RxCe - Cultural Competency in a Pharmacy Setting Materials

IMPROVING CULTURAL COMPETENCY IN THE PHARMACY SETTING

Steve Malen, PharmD, MBA

Dr. Steve Malen graduated with a dual degree: Doctor of Pharmacy (PharmD) and Master of Business Administration (MBA) from the University of Rhode Island. Over his career, he has worked as a clinical pharmacist in the retail, specialty, and compounding sectors. He specialized and taught on topics from vaccines to veterinary compounding. Dr. Malen has also written a science fiction novel and taught and co- founded the concept of Patient Empowered Blockchain (P.E.B.). Currently, Dr. Malen continues to write, teach, and consult various companies in the healthcare sector.

Topic Overview

The United States is regarded as one of the most culturally diverse countries in the world. With diverse cultures also come challenges. This is particularly true of access to healthcare services by different members of society. Health disparity can arise when explicit or implicit biases and prejudices are present in healthcare. One way to reduce health disparity is to cultivate cultural competence. cultural competence is a clinician’s ability to recognize that a patient has cultural influences that shape the patient’s life and social interactions, followed by the clinician’s ability to respond to these influences and acknowledge them.

Accreditation Statement:

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is

Pharmacist 0669-0000-23-005-H99-P

Pharmacy Technician 0669-0000-23-006-H99-T

Credits: 2 hours of continuing education credit

Type of Activity: Knowledge

Media: Internet Fee Information: $6.99

Estimated time to complete activity: 2 hours, including Course Test and course evaluation

Release Date: January 28, 2023 Expiration Date: January 28, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From January 28, 2023, through January 28, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “educational activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Define health disparities

Describe what is meant by cultural competency

Review patient characteristics such as gender, and sexual orientation and how these groups can experience health disparities.

Identify tools to address discrimination and health disparities in the pharmacy setting

Disclosures

The following individuals were involved in the development of this activity: Steve Malen, PharmD, MBA, and Susan DePasquale, MSN, PMHNP-BC. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.

Introduction

Cultural competence in the pharmacy setting can help reduce discrimination and disparities in healthcare. Pharmacists and pharmacy staff can improve patient outcomes and satisfaction by raising the level of cultural competency in their daily practice. Success in this endeavor requires an understanding of what is meant by cultural competency, and the relationship between cultural competency and health disparity. Once these concepts are understood, strategies can be developed to address discrimination and health disparities in the pharmacy setting and to increase the cultural competence of pharmacists and pharmacy staff.

Diversity in the United States

The United States is regarded as one of the most culturally diverse countries in the world.1 This is borne out by the recent US Census Bureau report that lists White American, Black or African American, Indian and Alaska Native, Asian American, Native Hawaiian, and Other Pacific Islander among the races residing in the US. In addition to racial groups, ethnic groups such as Americans of Hispanic origins add to the cultural diversity.1 Many of the world's religions are also represented in the US, and about one-fourth of Americans do not identify with any of them. There are also multiracial segments of the population, people of differing sexual orientations, genders, gender orientations, and socioeconomic statuses.2 These ethnic, racial, and other differences form a unique, American character and tapestry that offers so much to the experience of living in the US or visiting.1,2

Cultural Diversity and Biases, Stereotypes, and Prejudices

With diverse cultures also come challenges. Language is one of the challenges.1 English is the predominant language spoken in the United States; however, there are many other languages. Spanish is the second most frequently spoken language in the United States.1 While language diversity is a strength, it can also give rise to potential barriers to communication.

Another challenge that arises out of diversity is that people from different cultures or lifestyles may develop biases, stereotypes, and prejudices from a lack of understanding or appreciation of cultures or lifestyles different from theirs.2

Cultural Diversity and Health Disparity

Health disparity can arise when explicit or implicit biases and prejudices are present in healthcare. Health disparity is defined as “a difference or inequality that occurs in health status or in the provision of and access to health care that is often linked with social, economic, and environmental disadvantage.”3 Said another way, with health disparity, a patient’s access to healthcare is linked to the patient’s race, ethnicity, gender, age, socioeconomic status, sexual orientation, disability status, or another characteristic that should not factor into the patient’s care.3 This is the opposite of “health equity,” which is present when all members of society have fair access to healthcare without regard to the characteristics enumerated above.4

The existence of improper disparities in the use or access to healthcare services is well documented and widely acknowledged.3-5 In 2002, the Institute of Medicine (IOM) released a report bringing to light disparities in the delivery of healthcare services to racial and ethnic minority patients.4,5 The IOM report found that “[b]ias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare."5 Health disparity is a form of discrimination. Patients can be harmed when health disparities prevent them from accessing healthcare services. One way to reduce health disparity is to cultivate cultural competence.2

Defining Cultural Competence

Culture may be understood as human patterns, beliefs, and values that are shaped by a person’s racial, ethnic, religious, social, or institutional origins

or affiliations. It can manifest through language, thoughts, communications, actions, and customs.2

Pharmacists and pharmacy technicians should understand that there are many cultures that have distinct patterns, beliefs, and values.6 Pharmacists and pharmacy technicians can be more effective in their delivery of pharmacy services if they are culturally competent. But what does it mean to be culturally competent?6 This question may be more complex than it seems. This is partly because the literature in this area lacks consistent definitions and terminology.6 Many terms are used interchangeably, but they can have different meanings, e.g., “cultural awareness, cultural respect, cultural safety, cultural understanding, and culturally appropriate healthcare.”6 In addition, cultural differences can be nuanced and complex. There can be variations within different cultural and ethnic groups.6 This requires flexibility on the part of a pharmacist or pharmacy technician to be open to adapting to these variations.

Any definition given here is a starting point and not the end of the issue. One definition of cultural competence is a clinician’s ability to recognize that a patient has cultural influences that shape the patient’s life and social interactions, followed by the clinician’s ability to respond to these influences and acknowledge them. When a clinician is in contact with a person, the clinician needs to be open and respectful. This can create trust in the clinician- patient relationship, which can lead to positive patient outcomes.2 In healthcare, cultural competence means that a provider delivers effective healthcare across diverse cultures.7 This requires effective communication skills, and it may involve collaboration with a multidisciplinary team for broader input. Clinicians who are sensitive and aware of a patient’s cultural background are more likely to achieve mutual understanding during clinician- patient encounters and to consider healthcare interventions that are appropriate for the patient, given the patient’s culture.7

Groups who Experience Health Disparity

Patients should have access to healthcare, and they should not receive different care because of a personal characteristic that is not relevant to their care. Patient populations have been denied equal access to healthcare based on ethnicity, race, HIV/AIDS and infectious disease status, language (limited English proficiency (LEP)), gender, sexual preference, gender identity, disabled status, socioeconomic status, and educational levels. All of these population groups are extremely important, but only a few can be covered here. The aim of the following examples is to show how discrimination and health disparity are connected, and why cultural competence is essential to reduce them.

Race and Ethnicity

Race and ethnicity are often grouped together. This is because these terms blur when it comes to culture, values, and beliefs.8,9 Some scholars argue that society needs to move beyond certain concepts of race and ethnicity, and examine instead how these terms relate to socio-political processes, social class, gender, and social relationships.8 This discussion is beyond the scope of this course, but it highlights the complexity that may be encountered when a pharmacist or technician is exploring culture, race, and ethnicity in the pharmacy setting.

The important inquiry here is how a lack of cultural competency impacts patient outcomes. This is sometimes seen when a certain racial or ethnic group has a higher incidence of a particular disease. This may be an important factor to consider when diagnosing and treating a patient, but as Moskowitz, et al. (2012) suggest, these stereotypes may lead to unconscious diagnoses that unduly influence treatment plans.10 For example, a pharmacist as a member of a medication management team may read that hypertension is widely reported as being more prevalent among African Americans and Native Americans than among White Americans.10 A male African American patient has been prescribed hypertension medications. These medications may be appropriate but the pharmacist could provide a deeper look at the patient’s

hypertension medications to ensure that they are not being prescribed as a matter of course based on the patient’s race and gender but that a more thorough consultation or review occurred.

This unconscious bias, described by Moskowitz, et al., is generally known as implicit bias.10 Implicit bias involves biases and stereotypes that clinicians are unaware they have; however, these biases and stereotypes unconsciously direct their conduct and decision-making in clinical settings.10

HIV/AIDS and Infectious Disease Status

Studies consistently show that patients with HIV/AIDS and other infectious diseases (e.g., viral hepatitis, sexually transmitted disease, tuberculosis) experience unequal access to care, and consequently, they have poorer health outcomes.11 This overlaps with other population groups since race, ethnicity, and gender may also influence health disparity.11 For example, compared with nonminorities, women and African Americans receiving treatment for HIV are less likely to receive antiretroviral therapy, protease inhibitors, and prophylaxis for pneumocystis pneumonia.11 These disparities have been reflected in AIDS mortality data for some time.11

Language: Limited English Proficiency (LEP)

As mentioned above, English is the primary language spoken and used in the US. Patients who have limited proficiency in the English language often experience poorer access to healthcare.12 Nguyen, et al. (2022) reported how LEP created a barrier to proper postoperative care, including prescription medication refills.12 This is where a pharmacist or pharmacy technician may be culturally aware that a patient with LEP may need follow-up to ensure the patient understood the prescription instructions.

The U.S. Department of Health and Human Services (HHS) recognizes the intersection of culture and language (literacy). Health literacy measures whether a patient can understand medical literature and communications from the healthcare provider. As a consequence, the HHS has developed the

National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. The standard states that “health care organizations must make available easily understood patient-related materials … in the languages of commonly encountered groups …”12

The National Standard not only requires that materials be culturally responsive, but they must also meet the literacy levels of patients.12,13 Culture and language are interrelated. Culture shapes attitudes and beliefs, and can influence a person’s health literacy.12

Health literacy continues to be a problem and will only become more pronounced given the projected growth of LEP populations.14 This provides an opportunity for pharmacists and pharmacy technicians to provide understandable materials when it comes to dispensing medications and providing refills.

LGBT and Gender Identity

Patients in the LGBT community confront bias and discrimination that contributes to healthcare disparities.15 In addition, providers may lack knowledge about LGBT, and may even convey personal discomfort to the patient.15 The same is true of transgender patients.16 Pharmacists and pharmacy staff are not immune from these biases and prejudices.15,16 At the same time, pharmacists and pharmacy staff are uniquely positioned to reduce health disparities in these populations and engage in cultural competence.

The Impact of Intersectionality in Shaping Sexual Identity

Intersectionality, a term coined by Kimberlé Crenshaw, has become a powerful analytical tool that illuminates how various social categories such as race, gender, and class intersect and overlap, culminating in a complex system of privileges and oppressions. It is a prism for understanding how different aspects of a person’s identity can influence their experiences, including the expression and perception of sexual identity. This concept prompts a profound evaluation of how one’s sexual identity is not solely a manifestation of individual preferences or orientations but is profoundly impacted by the multifaceted network of intersecting social identities and affiliations.

Firstly, cultural and racial backgrounds play a pivotal role in the formation and expression of sexual identity. Different cultures possess unique sets of norms, beliefs, and expectations concerning sexuality and gender. For some, there may be a pronounced stigma associated with being anything other than heterosexual, which can impede the exploration or expression of one’s sexual identity. In contrast, some cultures may be more inclusive, allowing for a more fluid and open expression of sexual identities.

Socio-economic status is also integral in intersectionality, determining access to resources, education, and spaces that can affirm or challenge one’s sexual identity. Economic privilege might afford someone access to safe spaces, mental health resources, and supportive communities, enabling them to navigate their sexual identity amidst a conducive environment. Conversely, economic hardship might limit access to such resources, exacerbating the difficulties associated with exploring and affirming one’s sexual identity.

Gender also significantly intersects with sexual identity. The societal expectations and stereotypes associated with masculinity and femininity can shape how one experiences their sexuality. For example, the societal trope of masculinity often comes loaded with expectations of heterosexuality, potentially making it challenging for men to express non-heterosexual identities openly.

Additionally, the legal and political environment of one’s location also shapes experiences of sexual identity. Laws and policies can either affirm or negate certain sexual identities, impacting societal attitudes and individual experiences. Progressive laws that protect LGBTQ+ rights, for instance, may foster environments where people feel safer exploring and expressing their sexual identities.

Therefore, intersectionality is a vital lens through which the complexities of sexual identity can be appreciated and understood. By considering how various social identities and systems intersect, one gains a deeper understanding of the multifaceted influences shaping individuals’ experiences and expressions of their sexual identity. Thus, intersectionality facilitates a nuanced conversation that goes beyond singular identities, fostering a richer dialogue that captures the diversity of human experiences in the realm of sexual identity.

Assessing Cultural Competence

The first step of any effort to improve cultural competence is the awareness that it is needed as an antidote to health disparity. Once this is understood, each person and pharmacy should take the next step: assess the cultural competency of the pharmacy staff and pharmacy.

The US Substance Abuse and Mental Health Services Administration provides free resources that may be used to assess cultural competency. It provides “counselor self-assessment tools, guidelines and assessment tools to implement and evaluate culturally responsive services within treatment programs and organizations, and forms addressing client satisfaction with and feedback about culturally responsive services.”17 These tools are in the public domain, and they provide a good departure point for assessing cultural competency.17 Other tools used for assessing pharmacy students include the Clinical Cultural Competency Questionnaire.18

Barriers to Health Equity and How to Overcome Them

Barriers to the effective delivery of healthcare arise because of poor clinician-patient communication. Pharmacists and staff can utilize cultural humility within the clinician-patient relationship to improve communications with patients. Pharmacists and staff must clinically accommodate patient preferences and needs, which may require modifying practice processes and styles, and facility designs and decor.

Communicating with Patients

Language differences are the primary hindrance to pharmacists and pharmacy staff providing effective pharmacy services to patients. This will only become more pronounced as patient populations become more ethnically diverse.19 Good communication skills when communicating with LEP patients are essential.19 This should not be surprising since good communication skills with patients are not only needed to promote cultural competence but are generally necessary for positive patient interactions and satisfaction.20

Cultural Humility

Good communication skills are important, but what can a pharmacist or pharmacy technician do to improve them? One approach is to incorporate cultural humility into the clinician-patient relationship.4 Cultural humility describes a relationship with a patient that honors the patient’s beliefs,

customs, and values.4 A pharmacist or pharmacy technician would need to engage in regular self-reflection, combined with a willingness to learn from the patient.4 Cultural humility is not the same as cultural competence. Cultural humility “de-emphasizes cultural knowledge and competency and places greater emphasis on lifelong nurturing of self-evaluation and critique, promotion of interpersonal sensitivity and openness, addressing power imbalances, and advancement of an appreciation of intracultural variation and individuality to avoid stereotyping. Cultural humility encourages an interpersonal stance that is curious and other-oriented.”4 The wording here is important: Cultural humility “de-emphasizes cultural knowledge and competency,” but it does not eliminate them.4 It promotes cultural competence from a different focal point.

Accommodate Patient Needs, and Preferences

Pharmacists and staff must clinically accommodate patient preferences and needs.21 This will invariably require modifying practice processes and styles.21 This could involve using interpreters, the use of pictures, images, or computer-based information.4,22 Pharmacists and staff may need to develop processes to gather cultural information that may be relevant to the patient’s care.23 An example given by Misra-Hebert, et al. (2012) was a patient who believed his illness was caused by a “hex” his wife had placed on him.22 This information could be extremely relevant since a patient who believes an illness was caused by a hex may believe that adherence to a treatment plan is futile. Engaging this patient respectfully could be the difference between the patient following the treatment plan, or not.

A pharmacy could provide culturally specific treats or display cultural artwork and decor that reflects the diversity of the patient population to create a welcoming and inclusive environment. This could rotate periodically.

Pharmacists and staff must respect patients' modesty, and take into account cultural differences in communication styles. Shaking hands could be offensive to certain people. It is good practice to let the patient or coworker lead with communication styles and interactions.

Inclusive language, that considers all gender identities, should be used. A clinician should use the pronoun "they" instead of "he" or "she," and avoid making assumptions about a person's gender based on their appearance.24 One example includes referring to someone’s doctor by a pronoun that assumes they are a particular gender without verifying the gender. First names can be gender-neutral, and names that are foreign to English or a clinician’s culture could be vague when it comes to gender. That is why it is better to play it safe and not assume gender. A transgender patient may also become offended if their gender is misstated. Let the patient lead in regard to pronoun usage.

Patients may have financial needs. A pharmacy should provide them with available financial assistance, including information about public insurance options, Medicaid, or the Children's Health Insurance Program (CHIP). Studies have found that financial assistance improves adherence by decreasing the financial burden on the patient.25

Disabled patients may require additional services and resources. A pharmacy can make information available in a variety of formats, such as large print, braille, and audio, to accommodate people with vision or hearing impairments. Provide training to all staff members on disability sensitivity and how to provide appropriate care and support to patients with disabilities. Involve disabled individuals in the design and planning of the facility to ensure that it meets their needs and is welcoming to all.26

Core Competencies for Pharmacy Staff

Cultural awareness refers to the ability to recognize and understand the impact of cultural differences on communication and interactions with others. It is important for pharmacy staff to have a basic understanding of cultural awareness in order to provide culturally sensitive and competent care to patients from diverse backgrounds.

Core competencies that pharmacy staff should consider when it comes to cultural awareness:

Recognize the impact of culture on health beliefs, behaviors, and communication: Pharmacy staff should be aware that cultural differences can influence how patients perceive and approach their health and healthcare. In order to take care of patients, we need to understand where they are coming from. Motivational interviewing is the practice of getting patients to want to take control of their health. Understanding the culture of the patient is an important factor in what will motivate patients to control their health. It is also important to note that each culture is not monolithic, so there could be a large variation in each ethnic community.27,28

Understand and respect cultural differences: Pharmacy staff should respect and appreciate the cultural differences of their patients and avoid making assumptions or stereotypes. This statement may seem contradictory, but it is not. There are differences in cultures; however, not everybody in each culture is identical. People may do things because of their culture, but that doesn't mean everybody in that culture does the same thing. However, we must respect the general variation in behaviors of patients from culture to culture. Of course, this has limits if the behavior is offensive or rude. If pharmacy staff either is offended or feels threatened by patients or other staff, this must be reported to be reviewed by management.

Communicate effectively with patients from diverse cultural backgrounds: Pharmacy staff should be aware of the potential barriers to communication that may exist due to cultural differences and take steps to overcome them. These barriers may be language however it could also be trusted in healthcare. Some people come from countries where there is mistrust in healthcare, so they bring that mistrust with them. Pharmacists and pharmacy staff may have to work harder to create trust. As mentioned above, a clinician may use cultural humility to engender trust.

Seek out cultural competency training: Pharmacy staff should be willing to seek out training and resources to improve their cultural competency and understand the unique needs of their patients.29

Promote a culturally inclusive environment: Pharmacy staff should work to create a welcoming and inclusive environment for patients from diverse cultural backgrounds. This can involve making sure that informational materials are available in multiple languages, providing interpreters as needed, and being sensitive to cultural differences in body language and communication styles. Instead of “talking the talk” with cultural inclusion, you should “walk the walk.” Language barriers can impact health in significant ways, so setting up systems in the pharmacy that allows communication with patients who speak different languages is reasonable, and these technologies are available and are not that expensive.30

Address implicit bias: Have an awareness of the role implicit bias can play in communication, clinical judgments, and decision-making. Mitigate implicit bias in the pharmacy setting.31

Cultural competency is a virtue that should be constantly sought by every person and organization. Everyone has implicit biases that affect how they communicate or interpret communication. This means that patients and coworkers will also have implicit biases that can contribute to miscommunication. In healthcare, miscommunication could be the difference between a patient being adherent to a treatment plan or having trust in the healthcare provider. Pharmacists and pharmacy staff have a unique opportunity to communicate with patients as they fill or refill prescriptions and help patients with over-the-counter products.

Summary

The United States is regarded as one of the most culturally diverse countries in the world. With diverse cultures also come challenges. Language is one of the challenges. Health disparity can arise because of cultural

diversity, and explicit or implicit biases and prejudices that are present in healthcare. Health disparity is defined as differences or inequalities that occur in the delivery or access to healthcare. It is often linked to social, economic, and environmental disadvantages. Health disparities can harm patients when they are prevented from accessing healthcare services.

Cultural competency can mitigate health disparity. Cultural competence is the ability to recognize that a patient has cultural influences that shape the patient’s life and social interactions. When a clinician is in contact with the person, the clinician is able to be open and respectful. This creates trust in the clinician-patient relationship, which can lead to respectful exchanges, and improved patient outcomes.

Patient populations have been denied equal access to healthcare based on ethnicity, race, HIV/AIDS and infectious disease status, language (limited English proficiency (LEP)), gender, sexual preference, gender identity, disabled status, socioeconomic status, and educational levels.

Cultural barriers to the effective delivery of healthcare services often arise because of poor clinician-patient communication. Pharmacists and staff can utilize cultural humility within the clinician-patient relationship to improve communications with patients. Pharmacists and staff must clinically accommodate patient preferences and needs, which may require modifying practice processes and styles, and facility designs and decor.

References

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DISCLAIMER

The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary

from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.

Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course, or course material.

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