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There are many determinants of health, which, when at a disadvantage, result in inequalities, disparities, and inequities. These determinants can be biological, social, and environmental in nature. Through the evaluation of social factors and socioeconomic gradients in health, the index of disparity can be measured (Center for Disease Control and Prevention [CDC], 2014). The magnitude of this public health problem varies based on the population evaluated, but regardless of how big or small, it is an ongoing issue that needs to be addressed and reduced. As a future healthcare professional, I plan to stay true to my values and beliefs while following the four moral pillars to aid in this combat.
To create a culture of health and wellness for all, traditional approaches need to be abandoned, and cultural competence and health literacy must be established and promoted. This can be achieved through the modification of evidence-based medicine practices, development of organizational policies and trainings, community-based research, and clinical advocacy.
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Health is defined by the World Health Organization (WHO) (2014) as “a state of complete physical, mental, and social well-being, not just the absence of sickness or frailty.” An individual’s state of health is influenced by biological, socioeconomic, psychosocial, behavioral, and social factors. These factors include, but are not limited to, an individual’s genetic make-up, employment, education, income, mental health, ethnicity, and race. A population’s health is said to be determined by genetics, individual behaviors, social and physical environments, and health services (Center for Disease Control and Prevention [CDC], 2014).
Health inequalities exist when the attainment of health is different among individuals and groups of individuals. When these differences are due to socio-economic positions, they are considered a health disparity. Distribution of money, power, and resources throughout civilization determine socio-economic status. The lower the socio-economic position, the greater the risk of poor health due to systemic obstacles placing the individual(s) at a baseline disadvantage. If differences in health outcomes between individuals or groups of individuals are avoidable or unjust, a health inequity exists (CDC, 2014).
A culture of health and wellness for all cannot exist when these variations and inequalities in healthcare occur. These disproportions can be combated through the establishment of suitable governmental policies and the promotion of cultural competency throughout the healthcare field.
My personal values of trust, respect, honesty, and integrity are what drove me to the profession of pharmacy. As a pharmacist, we adhere to our profession’s code of ethics, in which we pledge to uphold the covenantal relationship that exists between us and the patient (American Pharmacists Association [APA], 1994). To build such a relationship, I must foster trust, not only from my patient but also from society. When I gain this trust, it is my moral duty to protect it. As a pharmacist, I must respect the autonomy and dignity of each patient that I treat and care for, which I achieve by encouraging patients to participate in their healthcare decisions and allowing the patient to determine the course of their treatment.
To accomplish this effectively, I must ensure health literacy by communicating at an understandable level. I respect the personal and cultural differences among each individual patient and expect the same respect in return. In all relationships that I establish, both personally and professionally, I act with honesty and integrity (APA, 1994).
I believe that it is my duty as a pharmacist to serve individual, community, and societal needs. Often these needs are beyond what I can accomplish on my own, necessitating advocacy and the establishment of inter-professional relationships. By adhering to the four pillars of moral life (respect, justice, non-maleficence, and beneficence), health inequalities can be reduced (Jahn, 2011). Growing up in Metro Detroit, I recognized early on that discrimination and exclusion based on mental illness present a significant health disparity.
Mental illness is defined by the American Psychiatric Association as “health conditions that involve changes in emotion, thinking, or behavior,” which includes substance use disorders (Parekh, 2018). Through my professional experience in behavioral health units and personally, I have recognized the magnitude of this epidemic and the major impact this disparity has on public health. My passion for treating the underserved and overlooked has driven me to become a board-certified psychiatric pharmacist with further certification in pain management. There is a consistent cycle between mental illness and communicable diseases. For example, Human Immunodeficiency Virus (HIV) and mental illness are closely interlinked (Pascoe & Richmond, 2009).
Roughly 23% of those who are mentally ill are also HIV+ compared to only 0.3% of the general population; and up to 40% of HIV+ individuals will experience major depression due to their membership in socially disadvantaged and marginalized populations (Bridge, 2016). Often, these patients do not seek or have access to their proper healthcare needs (Pascoe & Richmond, 2009). It is my goal, through my work as a psychiatric pharmacist, to move towards establishing health equity in this patient population to provide better patient health outcomes and quality of life.
The first step of establishing this health equity is focusing on cultural competency. Cultural competence is defined by the U.S. Department of Health and Human Services as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (CDC, 2014). Through my attainment of my Masters in Health Services Administration (MHSA), my goal is to attain a position in administration.
As a pharmacy administrator, I would have the authority to implement these policies and visions to establish cultural competence. Modifying evidence-based practices (EBPs) is a necessity (American Psychologist, 2006). Studies are often not tested among different patient populations, especially among minorities. Such vigilance, evaluating research performed in these populations, and guiding treatment based on appropriate studies is vital for equal health outcomes and attaining equity. As an administrator, I would ensure my organization considers the needs of the community, both clinically and culturally, when implementing EBM.
In regards to behavioral health, a cultural factor to consider and evaluate within an institution is their view of mental illness. Is there a holistic health treatment approach, and what level of stigma exists? These are assessments I would make and then use the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration’s (SAMHSA) toolkit to modify the necessary EBMs. The steps to improving cultural competency suggested by SAMHSA’s toolkit include first decomposing the EBM and determining which components need to be modified, followed by the development, documentation, and testing of these changes, and then evaluating the differences (Bridge, 2016).
In the National Institute of Health’s (NIH) Journal of Behavioral Medicine, “Discrimination and Racial Disparities in Health: Evidence and Needed Research,” Williams and Mohammed (2018) evaluated the effect of discrimination and racial disparities on health outcomes, discovering “racial discrimination has a direct link to physical illness” (p.32). Their studies showed those who endured discrimination based on race developed health conditions ranging from hypertension to breast cancer, and additional disease risk factors (Williams & Mohammed, 2018).
In “Preventing Race-Based Discrimination and Supporting Cultural Diversity in the Workplace: An Evidence Review” by VicHealth, Trenerry, Franklin, and Paradies (2012) performed an evidence review of two case studies evaluating the extent of racial discrimination within the workplace. Their evaluation resulted in the development of five key motives for its elimination: implementation of organizational accountability and development, diversity training, resource development and provision, service as a site for positive inter-group contact, and service as role models in anti-discrimination and pro-diversity practices for other organizations.
Trenerry, Franklin, and Paradies (2012) discussed that the key principle for racial discrimination elimination within an organization is to include a “top-down” central team that has an array of responsibilities for senior members to lead, while also implementing a “bottom-up” strategy to promote transparency and trust among employees.
According to community studies conducted by Williams, Neighbors, and Jackson (2003), racial discrimination yields negative health outcomes including depression, psychological distress, and anxiety. In the context of mental illness, the American Psychological Association (APA) has adopted practice guidelines to assist in tailoring their treatment algorithms and approaches. The evidence-based psychological practice guidelines developed require attention to race in addition to several other cultural differences (APA, 1994). I would utilize all these strategies when addressing “race” within my facility as an administrator and as a psychiatric pharmacist.
An article titled “Translating Research Evidence into Practice to Reduce Health Disparities” was published in The American Journal of Public Health. In this article, Koh, Oppenheimer, Massin-Short, Emmons, Geller, and Viswanath (2010) used a social determinant approach to create a public health system in hopes of completely eliminating health disparities. They suggest a heightened emphasis on translating and spreading proven interventions in ways that will reach all people. Koh et al. (2018) utilized the RE-AIM Model for this translation in attempts to reduce the gaps between research and practice implementation.
This model focuses on realistic changes and emphasizes “scaling up.” Scaling up is further explained as calling on researchers, practitioners, and policymakers to move beyond pilots, time-bound and specific targets, and progress towards expanding treatment access and adherence support (Koh et al., 2018).
The Annual Review of Public Health suggests an additional approach to improve public health by reducing disparities through the establishment of “Community-Based Participatory Research (CBPR).” CBPR involves gathering academicians, community members, and clinical researchers (Israel, Schulz, Parker, & Becker, 1998). Research performed by Israel, Schulz, Parker, and Becker (1998) indicates that CBPR can further drive the pioneering research necessary to control this public health problem by taking an “all-view” approach.
The WHO’s report “Health Equity Through Intersectoral Action” (2003) demonstrated the impact of interdisciplinary work through the evaluation of 18 case studies from all types of countries. This report outlines how taking a social-determinant approach reduces health inequities, and therefore, health disparities (Glasgow, Lichtenstein, & Marcus, 2003). As a healthcare provider and administrator, I would utilize this approach within my practice.
In conclusion, health inequalities, disparities, and inequities are major public health problems that we, as healthcare providers, need to work towards reducing in our future careers and practices. For all individuals to have the same opportunity to attain their full health potential without any disadvantages due to socio-economic factors, different approaches and trainings than what are conventional will be required.
As a future psychiatric pharmacist and health service administrator, it is my goal to incorporate my values of trust, respect, honesty, and integrity to combat the disparity index that faces the mentally ill. I will do this through EBM assessment and modification via the SAMHSA toolkit, utilization of Trenerry, Franklin, and Paradies’ five key motives, implementation of policies and protocols that promote the “top-down” and “bottom-up” approach, integration of community-based research, and the utilization of a social determinant approach within my organization. With interdisciplinary work, advocacy, and passion, we as the future generation of healthcare professionals can make a positive change in public health and wellness and reduce inequalities.
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