09_C1.indd www.pharmacist.com December 2008 • Pharmacy Today 51 review Go to www.pharmacist.com and take your test online for instant credit. Objectives: To introduce historical and sociocultural influences on health and health care decisions that should be considered by pharmacists and other health professionals when serving Amish patients and to describe the roles of pharmacists in working with Amish populations, as an example of culturally and linguistically appropriate care. Setting: Community independent pharmacy in Arthur, IL, from 1991 to 2008. Practice description: Reflections of a pharmacist–owner whose community prac- tice serves a sizeable Amish population. Case summary: The Old Order Amish are a religious group that values health and actively participates in its health care decisions. The Amish possess a strong sense of community responsibility and often seek advice of friends, family, and community in health care decisions. Their explanatory models of health and illness differ, in some respects, from the larger American society. The Amish are open to the use of folk medi- cine, complementary and alternative medicine, and conventional care when deemed nec- essary. They are receptive to health care information and explanations of options from trusted sources and use increased self-care modalities, including herbal remedies. Results: Knowledge of salient cultural differences is important, but care should be given to avoid stereotyping patients because Amish rules and customs differ across dis- tricts. Culturally competent pharmacist care should be individualized based on patient needs and in consideration of aspects of differences in Amish cultures and districts. When serving Amish patients, special consideration should be given to addressing poten- tial barriers to health care use, such as unique dialects, affordability issues for largely cash-paying customers, lower prenatal care use, and lower vaccination rates. Conclusion: Enhanced awareness and sensitivity to Amish lifestyles and beliefs can lessen misconceptions and minimize barriers that interfere with optimal provision of patient-centered pharmacy care and services. By working through established com- munity norms, building trust, and effectively applying cultural competency techniques, pharmacists can best serve the Amish communities. Keywords: Amish, community pharmacy, cultural competence, barriers, alternative medicine. Pharmacy Today. 2008(Dec);14(12):51–63. Pharmacists’ considerations when serving Amish patients Stephanie Y. Crawford, Aimée M. Manuel, and Bruce D. Wood review ©2008 by the American Pharmacists Association • All rights reserved. • Printed in U.S.A. Stephanie y. crawford, Phd, is Associate Professor and Associate Head, Depart- ment of Pharmacy Administration, and aimée m. manuel is Student Pharmacist, College of Pharmacy, University of Illinois at Chicago. Bruce d. Wood, BS, is Pharma- cist–Owner, Dicks Pharmacy, Arthur, IL. correspondence: Stephanie Y. Crawford, PhD, Department of Pharmacy Adminis- tration, College of Pharmacy, University of Illinois at Chicago, 833 S. Wood St. (mc 871), Chicago, IL 60612. Fax: 312-996- 0868. E-mail: crawford@uic.edu continuing education credits: See learning objectives below and assess- ment questions at the end of this article, which is ACPE universal program number 202-000-08-246-H04-P in APhA’s edu- cational programs. The CE examination form is located at the end of this article. To take the CE test for this article online, go to www.pharmacist.com/educa- tion and follow the links to the APhA CE center. disclosure: The authors declare no con- flicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria. acknowledgments: To Theresa Binion, Executive Director for the Arthur-Amish Country Visitor Center, for reviewing background information pertaining to the Amish residing in the Arthur, IL, area. Funding: Article development sup- ported in part by a grant from the Project EXPORT Center for Excellence in Rural Health, the National Center for Rural Health Professions, the University of Illi- nois College of Medicine at Rockford, and the National Institutes of Health National Center on Minority Health and Health Disparities. The contents of this article are solely the responsibility of the authors and do not necessarily represent the of- ficial views of the sponsors. Published concurrently in Pharmacy Today and the Journal of the American Pharmacists Association (available online at www.japha.org). Abstract 52 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. review A ccording to the American Pharmacists Association Code of Ethics for Pharmacists, the primary obligation of a pharmacist is individual patient care, and service obli- gations sometimes extend beyond the individual to the com- munity and society.1 Ethical guidelines also note the need for pharmacists to respect individual and cultural differences. Cultural competence involves the ability of individuals and systems to deliver culturally and linguistically appropri- ate services, interventions, and care.2,3 Aspects of culture include race and ethnicity, gender, age, religion, socioeco- nomic status, geographic region, disability, sexual orienta- tion, and health beliefs, among others. Cultural competency techniques (at the systems level), designed to reduce health disparities, have been described elsewhere2–4 and are sum- marized in Table 1. Table 1 provides brief descriptions of the applicability of the techniques to Amish populations, which will be discussed in this article. The effective use of cultural competency techniques should result in (1) greater knowl- edge of illness, disease, and treatments; (2) improved com- munications; (3) increased trust; and (4) improved under- standing of patient beliefs and expectations.2 The Amish require special considerations from health pro- fessionals because of unique aspects of their culture, which varies in different districts across the country. Currently, a limited body of published information is available for health professionals treating the Amish. A better understanding of Amish perspectives on health and health care practices can help provide patient-centered care to this population. Because of shortages of health professionals in many rural locations (including communities near Amish settle- ments), necessary health care services may be unavailable or limited. Dickinson et al.5 reported that 96% of Amish respondents in a small Wisconsin survey stated that they would use the services of a pharmacist, if one were avail- able. Using reports in the literature and the experience of a pharmacist practitioner, the current article introduces his- torical and sociocultural influences on health care decisions that should be considered by pharmacists and other health care practitioners when serving the Amish community and describes the role of the pharmacist in working with Amish patients. Although relatively few pharmacists will interact with Amish patients on a routine basis outside of localized regions with heavy populations, this report aims to increase understanding of the community and to illustrate the appli- cability of general cultural competency recommendations to a specific subpopulation. At a Glance Synopsis: Enhanced understanding of Amish beliefs and culture can help pharmacists serving Amish com- munities to minimize barriers that may interfere with optimal care. The reflections of a pharmacist–owner whose community practice serves a sizeable Amish pop- ulation and observations from the literature are provided to inform pharmacists of special considerations when serving the Amish. Unique dialects, affordability issues for mainly cash-paying customers, lower prenatal care use, and lower vaccination rates may be potential barri- ers to health care use in this population. The Amish use folk medicine, complementary and alternative medicine, and, when deemed necessary, conventional care. They are receptive to health care information and explana- tions of options from trusted sources and use increased self-care modalities, including herbal remedies. Analysis: Culturally competent pharmacy care should be individualized in consideration of aspects of differences in cultures and rules among Amish dis- tricts. To effectively counsel patients on therapeutic use and safety and to check for potential drug interactions, pharmacists serving Amish communities should strive to be nonjudgmental about folk care and knowledge- able of herbal remedies and vitamins. The Amish may be receptive to vaccination outreach programs if the topic is openly discussed and individual concerns are addressed. Outsiders to Amish communities need to establish rela- tionships in order to be accepted, usually by first consult- ing and working with community church leaders through established local community structures. Collaborative efforts then can be established with other health profes- sionals serving the Amish community. Learning objectives n List four potential outcomes of effective cultural competency techniques. n Provide six examples of cultural competency techniques that are applicable to Amish cultures. n State health beliefs and explanatory models of health and illness accepted in Amish cultures. n Differentiate the three sectors of the health care system that may be used by Amish people. n Name four reasons for lower vaccination rates among the Amish. n Identify examples of how pharmacists can help alleviate logistical, communication, and cost barriers to effective health care provision for Amish patients. www.pharmacist.com December 2008 • Pharmacy Today 53 review Go to www.pharmacist.com and take your test online for instant credit. review Table 1. Summary of cultural competency techniques and applicability in serving Amish patients Cultural competency techniquesa Applicability to Amish populations Language assistance services (interpreter services or bilingual providers) Individuals may speak English and/or a blended English–German dialect (e.g., Penn- sylvania Dutch). Language assistance services may be needed if patients have lim- ited English proficiency, although many Amish community members are bilingual. Recruitment, retention, and training of staff who reflect community diversity Hire and train staff who are respectful of, sensitive to, and knowledgeable of patient health beliefs, practices, and illnesses. Coordination of efforts with traditional healers Consider possible patient use of alternative care and folk care providers (e.g., brauchers) and remedies. Collaboration with community health workers Attempt to work with district bishops and other church leaders through established local structures to disseminate information in the Amish community; collaborate with other health professionals, as appropriate, in offering preventive and educa- tional services locally. Use of appropriate health interventions Develop and/or disseminate culturally and linguistically appropriate health promotion and education materials. Inclusion of family and community members Decisions about illness and health behaviors often emanate from discussions with family and community members; work with the patient and his or her support group (as appropriate and allowable). Immersion into culture Make staff available to patients in one-on-one interactive counseling sessions, invite Amish community members to service functions, and learn about the culture and community. Administrative and organizational accommodations Establish accommodating service hours and on-call policies; consider pharmacy delivery service to Amish community; create organizational climate of respect and cooperation. aSources of competency techniques: references 2– 4. Setting Located in east-central Illinois, the town of Arthur has a popula- tion of approximately 2,300, and its surrounding farmland area is settled by the largest concentration of Amish people in the state.6 The community was founded by a small number of families in 1865 and is currently home to more than 4,500 individuals.7 The local Amish have one church, but 25 different Amish church districts are located around Arthur (personal communications, Theresa Binion, November 2008), spanning 12 miles east and west and 15 miles north and south of town.8 Each district has its own set of rules (Ordnung), which govern customs and practices. Dicks Pharmacy, a community independent pharmacy, is located in the town of Arthur.9 Two full-time equivalent (FTE) pharma- cists (including the owner), one FTE pharmacy technician, two FTE clerks, and six part-time clerks are employed at the phar- macy. Dicks Pharmacy dispenses an average of 185 prescriptions per day and is open from 8:00 am to 6:00 pm Monday through Saturday (closing 5:30 pm on Saturdays). The original pharmacy was established in the 1920s or 1930s. Bruce Wood began working at the pharmacy in 1991 and became the pharmacist proprietor 5 years later. Wood has a notable his- tory of community and professional service and has engaged in civic activities for the greater Arthur community, including serving as current president of the local chamber of commerce. Approximately 25% to 30% of the patients and customers at his pharmacy are Amish. Based on 17 years’ experience, his per- spectives and advice in serving the Amish community are sum- marized and presented as a first-person account in the following section and, where possible, throughout the article as an adjunct to the literature. Although one individual’s observations cannot be considered generalizable to the larger population, relevance and practical applicability are augmented by including a pharmacist practitioner’s reflections. Wood’s introductory reflections on serving the Amish “We have a typical, old-fashioned community pharmacy. Cus- tomer service is what we stress the most. At Dicks Pharmacy, our experience with serving the Amish has been pretty similar as with serving our other ‘English’ (as the Amish refer to us) customers. The Amish that live in our area are very concerned with their health and that of their children as well. One might note 54 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. review that there seems to be a higher incidence of certain disease states in this group over others (for example, whooping cough). Aside from vaccinations, we do see that the Amish are quite active in receiving medical care. In Arthur, many Amish receive traditional (conventional) care; however, some do use the other methods of alternative care. “When seeking care, the Amish do not necessarily need to go to the doctor’s office and often practice self-care. They call me a lot (sometimes early in the morning before the store opens), often asking, ‘Do you have [medication or other treatment].’ They call to find out my recommendations for themselves or their families. They also call seeking advice for veterinary medications. On the farms, they have more use for veterinary preparations. “In the pharmacy, we counsel the Amish the same way as the English. For all of our patients, we interact on a one-on-one basis regarding how medications should be taken and how patients can take care of themselves. “The Amish customers that we serve are primarily cash- paying customers. A few of our customers require the assistance of the church to pay some more outstanding bills. We also have some Amish customers that do have a form of insurance. I have really enjoyed serving the local Amish community in the Arthur area.” When asked about the training, if any, that his staff (pharma- cists, pharmacy technicians, and clerks) receive before interact- ing with Amish patients, Wood added the following: “I tell staff that they (the Amish) are very honest. They are willing to learn. They are interested in taking their meds. Most of the people hired have lived in the community a long time and respect the Amish traditions.” Brief history and background of the Amish The Amish originated from the Anabaptist movement of the Swiss Brethren. A number of people fled Switzerland in 1525 to escape religious persecution by Protestants and Catholics.10,11 These people were called Anabaptist Christians because they rebaptized their adult followers. From Switzerland, the movement spread to Germany, France, and the Netherlands.12 The Anabap- tists believed in the separation of church and state and a commit- ment to pacifism and nonviolence and were considered radical. A key leader in the Anabaptist religion was Menno Simons, whose followers were called Mennonites. Members of the Mennonite religious group became less strict in their ways of life over time and began to adopt more modern practices.13 Some followers, however, had different biblical interpretations and did not believe in the laxity of practices, which resulted in embracing too many worldly conveniences. Among these was a Swiss–German Men- nonite named Jacob Ammann (sometimes spelled as Amman). In 1693, a conservative group of Mennonites broke off from the religion to follow Ammann—they became known as Amish.10,13 The Amish migrated to America, first settling in a Pennsylvania colony in the early 18th century.10,14 Three major Amish groups exist: the Old Order Amish and the more progressive Amish Mennonites, which include the Beachy Amish (e.g., car ownership and use of electricity from public utili- ties allowed) and New Order Amish (e.g., use of electricity and telephones in homes and use of modern farm equipment may be permitted). The Old Order Amish is the largest and strictest (most conservative) group in terms of traditional beliefs and practices. As the most populous group and the most iconic with societal perceptions of conduct,12 any reference to the Amish from this point forward in the article refers to the Old Order Amish. The populations of different Amish communities can total hundreds or thousands of individual members. Amish community structures consist of settlements, church districts, and affilia- tions. Settlements are composed of proximate households. The size of settlements may range from small, including only a few households and their religious leader, to large settlements that might encompass several counties.11 Self-governing church dis- tricts (i.e., congregations) are established within geographic areas of each settlement. The size of congregations depends on how many families can gather at a farm dwelling or home.11 Each autonomous congregation typically consists of about 20 to 40 families, and every church district is led by a bishop—the chief authority who decides how conservative the congregation will be by clarifying the code of conduct, religious practices, and rules (Ordnung) of social behavior.5,10,11,15 Approximately 1,710 Amish congregations exist.16 Groups of church districts with similar dis- cipline structure can commune together, and these congregations represent an affiliation.11 Amish behaviors and practices should not be generalized or stereotyped in a singular image, as diversity exists among groups within Amish communities.17 Amish culture varies by location; different bishops may approve different prac- tices across respective church districts. Each district may differ across the United States in terms of religious practices, customs, conduct, dress, buggy styles, and other rules. Noted concentrations of Amish communities in North Amer- ica are located in 27 states and Ontario, Canada, with the great- est numbers of Amish people and districts in Ohio, Pennsylvania, and Indiana.16 In 2008, Professor Donald Kraybill (Elizabethtown College) estimated that the Amish American population totaled 231,000 Old Order and New Order Amish, including children; adult baptized members were estimated to total 105,000.16 The Amish are considered to be conservative Christians who live a simple life in geographic and social separation (though not seclu- sion) from the predominant American culture.18 The basic Amish tenets include integrity, order, responsibility, obedience (to par- ents, church, and God), nonresistance, and consideration of the human body as God’s temple.12 The Amish lifestyle The Amish believe in conserving their traditions and practices, and they reject or avoid unnecessary material possessions. They are well known for living a simple life with minimal technology www.pharmacist.com December 2008 • Pharmacy Today 55 review Go to www.pharmacist.com and take your test online for instant credit. review in the fast-changing world around them. The Amish dress plainly and have a limited use of modern conveniences for fear of becom- ing too worldly.11 Technology can be adopted if approved by the district bishop, based on group discussions with congregation elders about its effect on the community way of life.15 Electricity is rarely, if ever, used in Amish homes. Electric generators are used in some Amish communities for work reasons, such as welding, milk production, and battery recharging.10 The Amish generally travel by walking and riding a bicycle or horse-drawn buggy. They may hire a driver or take a bus or taxi for distance travel. In an emergency, they may have a non-Amish person drive them, for example, to the nearest hospital.12 The Amish neither watch television nor have telephones inside their homes because those are means of bringing the outside world into the home, which is verboten. Use of business, public, or communal phones may be permitted by a district bishop, espe- cially for outgoing calls.10 Attitudes toward phone ownership are changing, with reluctance, in some communities as more Amish have access to cell phones and their multiple capabilities.19 The Amish settle in rural communities, and farming is the historical way of life for Amish households. As farmland has grown more scarce, other sources of income and livelihood have grown.20 More Amish men have found jobs in bookstores and voca- tional crafts, such as woodworking/carpentry, canning, carriage making, performing repair work, and working in farm equipment stores and print shops.14,21 Amish women work around the house (e.g., tending the garden, cooking natural foods from the garden and farm, making clothes).10 The Amish also sell homemade fur- niture, quilts, produce, and prepared foods and other goods near their homes or in nearby markets; this trade is fueled by curiosity and demand from tourist shoppers and others.14,20 Most Amish children are formally educated only through the eighth grade, which is deemed a sufficient level to live the Amish lifestyle.14,22 The Amish resist sending their older children to high school because of concerns that outsiders (i.e., non-Amish peo- ple) and higher education will negatively alter their thinking and behaviors. The lifestyle and culture of the Amish directly affect their views on sickness and health care.11 Wood’s reflections. “They (the Amish) leave school after a limited number of years of formal education, but they continue to read voraciously. Amish families read a great deal in the evenings. Reading is a normal activity in the home; they do not watch tele- vision or play video games. They also read a lot on health care. They listen attentively to advice and are avid readers most of the time. They will do research on all kinds of things, including their medications, and they definitely ask questions.” Amish health beliefs and health care practices The Amish value health, are health conscious, and generally rec- ognize when someone is sick.11 Their explanatory models of illness and treatment approaches, however, differ in some respects from those that are traditionally used by people in the larger American society. The Amish do not perceive illness as a frailty but rather as part of life.10 They believe that good health, both mental and physical, is a gift from God that they can help achieve by working hard, living simply and cleanly, and eating a well-balanced diet. In Amish terms, a healthy person is one who “gets up early, gets enough rest, needs fresh air, eats as naturally as possible, wants to work, wants to be healthy, helps to create a happy atmosphere, accepts what one has and goes on, does not worry; at least not too much, has faith, and has not too much stress.”12 Compared with the traditional biomedical perspective, the Amish possess a holis- tic outlook on health and healing. The Amish are actively involved on a daily basis in decision making and actions about health and treatment of illness.12 Many Amish may take food supplements, vitamins, and eat natural or organic food.11 A strong sense of soli- darity, responsibility, and caring for their own exists within Amish communities.23 They promote individual, family, and community well-being. Three sectors of the health care system may be used by the Amish. In the terminology used by the National Center for Complementary and Alternative Medicine, these sectors include conventional care and complementary and alternative medicine (including biologically based therapies, energy/biofield therapies, and manipulative and body-based therapies).24 These practices are commonly categorized as folk care, alternative care, and professional care in literature on the Amish.12,15,25 No aspect of professional medical or other health care is forbidden among the Amish; however, individuals may show more reluctance or hesi- tancy toward using certain services,11 and health care practices may vary among districts. The Amish generally embrace use of conventional medicine in treating incapacitating and traumatic diseases and infections. With nondebilitating chronic illnesses, treatment modalities include conventional care, folk care, and complementary and alternative medicine.25 Folk care and complementary and alternative care Folk care includes the influences of the popular sector (i.e., seek- ing advice on illness from family, friends, and community mem- bers).15 When a member of the Amish community becomes ill, the family members generally weigh their options, including folk care and alternative medicine, before seeking professional care. This pattern has led to misconceptions that the Amish shun pro- fessional care. Folk care is indigenous in Amish communities, and treatments are passed down through generations. Examples of folk care may include heavy use of teas, chelation therapies, onions, mustard plasters, camphor applications, herbs, and, increasingly, commercial herbal remedies.10,14 (Depending on the source, herbal remedies are included under both folk care and alternative care.) The Amish often grow gardens of herbs and teas to use as curative medicine.12 If approved in the district, folk care is generally provided in the home or Amish community, using home remedies or the services of brauchers, who are Amish 56 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. review healers. Practitioners serving Amish communities should strive to be nonjudgmental about folk remedies and knowledgeable on herbal remedies and vitamins so that they will be able to counsel patients on therapeutic use and safety and check for potential interactions.18 The Amish may be hesitant to discuss their use of herbal remedies, home remedies, and alternative care.19 Wood’s reflections. “We realize that the Amish today do take herbal remedies, but getting them to tell us that they are using something other than the prescribed medications is often difficult (as with the general population). Most of the time, we just have to ask what else they are using for this or that condition, and then they will spill the beans about what else they are taking. Unfortu- nately, we do not always ask if they are taking something else. As with any of our patients, all we can do is counsel them on what we know about their conditions, medications, and lifestyles.” The term braucher comes from the word brauche, which means folk-healing art.26 Some Amish believe that individuals inherit the power of healing through touch.14 Brauchers are Amish practitioners who generally use their warm hands to touch (or place near the person’s body) and physically manipulate the prob- lem area in an attempt to draw out the illness. Brauchers do not have prescriptive authority, although they can recommend herbs and many folk remedies. Brauchers sometimes refer to them- selves as braucher–chiropractors; however, they are not licensed practitioners (and are not recognized to practice chiropractic medicine by the state) but may have observed aspects of chiro- practic treatments from others. In an article from 1981, Emanuel Stoltzfus, a full-time self-described braucher–chiropractor, said that he discovered one day that he had “electric” in his hands and could feel where a person was sick and would treat accord- ingly.26 Brauchers learn the techniques of the art of healing from a member of the opposite sex upon promising to keep the art a secret. Brauchers are generally seen when Amish patients do not know what is wrong or want to avoid drug therapies.10,26 Amish parents often take their ailing babies and small children to visit the braucher because the children are too young to readily describe their pain or other symptoms. The braucher is said to be able to touch the child and pull out the pain.10 Brauchers prac- tice their folk art using physical manipulations, charms, incanta- tions, and sacred rituals.26 In past years, aspects of traditional European occult practices (e.g., sorcery and “black magic”) may have routinely been included in the practices of Amish brauchers and other community healers; such practices have largely been abandoned.11,25 Mixed feelings exist within the community about the prac- tice of brauche, with some Amish questioning the practice and/ or expressing skepticism and embarassment11; however, many Amish believe that brauchers can help some people.10,26 In certain districts, brauchers may be the preferred care provider because they are easily accessible and less expensive and are trusted as members of the community. Brauchers and other folk care pro- viders do not charge a fee (for historical reasons and to avoid the appearance of practicing medical therapies without a license), but donations are accepted and sometimes expected. In addition to money, donations may include brokered goods or services.10,12,26 Wood’s reflections. “Personally, I have only once been approached by the Amish about what a braucher had told them, and that was a number of years ago, so I do not remember the exact details at all. If I remember correctly, the information that they had been given was fairly accurate, and we did not have a problem assisting the family member in what they were look- ing for. The use of brauchers in this area does not appear to be very high.” The Executive Director for the Arthur-Amish Country Visitor Center provided further insight, stating that the use of a braucher does not exist in the Arthur, IL, area (personal com- munications, Theresa Binion, November 2008). Some authors include powwow healers (including brauchers and informal family/friends who use sympathy curing or faith healing) under the category of alternative healers,11 but most categorize as folk care providers. Examples of alternative care services that may be used by the Amish include traditional chiro- practic care, lay midwifery, reflexology, massage, foot treatments, homeopathy, iridology, and herbal therapists.10,12 Alternative care may be sought regularly by the Amish for body adjustments, treat- ment of back pain, and other maladies for which patients believe it may be effective. Alternative care providers charge a fee for ser- vices, which is perceived to be less expensive than physicians. Conventional care Professional or conventional care is offered by health care practi- tioners who have been formally educated and trained in the domi- nant medical and health system. Most Amish members pay their bills in cash for services and care rendered at hospitals and by physicians, nurses, dentists, pharmacists, and other providers in the traditional professional sector. Most Amish families have a physician whom they visit when they recognize the need for scientific medical practice. Reasons for choosing a family physician extend beyond medical knowl- edge and include family tradition, proximity, recommendation by others, affordability, trust, sympathy, and integrity.11,12 Con- ventional care is generally sought by the Amish in cases of high fever and when surgery or stitches, hospital care, or prescription medication are needed. Compared with non-Amish, the Amish are much less likely to seek professional care for preventive medicine because of lack of convenience, high costs, and a perception that it is not necessary.5 Conventional care is most often sought when an emergency occurs. The Amish will visit hospital emergency departments in cases of severe abdominal pain, chest pains, lacerations, frac- tures, and traumatic injuries, among other urgent conditions.10,27 Farm accidents resulting in severe injuries are commonly seen on an emergency basis. Children are often the victims of these trau- matic injuries (e.g., falls, machinery accidents, animal injuries) www.pharmacist.com December 2008 • Pharmacy Today 57 review Go to www.pharmacist.com and take your test online for instant credit. review in Amish communities because they begin working the farm at a young age.28 A number of emergency visits and deaths also result from lack of protections with respect to buggy and automobile accidents.27,29 Prenatal care Medical means of birth control reportedly are not practiced in Amish communities,15 and average households include six or seven children.6,14,30 Most Amish women visit a physician for initial confirmation of a pregnancy diagnosis.25 However, most Amish women do not seek professional prenatal care throughout the pregnancy. If prenatal care is initiated, it is often late in the preg- nancy, such as the third trimester.15 Reasons for minimal prenatal care use include (1) Amish views of uncomplicated pregnancies as valued normal states that do not require medical interventions and (2) logistical barriers pertaining to transportation difficul- ties, child care arrangements, and costs.15 Many Amish women prefer to deliver their babies at home using house-call physicians, nurse midwives, or lay midwives and other alternative care pro- viders. If the expectant mother shows serious symptoms that could result in a high risk of complications, the delivery will be scheduled to take place in a hospital.10,15 Wood’s reflections. “All of them (expectant Amish mothers) seem to get prenatal vitamins. They are more aware of the situ- ation than they were in years past. They know the healthier their bodies, the healthier their babies. The Amish buy more breast shield, breast pumps, and nursing pads than others, which may be indicative that they breast-feed more often.” Hereditary disorders In addition to an increased incidence of twinning, some dis- tinct Amish communities in different regions show a higher prevalence of certain chromosomal and genetic abnormalities (e.g., Ellis-van Creveld syndrome or dwarfism, cartilage–hair hypoplasia, pyruvate kinase deficiency anemia, hemophilia).11 The hereditary disorders result in part from common blood- lines of offspring from endogamous unions among members of a relatively closed society.20,22 Genetic screening and counsel- ing have been advocated for high-risk populations when early diagnosis may decrease morbidity and mortality.31 Pharmacists and other health professionals could serve as sources of refer- ral to medical and public health specialists in genetics, when deemed appropriate. Such initiatives, however, are controver- sial and may have psychological and ethical implications.31 Most Amish would reject prenatal screening.19 Efforts are undertaken within Amish communities to prevent genetic diseases and to understand their causes and outcomes.25 Professional care is not always sought for such genetic conditions because they are viewed as God’s will by the Amish, although some communities are accepting of promising gene therapy.32 Many Amish may have treatable autoimmune thyroid diseases.33 Wood’s reflections. “Many Amish (we serve) have hereditary thyroid diseases and need thyroid replacement medicines. They may start see the appearance of thyroid problems in their late teens or early 20s, and often the amount of replacement therapy can be very extensive.” Vaccination rates While not prohibited by their religious doctrine, many Amish people do not get vaccinated, which places them at increased risk for acquiring vaccine-preventable diseases.6 Outbreaks of rubella, childhood tetanus, pertussis, measles, poliovirus infec- tions, and Haemophilus influenzae type b (Hib) have occurred in Amish communities at disproportionately high rates.6,23,34,35 For example, Fry et al.35 found full childhood Hib vaccination coverage in two Pennsylvania Amish communities to be only 7% and 28%, whereas 95% coverage occurred in the non-Amish comparison group. On the other hand, Yoder and Dworkin6 found that 84% of respondents from households in an Illinois Amish settlement self-reported that all of their children had been vac- cinated (though these reports could not be validated with health records), which was attributed in part to learning about the low vaccination rates and outbreaks experienced in other Amish communities. Despite isolated success stories, vaccination cov- erage levels among the Amish tend to be very low. Wood’s reflections. “We have seen a few outbreaks of whoop- ing cough in the past 2 years. The Amish do not get vaccinated for this disease, nor do they get boosters as adults. I have not noticed any differences in vaccination rates in the Arthur com- munity in recent years.” The reasons most Amish do not get their children vac- cinated include lack of recognized need for vaccines, fears of adverse effects/vaccine safety for their children, religious or philosophical objections, and lack of priority in life.5,23,35,36 Another reason pertains to logistical barriers (e.g., need to travel long distances to get vaccinated, limited transportation in general, inconvenient clinic hours).23,35 Efforts can be made by pharmacists and other health professionals to help promote vaccination. The Amish may be receptive to vaccination outreach pro- grams if the topic is openly discussed and efforts are put forth to address individual concerns.6 Developing culturally and lin- guistically appropriate educational materials would be useful, and information approved by the district bishops and other church leaders can appear in local community newsletters and other readily utilized publications.12 Clinical and public health professionals in Amish communities could also try to set up immunization drives within Amish communities so that travel to the clinic or physician’s office would not be as burdensome, which would eliminate one of the logistical barriers. Local pharmacists can partner with local physicians, nurses, and/ or public health departments in attempts to contact church leaders to educate them on the greater benefits (and potential adverse effects) of vaccination. 58 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. Barriers and opportunities to pharmacist care and services The lack of available transportation is a logistical barrier that may limit access to medical and pharmacy care for Amish patients. To help alleviate that problem, Wood said, “We added delivery ser- vice at the pharmacy when I took over in the 1990s. The service is available for all patients, but mainly exists for the Amish and elderly patients, who use the service extensively. The delivery service was established to make life easier and to ensure that patients obtain their medications (new and refill) in a timely man- ner. There is no charge for prescription delivery. We deliver to five different counties over about a 20-mile radius (from Arthur, IL) on a weekday basis, starting each day at 3:00 pm.” Language Language barriers could be a challenge for health professionals serving an Amish community. Most often, Pennsylvania Dutch (also known as Pennsylvania German or Deitsch)—a blended dialect of German and English—is spoken in Amish communi- ties, at home, and at church.10,20 Children will learn English at school, but often preschool-aged children only speak Pennsyl- vania Dutch, if that is the language spoken in their home. The Amish refer to the non-Amish in their surrounding area as “the English” because that is the language they typically use.10,14,20 In rural areas, finding translators is difficult; therefore, health professionals must be as descriptive and complete as possible when counseling patients with limited English proficiency. Dem- onstrations (of correct medication use, for instance) often help. If language is a barrier, having patients repeat to the health care provider the counseling information that he or she heard, in order to help ascertain whether the communicated message was under- stood in the manner intended, may be helpful. Wood’s reflections. “The previous pharmacy owner spoke some German, and the original owner in the 1930s spoke fluent Ger- man. The Amish patients learned to watch what they said in the store in the presence of the former proprietors since they knew that the staff understood their personal conversations. I know virtually no German, but their [the Amish] English is usually very good; they learn both languages.” Costs of conventional care High costs can present another barrier to health care among the Amish. The Amish strive to live plain, uncomplicated lives, including the means of paying for health care.37 Many Amish self- pay for health care services and products. They are reluctant to accept any government insurance programs because of lack of trust in the knowledge sources and lack of community consensus and clear approval by the district bishops.11 Amish may perceive the buying of health insurance as a lack of faith.37 Some who work for non-Amish employers may accept health insurance coverage, but most Amish tend to eschew Social Security benefits or other financial assistance from the government, and most frown on commercial health insurance.10 This pattern is slowly changing. Wood’s reflections. “The local members of the Amish com- munity are some of the most trusted customers. They are more honest than the ‘English’ and more likely to pay their bills in full. Today, with the increase in members of the Amish community getting jobs outside of the family farm due to the scarcity of the farmland, insurance is more common. “I find it interesting that the percentage of Amish with Medi- care is certainly less than those in the general population, but higher than I had suspected as well. In this area, many of the Amish who are ineligible for Social Security benefits do qualify as beneficiaries for Illinois Cares Rx (an income-based state pre- scription drug assistance program for qualified individuals age 65 years or older, as well as other eligible beneficiaries, including some disabled). They are taking advantage of that plan, much like the rest of the population, but they do not get assigned to a Medicare Part D company because they (currently) do not qualify for Medicare.” Delaying or refusing a necessary visit to a physician or other health professional because of cost concerns or failing to obtain needed medications can cause patients to become sicker, which could result in even more costly and more complicated medical therapies.10 In line with reliance on support of the church and community, some districts form their own insurance fund, known as Church Aid or Amish Aid, to which each family contributes an initial amount and contributes again when someone is in need.10,14 Amish members accept financial assistance from these commu- nity funds, if they exist, only when they are personally unable to pay medical expenses. Even then, some individuals in the Amish communities will go without health care services if they believe the burden for the community would be too much. To help mini- mize costs, Amish people may venture outside of the United States (especially to Mexico) to obtain more affordable health care ser- vices.19 The Amish honor their financial obligations and pay their debts in a timely manner.37 Providers (e.g., hospitals, physicians) serving Amish populations may make special arrangements for these cash-paying customers, including discounted rates for ser- vices. If cost is a barrier, pharmacists may have an opportunity to recommend a less-expensive generic substitute or therapeuti- cally similar agent. In some communities, pharmacy owners allow members of the Amish community to charge prescriptions to the family for later (e.g., monthly) cash payment.14 Building trust Health care practitioners have an important opportunity to build trusting relationships with their Amish patients so that the patients feel at ease when asking questions and seeking help. Amish members welcome provision of health information from trusted sources.6,11 This desire for information facilitates oppor- tunities for pharmacists in Amish communities to counsel and educate patients, including welcomed explanations of options that can be considered. Outsiders to Amish communities need www.pharmacist.com December 2008 • Pharmacy Today 59 review Go to www.pharmacist.com and take your test online for instant credit. to establish relationships in order to be accepted, usually by first consulting and working with community leaders through estab- lished local community structures. Collaborative efforts then can be established with other health professionals serving the Amish community. Wood’s reflections. “Each month on the third Thursday, we host the Lincolnland Visiting Nurses blood screenings. Each month, there are usually 20 or so people wanting one of the various screenings they offer. There is a charge for the cholesterol screen- ings, but blood pressure and blood sugar tests are administered free of charge. Over half of the people seen in this 2-hour time slot are normally of the Amish faith.” Culturally competent care as aspect of patient-centered care The knowledge of salient cultural differences when serving cross- cultural patient populations is needed to provide competent phar- macy practice. However, all individuals within Amish cultures do not think or act the same, and care must be given to ensure that these patients are not stereotyped based on intrinsic and extrin- sic cultural aspects.2 Within the setting described in this article, each district in the Arthur, IL, area adheres to its own rules, including use of home remedies and conventional health care services (personal communications, Theresa Binion, November 2008). Universal application of the described general Amish char- acteristics to all patients in the subpopulation may result in sub- optimal health care decisions and actions.2 Individualized patient care by pharmacists is needed to help patients make the best use of their medications, promote safety, and avoid unintended and harmful effects. Conclusion To our knowledge, this is the first article to address pharma- cists’ considerations when serving Amish patients. Bruce Wood’s reflections supported much of the information culled from the literature review. Pharmacists in all settings play an important role in ensuring that patients get good health care. Special con- siderations may need to be made by health care practitioners when serving the Amish because of their culture, health beliefs, and lifestyles. Culturally competent pharmacist care should be individualized based on patient needs and in consideration of aspects of differences in Amish cultures and districts. Increased understanding and accommodation of Amish beliefs and culture can help pharmacists and other health care practitioners better serve the community and minimize barriers that may interfere with optimal care provision. references 1. American Pharmacists Association. Code of ethics for pharmacists. Accessed at www.pharmacist.com/AM/Tem- plate.cfm?Section=Search1&template=/CM/HTMLDisplay. cfm&ContentID=2903, November 5, 2007. 2. American College of Clinical Pharmacy, O’Connell M, Korner E, et al. Cultural competence in health care and its implications for pharmacy. Part 1. Overview of key concepts in multicultural health care. Pharmacotherapy. 2007;27:1062–79. 3. Shaw-Taylor Y. Culturally and linguistically appropriate health care for racial or ethnic minorities: analysis of the U.S. Office of Minority Health’s recommended standards. Health Policy. 2002;62:211–21. 4. Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities: a review and conceptual model. Med Care Res Rev. 2000;57(suppl 1):181–217. 5. Dickinson N, Slesinger D, Raftery P. A comparison of the perceived health needs of Amish and non-Amish families in Cashton, Wisc. Wis Med J. 1996;95:151–6. 6. Yoder J, Dworkin M. Vaccination usage among an old-order Amish community in Illinois. Pediatr Infect Dis J. 2006;25:1182– 3. 7. Amish Country Marketing. Arthur … “The heart of the Illinois Amish country.” Accessed at www.illinoisamishcountry.com, October 16, 2007. 8. Amish Country Marketing. The Amish. Accessed at www. illinoisamish.net/amish/amishmain.htm, December 17, 2007. 9. Wood B. Dicks Pharmacy. Accessed at www.dicks-pharmacy. com, May 8, 2008. 10. Brewer J, Bonalumi N. Health care beliefs and practices among the Pennsylvania Amish. J Emerg Nurs. 1995;21:494–7. 11. Hostetler J. Amish society. 4th ed. Baltimore, MD: Johns Hop- kins University Press; 1993. 12. Wenger A. Cultural context, health and health care decision making, 1994. J Transcult Nurs. 1995;7:3–14. 13. Amish Country Marketing. Amish religion. Accessed at www. amishillinois.com/religion/amish_religion.htm, November 5, 2007. 14. Weyer S, Hustey V, Rathbun L, et al. A look into the Amish cul- ture: what should we learn? J Transcult Nurs. 2003;14:139–45. 15. Campanella K, Korbin J, Acheson L. Pregnancy and childbirth among the Amish. Soc Sci Med. 1993;36:333–42. 16. Young Center for Anabaptist and Pietist Studies, Elizabeth- town College. Amish population growth 2007-2008 highlights. Accessed at www2.etown.edu/amishstudies/Population_ Trends_2007_2008.asp, November 11, 2008. 17. Nolt S, Meyers T. Plain diversity: Amish cultures and identities. Baltimore, MD: Johns Hopkins University Press; 2007. 18. von Gruenigen V, Showalter A, Gil K, et al. Complementary and alternative medicine use in the Amish. Complement Ther Med. 2001;9:232–3. 19. Graham L, Cates J. Health care and sequestered cultures: a perspective from the old order Amish. J Multicult Nurs Health. 2002;8:53–9. 20. Miller K, Yost B, Flaherty S, et al. Health status, health condi- tions, and health behaviors among Amish women: results from the Central Pennsylvania Women’s Health Study (CePAWHS). Women’s Health Issues. 2007;17:162–71. 21. Hostetler J. Amish life. Scottdale, PA: Herald; 1983. 22. Patton M. Genetic studies in the Amish community. Ann Hum Biol. 2005;32:163–7. 23. Centers for Disease Control and Prevention. Pertussis outbreak in an Amish community: Kent County, Delaware, Septem- ber 2004-February 2005. MMWR Morb Mortal Wkly Rep. 2006;55:817–21. 24. National Center for Complementary and Alternative Medi- cine. What is CAM? Accessed at http://nccam.nih.gov/health/ whatiscam, May 6, 2008. 60 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. review CE Credit: To obtain 2.0 contact hours of continuing education credit (0.2 CEUs) for “Pharmacists’ considerations when serving Amish patients,” complete the assessment exercise, fill out the CE examination form at the end of this article, and return to APhA. You can also go to www.pharmacist.com and take your test online for instant credit. CE processing is free for APhA mem- bers and $15 for nonmembers. A Statement of Credit will be awarded for a passing grade of 70% or better. Pharmacists who complete this exercise successfully before December 1, 2011, can receive credit. The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. The ACPE Universal Program Number assigned to the program by the accredited provider is 202-000-08-246-H04-P. “Pharmacists’ considerations when serving Amish patients” is a home-study continuing education program for pharmacists developed by the American Pharmacists Association. 25. Weaver-Zercher DL. Writing the Amish: the worlds of John A. Hostetler. University Park, PA: Penn State Press; 2005. 26. Miller L. The role of a braucher-chiropractor in an Amish com- munity. Mennon Q Rev. 1981;55:157–71. 27. Vitale M, Rzucidlo S, Shaffer M, et al. The impact of pediatric trauma in the Amish community. J Pediatr. 2006;148:359–65. 28. Rhodes D, Hupcey J. Farm injuries among Old Order Amish children. Clin Excell Nurse Pract. 2002;6:49–54. 29. Aaland M, Hlaing T. Amish buggy injuries in the 21st century: a retrospective review from a rural level II trauma center. Am Surg. 2004;70:228–34. 30. McArdle P, Pollin T, O’Connell J, et al. Does having children extend life span? A genealogical study of parity and longevity in the Amish. J Gerontol A Biol Sci Med Sci. 2006;61:190–5. 31. Ross L, Moon M. Ethical issues in genetic testing of children. Arch Pediatr Adolesc Med. 2000;154:873–9. 32. Grady D. At gene therapy’s frontier, the Amish build a clinic. The New York Times. June 29, 1999. 33. Allen E, Hsueh W, Sabra M, et al. A genome-wide scan for autoimmune thyroiditis in the Old Order Amish: replication of genetic linkage on chromosome 5q11.2-q14.3. J Clin Endocrinol Metab. 2003;88:1292–6. 34. Centers for Disease Control and Prevention. Poliovirus infec- tions in four unvaccinated children: Minnesota, August-Octo- ber 2005. MMWR Morb Mortal Wkly Rep. 2005;54:1053–5. 35. Fry A, Lurie P, Gidley M, et al. Haemophilus influenzae type b disease among Amish children in Pennsylvania: reasons for persistent disease. Pediatrics. 2001;108:E60. 36. Salmon D, Haber M, Gangarusa E, et al. Health consequences of religious and philosophical exemptions from immuniza- tion laws: individual and societal risks of measles. JAMA. 1999;282:47–53. 37. McCollum M. The uninsured: uncovered–and unfazed. Hosp Health Netw. 1998;72(14):38. www.pharmacist.com December 2008 • Pharmacy Today 61 review Go to www.pharmacist.com and take your test online for instant credit. review Assessment Questions Instructions: You may take the assessment test for this program on paper or online. For each question, circle the letter on the answer sheet corresponding to the answer you select as being the correct one. There is only one correct answer to each ques- tion. Please review all your answers to be sure that you have circled the proper letters. To take the CE test for this article online, go to www.pharmacist.com and click Education. Once you are on the Education welcome page, search for this article with the search function, using “CE” and a keyword. Follow the online instructions to take and submit the assessment test. This CE will be available online at www.pharmacist.com after December 31, 2008. You can also find it on www.pharmacytoday.org. 1. Which of the following is not an example of a cultur- ally competent technique that could be used in serv- ing Amish patients? a. Language assistance if patients speak Deitsch and demonstrate limited English proficiency b. Universal application of knowledge about Amish health beliefs to all Amish patients c. Outreach and working with church leaders through established local structures to disseminate information d. Consideration of possible use of folk care and alterna- tive care by Amish patients 2. What term is often used by the Amish to describe people who are not Amish? a. The Outsiders b. The Americans c. The English d. The Seculars 3. What Amish group is the most conservative regarding traditional beliefs and practices? a. Amish Mennonites b. Old Order Amish c. New Order Amish d. Beachy Amish 4. What Amish group is the most populous in the United States? a. Amish Mennonites b. Old Order Amish c. New Order Amish d. Beachy Amish 5. Which of the following is correct? a. All Old Order Amish adhere to the same social behav- iors and practices. b. The majority of pharmacists interact with at least one Amish patient routinely. c. The largest Amish population is located in the state of New York. d. Local bishops interpret the rules of conduct within each Amish church district. 6. What is the highest level of formal education for most Amish? a. Sixth grade b. Eighth grade c. Ninth grade d. Twelfth grade 7. Which of the following is not correct regarding Amish health beliefs and practices? a. The Amish view illness as an individual frailty. b. The Amish read a great deal about health care and ask questions about their medications. c. Amish people are health conscious and actively involved in health care decisions. d. The Amish possess a holistic perspective on health and illness. 8. Which of the following aspects of well-being is/are promoted in the Amish culture? a. Community well-being b. Family well-being c. Individual well-being d. All of the above alternatives are correct. 9. Which of the following is not an example of folk care in the Amish culture? a. Health advice from family and community members b. Teas used for health purposes c. Chelation therapies d. Traditional chiropractic care 10. Which of the following is generally forbidden in Old Order Amish culture? a. Use of telephones in homes b. Use of vitamins and herbal remedies c. Professional medical care d. Vaccinations 62 Pharmacy Today • December 2008 www.pharmacytoday.org review Go to www.pharmacist.com and take your test online for instant credit. review 11. Which of the following is not correct regarding brauchers? a. Brauchers are also known as braucher–chiropractors. b. Brauchers are licensed by the state and granted pre- scriptive authority. c. Brauchers may recommend herbal remedies. d. Brauchers are preferred healers in some Amish com- munities. 12. Which of the following does not typically charge a fee for services? a. Brauchers b. Homeopaths c. Lay midwives d. Herbal therapists 13. The Amish generally do not seek conventional care for which of the following? a. Traumatic injuries b. Infections c. Prenatal physician care beyond confirmation of preg- nancy d. Prescription medications 14. Which of the following is correct? a. Amish women routinely practice medical means of birth control. b. Most Amish are amenable to prenatal screening to detect hereditary disorders. c. Amish women tend to shun use of prenatal vitamins. d. Many Amish need thyroid hormone replacement thera- pies because of increased prevalence of some thyroid disorders. 15. Which of the following is not a reason for low vaccina- tion rates among Amish people? a. Lack of recognized need for vaccines b. Fear of adverse effects c. Religious doctrine prohibiting vaccines d. Transportation difficulties 16. Which of the following would not be an appropriate method for promoting vaccination use among Amish people? a. Developing linguistically appropriate educational mate- rials on vaccines for inclusion in community newslet- ters b. Establishing immunization drives within Amish com- munities to minimize travel burdens c. Partnering with local health departments and/or health providers to educate local church leaders about vac- cines d. Distributing comprehensive, technical product infor- mation on vaccines from product manufacturers 17. Which of the following languages is not typically spo- ken or learned by school-aged Amish children? a. English b. French c. Pennsylvania Dutch d. Pennsylvania German 18. Which of the following is not correct regarding pay- ment for health care services among the Amish? a. Many Amish pay for health care out of pocket. b. Many Amish are reluctant to use government insurance programs; however, these attitudes are slowly chang- ing. c. The Amish refuse all types of commercial health insur- ance. d. Some Amish church districts form their own insurance programs. 19. Which of the following is not correct? a. The Amish insist on paying for services at the time of service provision and would not agree to paying over time. b. The Amish honor their financial obligations and pay their debts. c. Even if their church is willing to pay, Amish people may go without needed health care services if they believe the community burden would be too great. d. Amish individuals may seek health care options outside the United States to minimize costs. 20. Which of the following is not correct? a. Pharmacists should build trusting relationships with members of the local Amish community in order to be accepted as health care practitioners. b. Knowledge of relevant cultural and district differences is an important aspect of providing competent pharma- cist care. c. All Old Order Amish adhere to the same philosophies, and pharmacists should treat all members the same. d. Individualized patient-centered pharmacist care is needed by Amish patients. www.pharmacist.com December 2008 • Pharmacy Today 63 review Go to www.pharmacist.com and take your test online for instant credit. 1. a b c d 6. a b c d 11. a b c d 16. a b c d 2. a b c d 7. a b c d 12. a b c d 17. a b c d 3. a b c d 8. a b c d 13. a b c d 18. a b c d 4. a b c d 9. a b c d 14. a b c d 19. a b c d 5. a b c d 10. a b c d 15. a b c d 20. a b c d CE ExaminaTion Form CE assEssmEnT QuEsTions—answErs Please circle your answers (one answer per question). ParTiCiPanT inFormaTion NAME ADDRESS CIT Y STATE ZIP E-MAIL WORK PHONE HOME PHONE How long did it take you to read the program and complete this test? _____ Hours ____ Minutes My signature certifies that I have independently taken this CE examination: ExCEllEnT Poor PlEasE raTE THE FollowinG iTEms. 1. Overall quality of the program 5 4 3 2 1 2. Relevance to pharmacy practice 5 4 3 2 1 3. Value of the content 5 4 3 2 1 PlEasE answEr EaCH QuEsTion, markinG wHETHEr you aGrEE or disaGrEE. 4. The program met the stated learning objectives: Agree Disagree After reading this CE article, the pharmacist should be able to: • List four potential outcomes of effective cultural competency techniques. ❏ ❏ • Provide six examples of cultural competency techniques that are applicable to Amish cultures. ❏ ❏ • State health beliefs and explanatory models of health and illness accepted in Amish cultures. ❏ ❏ • Differentiate the three sectors of the health care system that may be used by Amish people. ❏ ❏ • Name four reasons for lower vaccination rates among the Amish. ❏ ❏ • Identify examples of how pharmacists can help alleviate logistical, communication, and cost barriers to effective health care provision for Amish patients. ❏ ❏ 5. The program increased my knowledge in the subject area. ❏ ❏ 6. The program did not promote a particular product or company. ❏ ❏ imPaCT oF THE aCTiviTy The information presented (check all that apply) : 7. ❏ Reinforced my current practice /treatment habits ❏ Will improve my practice /patient outcomes ❏ Provided new ideas or information I expect to use ❏ Adds to my knowledge 8. Will the information presented cause you to make any changes in your practice? ❏ Yes ❏ No 9. How commit ted are you to making these changes? (Very commit ted) 5 4 3 2 1 (Not at all commit ted) 10. Do you feel future activities on this subject mat ter are necessary and /or important to your practice? ❏ Yes ❏ No ProGram EvaluaTion Pharmacists’ considerations when serving Amish patients Follow-uP As part of our ongoing quality-improvement effort, we would like to be able to contact you in the event we conduct a follow-up survey to assess the impact of our educational interventions on professional practice. Are you willing to participate in such a survey? ❏ Yes ❏ No This CE will be available online at www.pharmacist.com af ter December 31, 2008. To receive 2.0 contact hours of continuing education credit (0.2 CEu), please pro- vide the following information: 1. Type or print your name and address in the spaces provided. 2. Mail this completed form for scoring to: American Pharmacists Association—CE Exam P.O. Box 791082 Baltimore, MD 21279-1082 3. CE processing is free for APhA members. If you are not an APhA member, please enclose a $15 handling fee for grading the assessment instrument and issuing the Statement of Credit. A Statement of Credit will be awarded for a passing grade of 70% or bet ter. If you fail the exam, you may retake it once. If you do not pass the second time, you may no longer participate in this continuing pharmacy education program. Please allow 6 weeks for processing. Pharmacists who complete this exercise success- fully before december 1, 2011, may receive credit. The American Pharmacists Association is accredited by the Accredi- tation Council for Pharmacy Education as a provider of continuing pharmacy education. The ACPE Universal Program Number assignedto the program by the accredited provider is 202-000-08-246-H04-P. 64 Pharmacy Today • December 2008 www.pharmacytoday.org classifiedadvertising classifi edadvertising FOR MORE GREAT JOBS—GO TO WWW.PHARMACIST.COM MAY 2007 • PHARMACY TODAY 1 CVS Caremark redefi nes pharmacy by integrating the personalized reach of the nation’s largest retail pharmacy with the innovative delivery technology of the nation’s premier pharmacy benefi ts management provider. The result is health care that has the ability to enhance the lives of millions of patients in the United States. We leverage the tremendous resources of CVS Caremark to provide our pharmacists limitless possibilities to grow personally and professionally. 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C O M Nilotinib for CML 22 Heart health update 27 RxWiki: Pharmacy facts by the keystroke 44 SUPERVALU pharmacist Sherry Butler brings small-town service to patients 46 PQA paves the way for high-quality health care 49 Disciplinary action for TPN error 54 ICAAC 2007: INFECTIOUS DISEASE UPDATE FOR PHARMACISTS Visit www.pharmrmacytoday.org V p y y g ° J A N U A R Y 2 0 0 8 N V O L U M E 1 4 , N U M B E R 1 P H A R M A C Y T O D A Y N W W W . P H A R M A C I S T . C O M Nilotinib f or CML 22 Heart hea lth update 27 RxWiki: P harmacy f acts by the key stroke 44 SUPER VALU pha rmacist Sherry Bu tler brings small- town serv ice to pati ents 46 PQA pave s the way for high-quali ty health c are 49 Disciplina ry action f or TPN error 54 ICAAC 2 007: INF ECTIOUS DISEAS E UPDAT E FOR PH ARMACI STS P 55 Visit www.p harmacytod ay.org ° And did you know, as a practicing pharmacist, you are eligible to receive a full-year subscription to Pharmacy Today, absolutely FREE? Be in the know by joining thousands of informed pharmacists who subscribe to Pharmacy Today and receive the regularly featured MTM Tip, continuing education, Product Showcase, ISMP Error Alert, OTCs Today, Counseling Corner tip, and much more! Did You Know… Some things can’t be measured by degrees As the profession of pharmacy becomes more specialized and more demanding, the Board of Pharmaceutical Specialties offers a unique opportunity to demonstrate advanced clinical profi ciency in fi ve major practie areas: Nuclear Pharmacy, Nutrition Support Pharmacy, Pharmacotherapy, Oncology Pharmacy, and Psychiatric Pharmacy. Visit the BPS web site for details. Board of Pharmaceutical Specialties www.bpsweb.org 1100 15th Street, NW, Suite 400 | Washington, DC 20005-1707 68 Pharmacy Today • December 2008 www.pharmacytoday.org C olor-coded schemes for ophthalmic products have produced look-alike problems for nurses and pharmacists for many years. At the request of ophthalmol- ogists seeking a method to help differen- tiate eye products on their office trays, the American Academy of Ophthalmology (AAO) endorsed a color-coding scheme in 1996 that was later approved by FDA for use by manufacturers. This voluntary scheme is based on therapeutic class; for example, anti-infective ophthalmic containers and carton labels use a tan background, mydriatics and cycloplegics use red, miotics use green, beta-blockers use yellow or blue, and so on. For details, refer to www.aao.org /about /policy/ upload/Color_Codes_for_Topical_Ocu- lar_Medications.pdf. Although AAO intended to reduce errors with this policy, color coding instead often makes items in the same therapeutic class much more difficult to differentiate. Because of similar and highly stylized corporate logos, fonts, package sizes, and color combinations, designs that seem to work well in an office setting or patient’s home do not necessarily translate to pharmacies or other clinical locations. As a result, the USP–ISMP Medication Error Reporting Program has long received reports of mix-ups among items within each class. No to grab and go Errors with ophthalmic prod- ucts can occur with dispensa- tion or administration of these products on nursing units, in ophthalmology clinics, and in hospital and ambulatory care pharmacies; however, ophthalmologists continue to endorse the system. “The sys- tem results in a time saver for the physi- cian who can read the label on the drugs once a day—at the beginning of the day,” said an AAO spokesperson at a 2005 FDA Center for Drug Evaluation and Research hearing on the issue. This “grab and go” approach to selecting medications with- out fully reading the label can lead to medication errors. Despite ISMP’s efforts over the years to convince AAO, FDA, and drug manu- facturers that color coding can lead to errors, no changes have been made to improve safety. Confusion among these products continues, as evidenced by a recently reported mix-up between vials of Bausch & Lomb cyclopentolate 1% and tropicamide 1% (Figure 1). Bausch & Lomb is not alone in its adherence to the color-coding scheme. For example, for many years, Merck’s Timoptic (timolol) ophthalmic contain- ers had different colored caps, depend- ing on the drug’s concentration; light blue represented 0.25%, while yellow was 0.5%. However, Merck recently started using yellow caps for both con- centrations based on an AAO-endorsed update to the color-coding system. The old system recommended either blue or yellow caps for beta-blockers; the new scheme assigns yellow caps to beta- blockers and dark blue caps to beta- ISMPerroralert Caution regarding color-coded eye meds blocker combinations. Mix-ups have occurred with simi- lar packaging between ophthalmic and otic drops as well, where ear drops are instilled into the eyes. A community pharmacy reported that a prescription was written for Ocuflox (ofloxacin) 0.3% ophthalmic drops 5 mL. The prescription was entered into the pharmacy order entry system cor- rectly and 3 days after the eye drop was dispensed, the child’s mother called and said she had noticed the phrase “for use in the ears only” on her child’s eye drops. She was advised to discontinue the otic drops that had been given to her in error, and the ophthalmic preparation was dispensed. Carton coding not enough Cartons of Alphagan P (brimonidine tar- trate—Allergan) ophthalmic solution use color effectively to differentiate between the two available strengths of 0.1% and 0.15% (Figure 2). However, the enclosed bottles are not color coded and appear virtually identical. As a result, they could easily be replaced in the incorrect carton, increasing the risk of error. Alphagan P is an alpha-2 adrenergic agonist indi- cated for lowering intraocular pressure in patients with open-angle glaucoma or ocular hypertension. ISMP has contacted Allergan to ask that the actual bottles be color coded to match the cartons. ISMP has also requested that the size of the text denot- ing the strength be increased. In the meantime, outpatient areas, patient care facilities, and patients should avoid stor- ing Alphagan P bottles outside of their cartons. —Institute for Safe Medication Practices The reports described in this column were received through the USP–ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the Institute for Safe Medication Practices (www.ismp.org) or U.S. Pharmacopeia (www.usp.org) Web sites or communicated directly to ISMP by calling 800-FAIL-SAF (800-324-5723) or e-mailing ismpinfo@ismp.org. The topics in this column are covered in greater detail in Medication Errors, 2nd edition, written by ISMP President Michael R. Cohen, BPharm, MS, ScD. The book may be purchased from APhA at www.pharmacist.com or by calling 800–878–0729. Figure 1. A patient recently received atropine instead of cyclopentolate. Figure 2. Color helps differentiate strength on cartons but is missing from bot tles. The American Pharmacists Association (APhA) and the National Association of Chain Drug Stores (NACDS) are pleased to continue to offer a four-part webinar series presenting cutting-edge topics related to pharmacy-based immunization programs. The webinar series will highlight innovations in pharmacy- based immunization related to practice, advocacy, and science. PHARMACY-BASED IMMUNIZATION WEBINAR SERIES: INNOVATIONS IN PRACTICE, ADVOCACY, & SCIENCE Wednesday, January 21, 2009, 1:00 p.m. EST Federal and State Regulatory Update: Increasing Opportunities for Pharmacist-Provided Immunizations Thursday, February 19, 2009, 1:00 p.m. EST Challenges of Pharmacy-Based Immunization Services: Key Operational Issues Tuesday, March 17, 2009, 1:00 p.m. EST Emergency Preparedness and the Role of Immunizing Pharmacists Wednesday, April 15, 2009, 1:00 p.m. EST Innovations in Vaccine Science MORE DETAILS AND REGISTRATION COMING SOON… Visit www.nacds.org/immunization or www.pharmacist.com for more detailed program information in the near future! The National Association of Chain Drug Stores (NACDS) Foundation and the American Pharmacists Association (APhA) are accredited by the Accreditation Council for Pharmacy Education (ACPE) as providers of continuing pharmacy education. Each webinar offers participants the opportunity to earn 1.0 contact hours (0.1 CEU) of continuing pharmacy education credit. Statements of continuing pharmacy education credit may be printed online by visiting the NACDS Foundation's CE Center and completing an evaluation for each program. Then SAVE THE DATE now for these free live CE webinars! Attention Pharmacists Do You Immunize? Educate? Advocate? Supported, in part, by independent educational grants from: NEW SO KIDS CAN FEEL BETTER SOONER. NEW KIDS-EEZE ® CHEST RELIEF HONES IN AND RELIEVES CHEST CONGESTION WITHOUT OVERMEDICATING. Unlike multi-symptom remedies, Kids-EEZE Chest Relief with guaifenesin targets chest congestion without overmedicating. 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