the NHS a private healthcare sector
exists with a full range of hospitals and healthcare
professionals and healthcare provision. Individuals
choosing to be treated privately will have to cover
all the associated costs. However, many individuals
pay using insurance or private healthcare schemes
which may be a benefit of their employment for
themselves and their families.
For pharmacists the two systems mean that there
are employment opportunities within both NHS and
private hospitals. Likewise pharmacists employed in
community pharmacy might find themselves dispensing both private and NHS prescriptions. Community
pharmacists may find themselves providing medicines
for minor ailments via a free NHS scheme to eligible
patients, while other customers would have to buy the
same medicine themselves because they are not eligible for the scheme. Thus pharmacists need to understand the healthcare systems in which they are
working in order to be efficient and productive and
provide a quality pharmaceutical service to their
patients within the appropriate healthcare system.
Some other healthcare systems
In Australia the principle of universalityaims to provide
accessto the same standard of care for all citizens based
on a health insurance scheme called Medicare. All
citizens contribute via the taxation system, depending
on their ability to pay. However, unlike the UK NHS
system, while access to public hospitals is free, cash
benefits are paid from Medicare for the cost of access
to general practitioners and other healthcare specialties, such as dentists and optometrists. Prescription
medicines are provided from private pharmacies and
a pharmaceutical benefits scheme exists which provides a co-payment scheme for prescriptions and lists
of eligible medicines. The systemis fairly complex with
different levels of benefit depending on the status of
the individual (welfare entitlement of the citizen)
and the lists of eligible and non-authorized medicines. Patients may choose to pay extra for branded
19
SECTION ONE Pharmacy practice and society
products rather than generically prescribed medicines. Australian pharmacists require a good understanding of the pharmaceutical benefits scheme and
the medicines and brands of medicines available if
they are to provide both a good pharmaceutical service for their patients and navigate the s ystem.
In Ireland the emphasis of health care is on the
individual arranging their own private medical and
surgical services for themselves and their family.
However, there is a free healthcare scheme in cases
of hardship, called the General Medical Services
(GMS). This scheme also covers all under 16-yearolds and those over 70 years of age. Community pharmacies are privately owned and have to enter into an
agreement with the local health board to provide
GMS services. GMS provides a system of health care
in which many individuals are covered to a greater or
lesser extent by a drug payment scheme and a longterm illness scheme. Both are very convoluted and
provide a level of benefits for almost every group of
patients. These benefits can include a range of subsidized or free medicines and appliances. While the aim
is a private GMS, the work of pharmacists working
within the system will be increased by the system.
These three healthcare schemes are a mixture of
private and public. The public scheme either covers
the majority of the population or picks up the poorer
or more dependent sections of the population. In
Saudi Arabia all nationals are provided with free
health care and medicines. In that country, all community pharmacies are privately owned and are recompensed by the state for dispensing and the other
pharmaceutical services that they provide.
The different healthcare systems described above,
while not comprehensive, do indicate the variety of
healthcare systems available. Clearly pharmacists
have to work in the healthcare system of a particular
country. This may impose different systems of working because of characteristics of the provisions for
health care. It is essential that, whatever the situation,
pharmacists provide the best pharmaceutical services
for their patients within any limitations imposed on
them by the national healthcare system.
narcotic analgesics and other groups of potent medicines.
Some countries have a two-tier classification of
drugs:
*
‘Prescription only’ with dispensing limited to
pharmacists
*
‘Non-prescription’ medicines, also called ‘general
sales’ or ‘over the counter’ (OTC) medicines.
These medicines are available from pharmacies and
also from other retail outlets such as grocers,
supermarkets, newsagents and garage forecourts.
Some countries further divide non-prescription medicines into ‘pharmacy medicines’ and OTC medicines. ‘Pharmacy medicines’ are available for sale to
the general public but only from a pharmacy and
under the supervision of a pharmacist. Thus pharmacists have a direct input into the sale of these medicines. Germany, Ireland and the UK are examples of
countries which have this three-tier classification.
Australia also has a three-tier classification, but has
further divided pharmacy medicines into those that
can be sold:
*
Only under the direct supervision of a pharmacist
in a pharmacy and cannot be self-selected
*
In a community pharmacy on a self-selection basis.
The USA, Estonia and Saudi Arabia are examples of
countries with a two-tier system in which only pharmacists control access by the general public to prescription only medicines.
In recent years some medicines have been reclassified, usually from prescription only to pharmacy or
general sales classifications. This allows more medicines to become available to the general public for
purchase. It also gives the pharmacist more control
over the sale of medicines classed as pharmacy medicines. Such a process has given pharmacists a more
professional image and increased the professional content of their work. The reclassification process can go
from general sales to prescription only, but this would
only be expected if a drug was found to have major
side-effects not suitable for a general sales medicine.
This would be unusual.
Legal classification
of medicines
The legal classification used for medicines in a country
will have a direct impact on the practice of pharmacists. Most countries have laws to restrict access to
20
Advertising and availability
of medicines
Many countries have strict controls on the advertising
of prescription only medicines. For example, advertising to anyone other than a healthcare professional is
banned in the UK. These controls are to help protect
Models of pharmacy practice within healthcare systems CHAPTER 2
the public from the potential misuse of medicines.
However, in other countries, banning advertising is
considered to be a constraint on trade and so advertising of prescription only medicines is allowed, as for
example in China. With the advent of the Internet it is
very difficult for any country to completely control
the advertising of prescription only medicines, and
the general public can now access both advertising
and information about prescription only medicines
via the Internet. Some of the information on these
sites may contain inaccurate information. However,
having acquired this knowledge some patients consider themselves (often incorrectly) to be knowledgeable about medicines. They may become very
demanding of pharmacists and doctors in their quest
to obtain a particular medicine.
The advertising of pharmacy medicines and general
sales medicines is usually permitted. However, most
countries will have, as a minimum, some guidelines to
ensure that advertisements are truthful and do not
make excessive claims for their products. Again, this
advertising of pharmacy medicines may result in difficult patients who are not prepared for the pharmacist to
advise against, or refuse to sanction, their purchase of a
particular pharmacy medicine. Thus the laws governing
the advertising of medicines in their country will influence the everyday work of community pharmacists.
The availability of medicines in a country is usually dependent on the general wealth of the country, with the richer countries usually having a full
range of all the marketed medicines and the ability
to import from other countries as required. Thus
pharmacists in these countries will deal with many
hundreds of different medicines, especially if there
is a range of proprietary and generic medicines
available for the same drug. Pharm acists will need
to use their full range of knowledge and skill. This
situati on contrasts very sharply with poorer countries, in which even essen tial medicines (see Ch. 7)
may not be available. In such countries the role of
the pharmacist will be limited and some aspects of
clinical pharmacy will not be possible.
Education of pharmacists
The education of pharmacists follows a similar pattern
worldwide. This is not surprising since a few countries
have exerted a wide influence through a history of
domination. Europeans settled in many countries
in their quest for discovery and wealth and thereby
influenced the development of those countries. One
example was the British, whose empire dominated
many countries; the British Empire eventually evolved
into the less dominant but still influential British
Commonwealth.
More recently the creation of the European Community, later the European Union (EU), has resulted
in the need to harmonize the education and recognition of professionals throughout member countries.
This has resulted in a minimum of 4 years’ undergraduate university education for the awarding of an accreditable pharmacy degree in the EU. An agreement
to standardize the curricula between member countries within the EU has emerged. The 4-year degree is
followed by a 1-year practical training (called preregistration in the UK, internship in Germany) in a
pharmaceutical setting and under the supervision of a
pharmacist. In some countries the 1-year practical
training may be incorporated into the degree structure, thereby lengthening the degree.
Countries as geographically widespread as New
Zealand, Australia, Singapore, Brazil and Saudi Arabia
have also developed this 4 plus 1 model of pharmaceutical education.
Registration as a pharmacist
The legislation in most countries requires registration
as a pharmacist with a professional and/or regulatory
body or the state. For example, Singapore has a Pharmacists Registration Act requiring pharmacists to register with Singapore’s Pharmacy Board, while in the
UK, the Pharmacy and Pharmacy Technicians Order
is the legal basis setting out the registration requirements. Requirements usually include the prospective
registrant to have achieved success in a professional
examination, usually termed the registration examination, prior to applying for registration. Unless actually registered, a person cannot work as a pharmacist,
even if they have completed all the educational and
registration requirements. Pharmacists wishing to
work in a country other than the one in which they
were educated will usually have to complete further
training. This is likely to include practical training and
passing at least one examination. The latter may be
equivalent to the registration examination, but may
require more extensive knowledge before applying for
registration in that country.
In the UK, prospective pharmacists have to successfully complete the pre-registration year and the registration examination before registering with the Royal
Pharmaceutical Society of Great Britain (RPSGB).
21
SECTION ONE Pharmacy practice and society
The RPSGB is an example of a combined professional
and regulatory body. Plans are in place to separate
these two roles and establish a separate regulatory
body which will register and monitor ‘fitness to practice’ of pharmacists (see Ch. 10). It will have disciplin-
ary powers to deregister, if necessary. The other body
will have a professional role. Similarly other countries,
such as New Zealand, have recently and successfully
separated these functions.
In South Africa, pharmacists must register with the
South African Pharmacy Council, which is the statutory body. Its objectives include the control, promotion and maintenance of standards of pharmaceutical
education and pharmacy practice. It also plays a role
in the control and maintenance of the professional
conduct of registered pharmacists. This system is an
example of a separate registration body. Professional
organizations exist in South Africa, including the
Pharmaceutical Society of South Africa, to professionally represent pharmacists.
In Saudi Arabia, the Pharmacy Board of the Saudi
Food and Drug Authority acts as the regulatory and
registration body for pharmacy.
In very small countries such as Bermuda, which
does not offer its own pharmacy degrees, overseas
trained pharmacists are employed, usually with US,
Canadian or UK degrees. They are required to undertake a 1-month pre-registration training to acquaint
themselves with the Bermudan system before taking a
pre-registration examination. Success in the examination will allow the individual to register as a pharmacist with the Pharmaceutical Council of Bermuda.
Most of the r egulatory bodies place requirements on registered pharmacists including compliance with codes of practice or standards. For
example, the South African Pharmacy Council publishes Rules for Good Pharmacy Pra ctice and a list
of products that should not be sold in a community
pharmacy. Continuing professional development
(CPD) is rapidly becoming a mandatory require ment for continuing registration as a pharmacist.
Some countries require obligatory credits, for example Saudi Arabia requires 60 credits over 3 years.
Other countries simply require the pharmacist to
undertake CPD, while yet others, including the UK,
require written records.
The requirement for registration and the concomitant application of ‘ rules of professional behaviour’
and CPD places responsibilities and obligations on
pharmacists in their practice of pharmacy. Ignorance
of these ‘rules’ and CPD requirements may place a
pharmacist in the position of being disciplined by the
regulatory body and ultimately de-registered. Thus a
knowledge of the continuing requirements for registration must influence how a pharmacist behaves professionally both at work and during leisure.
Community pharmacy
From the earlier description of healthcare systems,
it is apparent that most community pharmacies are
privately owned. State owned pharmacies were
the norm in the former Soviet Bloc countries, but
these have now been privatized. In some countries,
for example Estonia and Switzerland, only pharmacists can own a pharmacy. Some countries limit the
number of pharmacies which a pharmacist can own.
In Germany, for example, pharmacists are limited
to owning no more than four pharmacies, while in
some Australian states the limit is no more than three
pharmacies. In Finland, no pharmacist can own more
than one pharmacy, but with permission, can own
up to three ‘subsidiaries’ in the neighbourhood. In
Finland, a 5–6-year masters degree in pharmacy is
offered in addition to a 3-year bachelors degree, but
a pharmacy can only be owned by a pharmacist with a
masters degree.
In some countries the ownership of pharmacies is
not restricted to pharmacists and the number of
pharmacies owned is similarly not restricted. This
arrangement gives rise to chains of pharmacies and
pharmacies within supermarkets. The UK, Australia,
USA, Lithuania and Saudi Arabia are examples of
countries with this latter model. Some countries have
regulations limiting the number of pharmacies within
a geographical area or even the location of pharmacies.
In a similar way to the registration of a pharmacist,
most countries will require a pharmacy to be registered and/or licensed with an appropriate body. This
body may impose conditions on the pharmacy, such as
required equipment, grades and numbers of staff,
dispensary size, having counselling areas, places for
health promotion leaflets, etc.
Some of these requirements mean that pharmacists
in such pharmacies will be expected to use the counselling room for medication reviews. This is the case in
the UK and Australia, for example. In some countries
there may be an emphasis on the provision of health
promotion advice, possibly accompanied by a leaflet.
Other pharmacies will have testing equipment to
provide, for example, cholesterol or Chlamydia testing. Yet other pharmacies may develop expertise in
extemporaneous dispensing.
22
Models of pharmacy practice within healthcare systems CHAPTER 2
Thus, depending on the country in which they
work, community pharmacists will find themselves
able to own a pharmacy or be employed in an independent pharmacy or a chain or supermarket pharmacy. The registering or licensing body decides the
conditions in which they work and the type of work
that they are required to undertake. These different
models will clearly affect the working conditions of a
pharmacist.
Hospital pharmacy
Pharmacists may work in either private or public
hospitals depending on the healthcare organization
in the country. The role of hospital pharmacists in
different countries will be dependent on the range
of medicines available, the distribution systems in
place and the extent of development of clinical
pharmacy and other specialist areas.
Hospital pharmacy was originally concerned
with the distribution and manufacturing of medicines. In many wealthier countries and those with
an abundant supply of medicines this function has
changed to one with more emphasis on clinical
pharmacy and the rational a nd appropriate use of
medicines. Thus pharmacists are not confined to
the dispensary, but will conduct patient medication
reviews, take part in ward rounds, provide therapeutic drug monitoring, deliver drug information
services and advise on medicines management.
Additionally, specialist pharmacists have evolved
with the spread of clinical pharmacy in areas such
as intensive care, HIV/AIDS and psychiatric
pharmacy, for example. With a diminution of the
manufacturing function, the distributive and
manufacturing functions in hospital pharmacy are
often delegated to others, for example pharmacy
technicians, who develop their own areas of specialization.
In many countries, hospital pharmacists have developed their own organizations. An example is the
Society of Hospital Pharmacists of Australia. These
organizations unite hospital pharmacists, promote
their role and provide routes for exchange of information and education and training.
Thus the practice of hospital pharmacy will depend
on the country, the availability of medicines and the
extent of development of clinical pharmacy.
Conclusion
While there are many similarities in the roles of pharmacists working in different countries, the dissimilarities are also evident. The role of pharmacists depends to
a great extent on the healthcare systems in place. In
most countries, there is a mix of private and public
health care and most community pharmacists will be
working in a private community pharmacy which will
contract to provide pharmaceutical services to both
private and state systems. Thus the pharmacist must
have a wide understanding of the system of charging
patients and the system for reimbursement from the
public healthcare system. The role of hospital pharmacists is changing from distributive and manufacturing
pharmacy to patient centred pharmacy . However, the
role of all pharmacists will be dependent on the medicines available and their legal classifications.
KEY POINTS
*
A wide spectrum of methods of healthcare
provision is used around the world because no one
system is ideal for all circumstances
*
There is a lack of equity in healthcare provision with
richer countries having more advanced systems,
but often providing financial aid to poorer countries
*
Healthcare systems must react to local needs
*
The potency of modern medicines requires
responsible distribution, usually by a pharmacist or
technician, in order to protect the public
*
Legal controls vary in classifying medicines,
advertising, availability and dispensing of
medicines
*
Most countries provide health care to citizens,
often alongside a private system, funded centrally
or by insurance schemes
*
Because of the diversity of schemes, pharmacists
must be fully conversant with the scheme in the
country in which they practise
*
Most countries adopt a two-tier or three-tier
classification of medicines and allow for
reclassification
*
Many countries allow advertising of pharmacy and
general sales medicines but restrict or ban
advertising of prescription medicines
*
A 4-year plus 1 model for pharmacist education is
normal, although ‘registration’ requirements vary
*
Ownership of community pharmacies might be
restricted in some countries by number, geography
or pharmacist qualification
23
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Chapter Three
Socio-behavioural aspects of health
and illness
K. Hannes Enlund
3
STUDY POINTS
*
Why social and behavioural sciences are important
in pharmacy
*
The meaning of health and illness
*
Factors incorporated into models of health
*
How people behave when they are ill
*
Behavioural aspects of health care
*
Factors affecting the treatment process
Introduction
For a full understanding of the use of medicines and
the role of pharmacy in health care it is necessary to
consider sociological and psychological factors which
often are tightly interwoven. These are still rather
new areas within pharmacy education and research.
Understanding and resolving medicine-related problems that result in suboptimal outcomes requires a
scientific basis, and earlier attempts to solve these
problems using ‘common sense’ approaches have
been only partially successful. Therefore there is a
need to broaden our perspectives by incorporating
relevant social and behavioural theory and research.
The purpose of this and the next chapter is to give a
broad overview of the health-related issues within a
social and behavioural framework to show the importance of ‘non-biological’ factors in understanding
health and illness with relevance to practising pharmacy. Illness can be seen either as a purely biophysical
state or more comprehensively as a human societal
state where behaviour varies with culture and other
social factors. A common view is that the pure biomedical model underemphasizes the human aspects
of patient care and neglects important psychosocial
issues. The social sciences have a shared focus on
understanding patterns and meaning of human behaviour, which distinguishes them from the physical and
biological sciences.
Pharmacists have to deal with many social and
behavioural issues in their daily work, either directly
or indirectly. The contribution of social sciences to
pharmacy and pharmacy practice can be summarized
in the following three areas:
*
Analysing pharmacy, i.e. helping in identifying
important questions relating to the use of
medicines, the practice of pharmacy and pharmacy
as a profession
*
Providing conceptual and explanatory frameworks
for understanding human behaviour in a social
context
*
Providing tools to study the use of medicines and
pharmacy.
The aim here is not to be all-inclusive, but rather to
highlight important contributions from social and
behavioural sciences. Many of the subjec ts presented could fill a book on their own, so it is evident
that only a brief introduction to each subject is possible in this chapter. This chapter will focus on the
definitions, dimensions and determinants of health
and illness. For a pharmacist it is also very important
to understand the d ifferent processes involved in
illness behaviour and treatment. There is also an
attempt to mention the major concepts and theories
in each con text. An overall framework is presented
in Figure 3.1. The interested reader is referred to
the specialized textbooks, other books and articles
on the topic that are included in the further reading
(Appendix 5).
SECTION ONE Pharmacy practice and society
experts vary greatly in their views on both physical
and mental disorders and their connections. Therefore we can ask whether disease is well defined or
even definable.
Illness is more a state defined by a layman or a
reactionto a perceived biological alteration of the body
or mind. It has both physical and social connotations.
Illness is also highly individual. It is influenced by cultural, social and other factors. It is important to note
that a person may havea diseaseand not be ill, might be
ill but not have a disease or might have both an illness
and a disease. Sickness is also a socially defined condition, a social status conferred on an individual by other
members of the society. This will be further elaborated
in the context of the sick role (p. 30).
The most widely used definition of health or wellness is that of the World Health Organization (WHO),
which states that: ‘Health is a state of complete physical, mental and social well-being and not merely the
absence of diseases and infirmity’. This definition has
been widely quoted, but is less used in daily practice in
health care. The definition has to be seen more as a
goal that is actively sought through positive actions and
not merely as a passive way of avoiding disease-causing
agents. Different definitions and models of health also
have practical relevance, as they are needed to guide
policymakers in their allocation of resources.
Figure 3.1*A model of the social and behavioural factors
involved in health and illness.
Defining health and illness
Health and illness mean different things to different
people. Most young people take health for granted.
We commonly think about health as the absence of
signs that the body is not functioning properly or
absence of symptoms of disease or injury. There is a
tendency to dichotomize health; either you are
healthy or not. However, health is not merely the
absence of disease, but rather a continuum of different states. There are degrees of wellness and of illness.
Disease, in contrast to illness, is something professionally defined and therefore also perceived to be
more accurate. This has also become the essential
framework for the organization we call health care.
However, research shows that physicians and other
26
Dimensions of health
The WHO definition distinguishes physical, mental
and social health. In some narrower definitions, only
physical and mental health are included, thus implicitly excluding resource allocation for other areas. A
broader definition may emphasize social and other
dimensions as well. One of the dangers is that the
broader the definition, the more we tend to medicalize our society as we include more and more everyday
things as part of the responsibility of clinical medicine
and public health (e.g. loneliness, attention deficit
disorders, domestic violence). On the other hand,
these broad definitions allow us to examine health
issues more comprehensively. The definition used will
also have economical and other consequences.
Most of us see physical health as being free from
pain, physical disability, acute and chronic diseases
and bodily discomfort, i.e. as the normal functioning
of the body’s cells, organs and systems. However, our
prior experiences of disease, age, education and a
variety of other personal and social factors will influence our perception of physical health.
Socio-behavioural aspects of health and illness CHAPTER 3
Mental health is composed of the ability to deal
constructively with reality and adapt to change without feeling threatened by it. A positive self-image and
an ability to cope with stressors and develop intimate
relationships are also part of mental health. Furthermore, enjoying the pleasures of ordinary life and making plans for the future are important aspects of
mental health.
The role of spiritual health has raised less research
interest. Some might consider this as merely part of
the mental health dimension, while others argue that
it is a separate dimension. It should not be confused
with religion or religiousness. A sense of spiritual wellbeing is possible without belonging to an organized
religion. Spiritual health has been characterized by
Miller & Price (1998) as the ability to articulate and
act on one’s own basic purpose of life, giving and
receiving love, trust, joy and peace, having a set of
principles to live by, having a sense of selflessness,
honour, integrity and sacrifice and being willing to
help others achieve their full potential. By contrast,
a negative spiritual health can be described by loss of
meaning in one’s life, self-centredness, lack of selfresponsibility and a hopeless attitude.
The impact of social health on the well-being of the
individual has been widely demonstrated. Social integration, social networks and social support have both
direct and indirect influences on health. A low socioeconomic status defined by educational level, income
and occupation is closely related to higher morbidity
and mortality.
Determinants and models of health
The history of medicine contains several theories, or
frameworks, for the origins of disease. One of the
earliest explanations was that mystical forces like evil
spirits could cause physical and mental illness. The
father of medicine, Hippocrates (460–370
oped the humoral theory to explain why people get
sick. According to this theory the body contains four
fluids (blood, phlegm, yellow and black bile) called
humours. When these are in balance we are in a state
of health and, accordingly, when there is an imbalance
we are sick.
In the Middle Ages illness was closely related to
religious beliefs and sickness was often interpreted as
God’s punishment for doing evil things. Priests led
most of the practice of medicine and became more
involved in treating the ill, sometimes torturing the
BC), devel-
body to drive out evil spirits. After the Renaissance
different scholars became more human-centred, one
of the most influential in the 17th century being Rene
Descartes. Descartes’ impact on scientific thought
has been extensive and lasted for centuries. His main
health-related ideas can be summarized in three
points: first he saw the body as a machine and described how action and sensation occur, second he
proposed that body and mind, although separate,
could communicate, and third that the soul in humans
leaves the body at death.
In the following centuries scientists learned more
and more how the body functions with the help of the
microscope and other technical advances. New theories, like the germ theory, tried to explain disease by
microbes, etc. All these advances led to the foundation of the current biomedical disease model, which
proposes that all diseases or physical disorders can be
explained by disturbances in physiological processes
which result from injury, biochemical imbalances and
bacterial or viral infections. The biomedical model
assumes that disease is an affliction of the body and
is separate from the psychological and social processes
of the mind.
A more recent and comprehensive model is the
biopsychosocial model that involves the interplay of
biological, psychological and social aspects of a person’s life.
Additionally, some ancient beliefs about ill health
and disease, still prevalent among primitive tribes and
in certain cultures, continue surprisingly strongly in
industrialized countries alongside conventional medicine. Wrong behaviour, diet, dirty water, weather,
accidents, black magic or witchcraft, spirits and God
are all mentioned as causes of diseases. ‘Don’t wet
your feet or you’ll catch a cold’ typifies certain superstitious thinking.
Genetic and biological
determinants
In current medicine there is much interest in the
genetic basis of disease. The origin of most health
problems seems to lie in human genes. The newspapers have declared the finding of the alcoholism, antisocial behaviour and obesity genes among others.
This leads to the lay impression that once the genetic
code has been solved all health problems will also be
solved without any need to pay attention to, for example, health habits. This is, of course, far too simplistic a way of thinking. The scientific interest in this
27
SECTION ONE Pharmacy practice and society
field lies in interactions between genetic endowment
and psychosocial factors in early childhood. Laboratory research with animals has shown that genetically
predisposed spontaneously hypertensive rat pups
cross-fostered by normotensive mothers did not develop hypertension as they matured. This study shows
that poor genetic endowment can be overruled by
favourable upbringing and environment.
Behavioural determinants
The leading causes of death today – heart disease,
cancer, stroke and accidents – are all associated with
behavioural risk factors. The origin of many chronic
diseases such as diabetes and hypertension can be
found in lifestyle factors. Sedentary lifestyle explains
a lot of the causes of these diseases without the need
to go to the gene level. Sometimes positive genetic
endowment can explain why poor health habits are
not leading to poor health. It is also remarkable that
the remedy for most of these lifestyle diseases can be
found in simple behavioural remedies like increased
physical activity, reduced stress, balanced diet and
quitting smoking.
Behaviour and mental processes are the focus of
psychology and they involve cognition, emotion and
motivation. Cognition involves perceiving, knowing,
learning, remembering, thinking, interpreting, believing and problem solving. Emotion is a subjective feeling that affects and is affected by our thoughts,
behaviour and physiology. Emotions can be positive/
pleasant or negative/unpleasant. People whose emotions are more positive are less disease prone and more
likely to recover quickly from an illness than those
with more negative emotions. Motivation applies to
explanations of why people behave the way they do,
e.g. why they start a health-related activity or why
they do not take their medicines as prescribed.
Psychology is also interested in interpersonal relationships, which includes thinking, feeling and doing with
someone else. Descriptions of cognition, affect,
behaviour and interpersonal interactions overlap and
it may be difficult to separate them; for example, in a
situation causing anxiety the person may think he is
not in control of the situation (cognitive component),
he is afraid (affective) and his hands are sweating
(behavioural) and he may ask somebody to help support him (interpersonal).
Stress is a condition that results when personal/
environmental transactions lead the individual to
perceive a discrepancy (real or not) between the
demands of a situation and the resources of the person’s biological, psychological or social system. The
connection between body and mind is also reflected
in how people react to stress. It can produce changes
in the body’s physiology and cause illness. Stress can
release hormones, especially catecholamines and corticosteroids, by the endocrine system through arousal.
Effects on the cardiovascular system can be important
and stress-related emotions such as anxiety and depression can play a critical role in the balance of the
immune system. Stress can be described as a stimulus.
Events and circumstances that are perceived as threatening or harmful, and which produce feelings of tension, are called stressors. However, stress can also be
seen as a response to stressors. The person’s physiological and psychological response to a stressor is
called strain. Stress can be seen as a process including
stressors and strain and the relationship between the
person and the environment as continuous interactions and adjustments.
Stress can also affect health through the person’s
behaviour. People who experience high levels of stress
tend to behave in a way that increases their chances of
becoming ill or injured. They consume more alcohol
and drugs and smoke more than people who experience less stress. Accident rates are also higher among
those with elevated stress.
Environmental determinants
The role of environmental factors (biological, chemical, physical, mechanical) in influencing human
health is widely accepted. The main pathways into
the human body are air (outdoor and indoor), water,
food and soil. The role of these environmental factors
in the pathogenesis of asthma, hay fever and others is
clear. However, environmental factors have a much
broader impact, starting in the prenatal phase (e.g. the
use of drugs like thalidomide during pregnancy has led
to severe birth defects).
The importance of the environment has been
demonstrated in migrant and time-trend studies of
disease. When people change environment their
disease risk patterns change. One interesting demonstration is the case of Japanese migrants. The further
they went across the Pacific the higher their incidence
of coronary heart disease and the lower their rate of
stroke. Japanese in Hawaii have rates of heart disease
intermediate between those in Japan and those in
California. Environment and lifestyle are the most
probable explanations of these differences.
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