With great power comes great responsibility. . . . The role of pharmacists in ensuring health equity

The nature of our role as primary health care providers puts us in a position of power. We speak the language of medicine and understand the health care system better than many. ¹ In fact, we act as knowledge brokers, helping others navigate a system we understand well. From drug formularies and shortages to medication prescribing, pharmacists all operate with an incredible amount of valuable insight. ¹ It influences our perspective and affects the way we think and act. Our knowledge is a form of privilege, and we often take it for granted. The health care system was built for health care providers—it’s designed in a way that allows us to function and communicate easily with each other. ¹ As a result, it may be harder for us to see health care through the lens of someone who isn’t holding this privilege—many of our patients. ¹ That’s why it’s important to use our positions to help address health inequities and close the care gaps that exist for our patients, particularly equity-deserving populations within our communities. ¹

What is health equity?

The World Health Organization (WHO) defines equity as “the absence of unfair, avoidable, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g., sex, gender, ethnicity, disability, or sexual orientation)” ² and states that “health equity is achieved when everyone can attain their full potential for health and well-being.” ²

Health and health equity/inequity are determined by a group of factors commonly referred to as determinants of health. ³ Such factors are decided by conditions that are mostly out of the individual’s control—such as where they were born, and where they live, work, and play.^2,4 They include income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biology and genetic endowment, gender, culture, and race/racism. ³

While considered one of the healthiest countries in the world, some Canadians have more opportunities to live a healthier lifestyle and therefore enjoy better health outcomes than others. ³ Indeed, it has been reported that those of lower socioeconomic status have worse health outcomes when compared to those of higher socioeconomic status.^5-7 Similar observations have been reported in those who live in rural and remote areas when compared to those who live in urban areas.^8,9

The pharmacist’s role in health equity

Pharmacists prevent and treat diseases through advice, clinical judgment, and the safe and effective use of medications. ¹⁰ Such a role cannot be completed without considering health equity. For example, if a woman of childbearing age comes into the pharmacy with a prescription for isotretinoin, you likely would not dispense the medication without asking a few questions about pregnancy and contraception practices. ¹¹ What if the patient’s hearing or vision was impaired? Or they did not speak English? Or had a learning disability? These are all health equity considerations that should influence how you would serve that patient.

Pharmacists are front-line primary health care providers who practice in the heart of communities where people live, work, and play. ¹² They see patients more frequently than any other health care provider and rank among the most trusted health care providers by the public.^13,14 Pharmacists’ interventions in many conditions have been associated with improved outcomes, high levels of patient satisfaction, and reduced costs.^15-21 Furthermore, more than one-third of the practicing pharmacists in Canada are internationally trained. ²² This is a strength that could help address some of the health inequities caused by factors like language, race, and culture.

Such facts, combined with the high prevalence of health inequities, have prompted many institutions and experts to call for an enhanced role of pharmacists in tackling health inequities. The Royal Pharmaceutical Society has encouraged pharmacists to think about not only the type of services they provide but also the way they are providing them. ⁴ They highly recommended that pharmacists think about creative ways to offer their services to reach equity-deserving populations who usually do not benefit from such services. ⁴ Similar recommendations were provided by Osasu, ²³ Kwan, ²⁴ Rothwell et al., ²⁵ and Hunter^26,27, and in this issue, Maximos. ²⁸ Furthermore, it has been reported that in rural and remote areas, pharmacists are the closest and, sometimes, the only health care providers that the community has access to.^29-31 This further highlights the importance of the enhanced role of pharmacists in tackling health inequities. Stated another way, any discussion of a full scope of practice is incomplete without a consideration of health equity (Box 1).

Box 1. Considerations of health equity.

Dakota is awaiting a hip replacement and is taking opioids for the chronic hip pain. They wonder how their cultural healing practices could complement their pain management.

Jean-François lives in northeastern Ontario and is deciding whether to try to refill their antihypertensive medications now or wait until their son (who speaks better English) visits on the long weekend.

Jamie is anxious about refilling their HIV pre-exposure prophylaxis medication at the pharmacy. Although nothing is said, they feel uncomfortable when picking up the medication and have never spoken to a pharmacist.

Oluwaseun quickly runs in and out of the pharmacy to pick up their prescription. As a newcomer to Canada, they feel a lack of connection to their pharmacists because their interactions always seem very transactional.

The Canadian Pharmacists Journal and health equity research and commentary

The focus of the Canadian Pharmacists Journal (CPJ) is on evidence for pharmacist care, studies that help us understand the full scope of pharmacist practice, and tools for implementation. As we explore the social milieu of pharmacy practice, equity research and commentaries are vitally important. Indeed, a quick review of the past 2 years of CPJ reveals 22 articles that address these issues (Table 1).

Table 1.

Health equity topics in CPJ over the past 2 years

Topic area	Title
Indigenous health	Community is medicine: First-ever gathering of Indigenous Pharmacy Professionals of Canada 32 Two-Spirit Peoples’ experiences accessing and receiving care from community pharmacies 33 Laying the groundwork for decolonization, Indigenization, and reconciliation in pharmacy 34 Tensions between Western and Indigenous worldviews in pharmacy education and practice: Parts I, II, and III35-37Equity, diversity, inclusion, and Indigenous training for pharmacy professionals 38
Accessibility, language, and communication	Reporting on knowledge, attitudes, and behaviours of pharmacists regarding the active offer of French language health services in Ontario: A quantitative survey study 39 Deaf, deaf-blind, and hard of hearing needs and perceptions of community pharmacy services 40 Pharmacist accessibility for non-native Japanese speakers: A cross-sectional study in Japan 41 Lost in translation: Assessing the readability of online information on community pharmacy services 42
HIV/PrEP	Community pharmacists’ acceptance of prescribing pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) 43 Target users’ acceptance of a pharmacist-led prescribing service for pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) 44 Role of the pharmacist caring for people at risk of or living with HIV in Canada 45
Cultural competence	Understanding the experiences of Black Nova Scotians with community pharmacists 46
	Pharmacists provide exceptional patient-centred care (but what if you’re Black?) 47
Gender and workforce	The gender wage gap in the Canadian pharmacy workforce in the wake of COVID-19 48 Long-term trends in the labour supply and productivity of pharmacists in Canada 49
Social prescribing	Social prescribing in pharmacies: What is it, does it work, and what does it mean for Canadian pharmacies? 50
Stigma	Buprenorphine-naloxone in chronic pain: Overcoming stigma for safer opioid management 51
Pharmacist role	Bridging gaps in Canadian health research: The critical role of sex, gender, and equity in shaping inclusive and evidence-informed health care 28
	Accessibility reality check 52

Perhaps our thoughts are best described in the editorial by Watson et al., ⁵² in July/August 2024, entitled “Accessibility Reality Check”. In this article, the concept of “accessibility” of pharmacists is explored in terms of the WHO’s Right to Health (the “AAAQ model”), which includes Availability (Do the right services exist in adequate quantity and location?), Accessibility (Can the services be reached and used?), Acceptability (Are services ethical and sensitive to culture, gender, and life cycle?), and Quality (Are pharmacy services provided at an acceptable standard of care?). Watson et al. highlight the areas of strengths and weaknesses of pharmacy practice according to the AAAQ model. We encourage you to reread this editorial, as it will serve as the framework for future editorial direction for the CPJ.

This is highlighted in this issue of CPJ where Maximos et al. ²⁸ underline the major role that health equity plays in strengthening the foundation of modern medicine and giving equity-deserving populations the voice that they deserve and are currently lacking. ²⁸

To our colleagues around the world: Health equity is an area where pharmacy as a profession already does well, but certainly can do better. We need more health equity work in pharmacy, not less. As such, we intend to prioritize health equity work and invite submissions to CPJ in the area of health equity in pharmacy practice—studies that improve our understanding of the field, implementation strategies (and their evaluation), and educational approaches. For this work, you have a safe place at CPJ.

Indeed, as superheroes, pharmacists have great power and a great responsibility towards health equity (mangled quote from Stan Lee, Spiderman).