The landscape of self-care in Australia: A pharmacy perspective

Abstract

The evolving landscape of self-care in Australia underscores the imperative of recognizing and integrating the crucial role of pharmacists in promoting greater levels of self-care. Although the social and economic justifications for self-care are acknowledged internationally and in the literature, there is very little policy recognition in relation to self-care specifically in Australian health policy. Additionally, the distinct contributions of pharmacies to self-care, i.e., their experiences and accessibility in primary health care, are not consistently highlighted. Community pharmacies in Australia are currently navigating a transformative shift, expanding their scope of practice to deliver highly individualized care, with a special emphasis on the implementation of professional services crucial for the sector's enduring viability. Although pharmacists already play a substantial role in supporting self-care, there exists a compelling demand for a systematic and structured approach. Despite the limited availability of theoretical frameworks or models for pharmacists in self-care support within the existing literature, tangible practical evidence attests to the success of interventions. In an era where patients increasingly assume responsibility for self-managing conditions, the pharmacist's role in facilitating self-care and judicious self-medication is pivotal, promising not only tangible benefits for individuals but also contributing significantly to the long-term sustainability of the healthcare system in Australia. This necessitates a strategic and comprehensive framework that positions pharmacists as essential catalysts in the broader landscape of healthcare, ensuring their contributions are optimally leveraged to enhance patient outcomes and system efficiency.

1. International context of self-care

Self-care has been highlighted by the World Health Organization (WHO) as integral to primary health care and is defined as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider”.¹ Self-care puts the patient at the centre of their own health care,² and encompasses all activities which contribute to physical health and mental health. The importance and relevance of self-care and patient engagement in health policies and health care systems are critical as the evidence indicates that individual and population involvement results in significantly improved clinical, economic and humanistic outcomes.³

International health services and providers have moved toward incorporating ways to increase patient involvement,4, 5., 6 and embedding patient-centred care principles. The spectrum of care needs to shift from ‘in-hospital care’ to ‘healthy living’ to foster proactive well-being, prevent illnesses, and promote sustainable healthcare practices that prioritize long-term health outcomes over reactive medical interventions. In similar health systems such as the United Kingdom (UK), there has been a significant strategic shift toward policy support for self-care focusing on ‘patient activation’ at every stage of healthcare including the prevention of illness, symptom relief and chronic illness.⁷ A recent UK inquiry recommended an enhanced range of options across the primary care sector, including greater integration between general practice, pharmacy and other health care services.⁸ The Pharmacy Integration Fund was established in 2016, to drive the greater use of pharmacists in new, integrated local care models.⁹

The “Self-Care Readiness Index 2.0”, developed by the Global Self-Care Federation in 2022, is the second edition of an advocacy initiative to establish self-care as a global health priority and examines the healthcare systems and the extent to which self-care is embedded into current policy documents and conversations in ten countries, including Australia.¹⁰ The Index provides a snapshot of self-care readiness in Australia, showcasing a composite score of 3.14 (based on a four-point scale, ranging from 1 for those not self-care ready to 4 for those who are very self-care ready), reflecting a robust foundation for self-care initiatives. This places Australia among the top countries in the index, reinforcing its commitment to fostering self-care within its healthcare policies.¹⁰

2. The landscape of self-care in Australia

Although the social and economic justifications for self-care are acknowledged internationally and in the literature, there is very little policy recognition in relation to self-care specifically in Australian health policy.⁷ The only official “endorsement” is an indirect reference in the National Preventative Health Strategy in the context of the importance of health literacy to support self-care.¹¹ While the Self-Care Readiness Index 2.0 places Australia among the top countries in the index, identified above, it is important to acknowledge that there is still significant work to be undertaken to understand the health-economic value of self-care in Australia.

Additionally, the distinct contributions of pharmacies to self-care, i.e., their experiences and accessibility in primary health care, are not consistently highlighted in Australian policy. This disparity raises crucial questions about the integration of pharmacy services into the larger self-care framework and the health system as a whole and prompts an examination of the barriers preventing the full realization of their potential. The cost-saving potential of self-care for the Australian health system has been determined “to be between $1,300-$7,515 per hospital patient, per year”.³

In an analysis of the “The State of Self-Care in Australia” published in 2018 by the Australian Health Policy Collaboration (AHPC), several key issues were identified.¹² The review pointed out insufficient evidence that existing programs effectively target those in need of self-care support.¹² Overall, the review suggested that Australia is not fully leveraging the potential of self-care as a component of healthy public policy and urged a reconsideration of current approaches.¹² The review concluded that the evidence considered in the review “establishes that the state of self-care and self-management policy, programs and support in Australia is fragile at best”.¹²

Furthermore, in October 2020, the Australian Minister of Health launched the “Self-care for Health: A national policy blueprint” report produced by the Mitchell Institute at Victoria University.³ Within the report, the Mitchell Institute advocates and prioritises several key policy areas for implementation including: “Improving health literacy for all; building self-care into health care practice; enabling consumers to be active partners in health care; assuring the quality and accessibility of digital health information; and developing measures for individual self-care and self-care support by health services”.³ Structural policy approaches included in the set of proposals are: “Implementing funding and service models to support self-care; driving investment in preventative health and self-care; establishing a national approach to enabling and supporting self-care; and supporting individual and population health through all public policies”.³ However, these texts do not explicitly mention the role of pharmacy.

3. Pharmacists' role in self-care

The International Pharmaceutical Federation's (FIP) report in 2017 titled “Pharmacy as a gate way to care – Helping people to better health”,¹³ adopted the WHO definition for self-care, and provides evidence on the role of pharmacy in self-care. Although FIP has adopted this definition, traditionally community pharmacy has generally associated self-care primarily with non-prescription medicines. However, it is important to ensure that the broader definition adopted by WHO is accepted by pharmacy. Pharmacists, a widely available and conveniently accessible healthcare resource,¹⁴ are ideally placed to meet the challenges of ever-evolving consumer needs and global healthcare systems.¹⁵ Community pharmacists, alongside GPs, are typically the first point of contact for patients into the health system (50). Pharmacists have an integral role as partners in collaborative care teams of health care professionals to enhance self-care.^15,16 Collaboration is driven by the need for greater efficiency and cost-effective health outcomes.¹⁷

The profession is broadening the scope of practice of community pharmacists in both the provision of dispensing and professional services.18, 19, 20, 21 Pharmacists' roles continue to expand and incorporate greater patient care responsibilities and provision of more individualized care.²² The core medicine's role of community pharmacists is evolving from the current focus on dispensing to medicine experts to deliver individualized care to patients through a combination of medicines supply, self-care advice, and working in collaboration with other health professionals. The shift to a service provider model is driven primarily by leadership of national and international professional organisations, innovative practitioners, education, government policies, remuneration and patient needs.²³

Professional services are defined as “an action or set of actions undertaken in or organized by a pharmacy, delivered by a pharmacist or other health practitioner, who applies their specialized health knowledge personally or via an intermediary, with a patient, population or other health professional, to optimize the process of care, with the aim to improve health outcomes and the value of healthcare”.²⁴ The implementation of professional services continues to remain a crucial aspect of the future professional and economic viability of the sector.²⁵ The focus on new professional services suggests that the profession is changing its practices and continues to realize the professional and financial benefit of service implementation and its integrated role within the broader healthcare system.²⁶

The role of the pharmacist in self-care has been evolving and increasing as the profession becomes more service and patient oriented.²⁷ Furthermore, supporting self-care is not limited to community pharmacy.²⁸ Hospital pharmacists have roles, too, particularly in developing patients' understanding about medicines and management of long-term conditions after discharge from hospital.²⁸ The same applies to accredited pharmacists when conducting medication reviews.²⁸ There is much evidence demonstrating pharmacists' input into self-care. Community pharmacists provide education and guidance in multiple areas of self-care, including nutrition and physical activity, hygiene and disinfection, lifestyle choices, sexual health and other key lifestyle areas. They dispense and advise on the use of non-prescription medicines and other self-care products and devices.

It is already known that patients largely self-manage conditions²⁹ and encouraging people to exercise greater levels of self-care, either for acute or chronic problems, has significant potential to directly affect demand for, and shift costs from, medical health care. Pharmacists are positioned to facilitate consumer self-care and appropriate self-medication.^30,31 Undoubtedly, the expansion of nonprescription medicines has given consumers greater choice providing community pharmacy with an opportunity to demonstrate real and tangible benefits to consumers by facilitating this process.³⁰

However, while community pharmacists already assist patients to effectively self-care, aspects of the support provided are generally carried out opportunistically, as separate episodic interventions, following dispensing of prescribed medicines, or conducting specific services such as a consultation for minor ailments, medication review, medical devices, or lifestyle services. Furthermore, an ongoing literature review did not reveal any theoretical frameworks or models for pharmacists to provide self-care or self-management support in a systematic, structured way and the system changes needed. However, there is evidence of self-care interventions in the literature.³²

4. Australian pharmacists' role in self-care

The extensive network of over 5800 community pharmacies plays a pivotal role in the Australia's healthcare landscape.³³ Community pharmacies are the most frequently accessed and most accessible health destination in Australia, with over 462 million individual patient visits annually and many pharmacies open after-hours, including weekends.³³ Each year, community pharmacies dispense a total of over 218 million prescriptions, with a value of $10.6 billion and 460 million sales of over-the-counter products, with a value of $5.2 billion.³³

The 7th Community Pharmacy Agreement (7CPA) in Australia outlines a comprehensive set of arrangements between the Australian Government and community pharmacies, spanning a five-year period from July 2020 to June 2025.³⁴ The agreement is designed to support the delivery of quality healthcare services and medications to the Australian public. The 7CPA includes provisions for professional programs and medication management initiatives aimed at enhancing the role of pharmacists in healthcare and improving patient safety and health outcomes. Early negotiations for an 8th Community Pharmacy Agreement (8CPA) commenced in August 2023, with an anticipated start date of March 1, 2024. The forthcoming agreement aims to shape the future of pharmacy services and ensure continued support for the delivery of quality healthcare to Australians.³⁵ The focus on shaping the future of pharmacy services in the 8CPA underscores the importance of self-care practices, as community pharmacies are positioned to play a key role in promoting and facilitating individual health and well-being for Australians.

In Australia, State and Federal governments have followed this international trend of adding to their policies the need for pharmacist prescribing. In Queensland, the State government is currently funding a pilot on pharmacist prescribing which will “allow community pharmacists in North Queensland to prescribe medicines for common conditions such as nausea and vomiting, reflux, and mild skin conditions, and provide health and wellbeing services including hormonal contraception, oral health screening, weight management and support to quit smoking”.³⁶ The NSW Government is funding three trials to evaluate pharmacists prescribing for uncomplicated urinary tract infections, resupply of certain contraceptives and four skin conditions.³⁷ The Victorian Government has announced a $19 million allocation for pharmacist prescribing.³⁸ The Western Australia and South Australia Governments have legislated for pharmacist prescribing for uncomplicated Urinary Tract infections.^39,40 The shift toward pharmacist prescribing in Australia is a significant stride aligning with the emphasis on expanding the roles of healthcare professionals. With pharmacists now authorized to prescribe for various common conditions in Australia, individuals gain increased autonomy in managing their health. This aligns with the broader concept of self-care, where individuals are encouraged to actively participate in their well-being, making informed choices about their health needs.

The pharmacist's role in self-care can be operationalised into four key areas (Fig. 1).

Fig. 1.

Pharmacists' role in assisting individuals, carers and the community with self-care.

4.1. Prevention

Pharmacists in Australia play a crucial role in disease prevention through various initiatives and services. They are involved with health promotion by screening for, and increasing the awareness of, certain conditions and discussing strategies such as making healthy lifestyle choices for preventing certain health issues.¹⁵ This includes health screening and intervention in lifestyle diseases such as obesity, diabetes, smoking, alcohol/drug abuse among others.^41,42 In Australia, community pharmacists have rapidly adopted broader roles in providing immunization services, since 2014 and in all states and territories since 2016, leading to increased vaccination rates.^43,44 Pharmacists with general registration are authorized to administer vaccines after completing specialized training, which includes cardiopulmonary resuscitation, first aid, and anaphylaxis training under state or territory legislation.^43,45 This expansion in immunization services in Australia through pharmacies has contributed significantly to increasing accessibility to vaccinations within the community. The rapid adoption of these broader roles by community pharmacists underscores their commitment to public health and preventive care. It reflects a shift toward a more patient-centred and holistic approach, wherein pharmacists actively engage with individuals to promote healthier lifestyles and provide essential preventive services. This evolution in the pharmacist's role not only enhances the accessibility of preventive measures but also contributes to the overall resilience of the healthcare system by reducing the burden of preventable diseases.

4.2. Detection

The increasing prevalence of point-of-care testing (POCT) in community pharmacies across Australia underscores the evolving role of these establishments in healthcare,⁴⁶ with emphasis on the potential for POCT to aid both acute and long-term condition management.⁴⁷ This includes monitoring of blood pressure, lipids, blood glucose and HbA1c control, measurement of peak expiratory flow rate or oxygen saturation levels, among others. Screening and risk assessment programs are being delivered through pharmacies with the aim of identifying patients who have certain undiagnosed or uncontrolled health issues and need further assistance. This expansion of services goes beyond acute conditions, extending to the comprehensive management of long-term health issues.⁴⁸ As an example, the National Stroke Foundation's ‘Know Your Numbers’ initiative exemplifies the collaborative effort between pharmacies and public health campaigns. Pharmacists participating in this program provide opportunistic blood pressure measurements and utilize a validated diabetes risk questionnaire (AUSDRISK) within community pharmacy settings. Through this proactive approach, patients at risk for cardiovascular disease or Type 2 Diabetes are identified. Subsequently, these individuals are either referred to appropriate healthcare professionals, such as their general practitioners, or receive targeted lifestyle modification advice tailored to their identified level of risk. This integrated approach demonstrates capacity of community pharmacy not only to detect health risks promptly but also to guide individuals toward effective preventive measures and early interventions.⁴⁹

4.3. Minor ailments

Australian community pharmacists play a pivotal role, particularly in addressing minor ailments. According to the Pharmaceutical Society of Australia (PSA), minor ailments are “conditions that are self-limiting, with symptoms easily recognized and described by the patient and falling within the scope of pharmacist's knowledge and training to treat”.⁵⁰ This encompasses a range of issues such as common colds, strains and sprains, acute diarrhea, constipation, muscle aches and pains, allergies, headache, rash, dermatitis and eczema, fevers, foot conditions such as corns and callouses and others.⁵¹ The literature has reported that consumers may not successfully self-diagnose (and consequently self-manage) their minor ailments.^52,53 Pharmacists also play an important role in providing individuals with evidence-based advice on non-prescription medicines in accordance with Quality Use of Medicine (QUM) principles and responsible self-medication.⁵⁴ Nonprescription medicines have the potential for adverse effects and frequent or continued inappropriate use of these medicines can be clinically unsafe,55, 56, 57, 58 and has shown to contribute to hospital admissions.⁵⁹ Community pharmacists are well positioned to support patient purchases of nonprescription medicines through the application of knowledge and skills, in an environment in which safety and quality are paramount.³¹ This is consistent with the Pharmacy Board of Australia's advice, that one aspect of good practice involves “facilitating the quality use of therapeutic products based on the best available evidence and patient needs”.⁶⁰ Through triage and appropriate referrals, pharmacists contribute to the efficiency and sustainability of the healthcare system.⁶¹ Recent studies highlight the clinical, humanistic, and economic benefits derived from structured minor ailment services provided by community pharmacists in Australia, further promoting self-care.61, 62, 63

Self-medication is a fundamental component of self-care defined as “the selection and use of medicines by individuals to treat self-recognised illnesses or symptoms”.^15,16 Non-prescription medicines, categorized as Schedule 2 and Schedule 3, are supplied under the supervision of registered pharmacists, ensuring responsible access. As the primary channel for non-prescription products, community pharmacies enable consumers to practice self-care for minor ailments effectively.^64,65 Australia's nonprescription medicines market is a $5.4 billion industry growing at 2.5%,⁶⁶ providing choice and access to approximately 16,000 nonprescription medicines that are on the Australian Register of Therapeutics Goods.⁶⁷ Community pharmacies in Australia remain the dominant channel for nonprescription products. Importantly to note, certain nonprescription products can be also bought in supermarkets, where a health care professional is not available. While patients consider pharmacies a logical place to start the care process,68, 69, 70., 71 it must be noted that the public tend to self-medicate for their minor ailments before seeing any health care provider.72, 73., 74, 75 This of course varies with the nature of the illness.76., 77, 78 Patients report that the advice of a pharmacist is one of the most important factors in decision-making when selecting a nonprescription medicine.⁷⁹ Their use demands a degree of care along with professional advice that is objective and based on evidence.⁸⁰ Pharmacists have an important role in responsible self-medication, by serving as a point of access for reliable sources of information. They maintain a critical role in safeguarding their patients from potentially inappropriate use limiting further healthcare utilisation, such as general practice or emergency department visits. Pharmacists facilitate this process, converting self-medication by the patient into responsible self-medication practices, meaning the medicines are safe, of quality, are effective; are suitable for conditions that can be self-treated, with the correct formulation, dosage, and form of administration.

4.4. Chronic disease management

Self-management is defined “as a patient's ability to manage symptoms, treatment, physical or psychosocial consequences and lifestyle changes inherent in living with a chronic condition”.^81,82 Self-management is considered essential to disease management and secondary prevention.⁸³ Most self-management activities are disease-specific⁸⁴ and involve increasing patients' confidence to manage their symptoms and disease (self-efficacy).84, 85, 86 Self-management support is a comprehensive and multidimensional concept that looks at how care is provided holistically to the patient, not just as separate episodic interventions.³² The pivotal objective of self-management support is to change behaviors to produce sustainable positive health effects.³² This may be achieved by increasing patients' skills and confidence in managing their disease through regular assessment, goal setting, and problem-solving support.⁸⁶ Increased self-management activity has been shown to improve clinical indicators, symptom management, hospital admissions and in some instances, event-free survival in people living with cardiovascular disease, hypertension, cerebrovascular disease and diabetes.³

Medication plays a crucial role in self-management, especially for patients with chronic diseases.⁸⁷ Community pharmacists, being key points of contact for patients collecting prescription medicines, are well-positioned to facilitate self-management practices and enhance medication safety. Aspects of self-management support are generally carried out opportunistically by community pharmacists in Australia, either during dispensing of prescribed medicines or when conducting specific services such as a medication review, improving medication adherence or lifestyle services. Under the 7CPA in Australia, several initiatives and programs focus on medication management, adherence, and review to support self-management for patients with chronic diseases. For example, the Medication Management Review (MMR) Program aims to optimize medication use and improve patient outcomes by providing comprehensive medication reviews for individuals with chronic conditions, while Dose Administration Aid (DAA) services assist patients in managing complex medication regimens, promoting adherence and reducing the risk of medication errors.³⁴

4.5. Health literacy

In Australia, the role of pharmacists in promoting self-care is closely intertwined with their capacity to enhance health literacy among individuals and caregivers. Health literacy stands out as a fundamental precursor to effective self-care, influencing the comprehension of health information,^88,89 guiding health behaviors,⁹⁰ and improving health outcomes.⁹¹ In a definition adopted by WHO, health literacy is defined as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”.⁹² The importance of health literacy is underscored by its variation across different demographic groups. Factors such as age, ethnicity, and income consistently impact health literacy levels in primary care settings. Older age is associated with more limited health literacy, leading to potential challenges in navigating health information and resulting in poorer health outcomes.^91,93 Similarly, belonging to a minority ethnic group, speaking a minority language, or having lower income or socioeconomic status are linked to limited health literacy.94, 95, 96

Pharmacists play a pivotal role in addressing and mitigating the impact of limited health literacy. Through tailored interventions, clear communication, and the provision of easily understandable health information, pharmacists empower individuals to make informed decisions about their health and engage in effective self-care practices. The PSA Pharmacy Self-Care Program launched in 1986, with NSW Government support, and was eventually implemented by one third of all Australian pharmacies. The self-care program provides resources and training to educate pharmacy staff, add value to an individuals' experience, and tailored health promotions and resources.⁹⁷ Healthcare information and advice, staff training, and health promotion of minor and chronic disease areas have been the major components of the program.⁹⁷ PSA Self-Care Fact Cards serve as essential tools for pharmacists in promoting self-care. These fact cards are utilised during counselling sessions with patients seeking guidance on minor ailments and non-prescription medicines. Pharmacists can leverage these cards to provide accurate, evidence-based information about self-care practices, empowering individuals to manage their health more effectively.⁹⁸ The fact cards are particularly valuable in scenarios where individuals may not require immediate medical attention but seek guidance on managing minor ailments or choosing suitable non-prescription medications. By equipping pharmacists with reliable information, the PSA Self-Care Fact Cards contribute to a broader strategy of promoting self-care and responsible medication use within the community.

5. Conclusion

In conclusion, the full potential of pharmacists to enhance self-care in Australia necessitates a concerted and multifaceted approach. Investing in the development of cross-disciplinary self-care core competencies for all relevant health professionals, with a specific focus on pharmacists, is crucial. This demands collaboration among stakeholders to ensure a comprehensive and unified approach to self-care education and practice. Encouraging collaboration within the health sector is essential to optimize efficiency, safety, and value, fostering an environment where the contributions of pharmacists are fully recognized. Sustained investment in long-term strategies to enhance individual self-care is imperative, acknowledging the profound impact on overall public health. Integrating pharmacists into the national policy on self-care is essential, recognizing their pivotal role in prevention, detection, and the management of minor ailments and chronic diseases. Furthermore, a national health literacy strategy, utilizing pharmacists' expertise, can significantly improve health literacy and empower individuals in their self-care journey. To ensure the sustainability of these initiatives, a suitable funding model for pharmacist self-care services should be implemented, alongside funding for research to substantiate these activities with evidence-based practices. By embracing these recommendations, Australia can pave the way for a robust and integrated system that maximizes the role of pharmacies in advancing self-care, ultimately contributing to a healthier and more resilient population.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

Sarah Dineen-Griffin: Methodology, Writing – original draft, Writing – review & editing. Shalom I. Benrimoj: Conceptualization, Methodology, Writing – original draft, Writing – review & editing.

Declaration of Competing Interest

There are no conflicts of interest to declare. Views expressed in this article are the views of the authors and are not necessarily the views of any other organization they may be affiliated with at the time of publication.