Cultural Competence Considerations for Health-System Pharmacists

Abstract

Purpose: An introduction to cultural competency is provided for health system pharmacists, including communication tools and considerations to personalize care for diverse patient populations. Summary: Disparities in patient outcomes, health care utilization, and treatment adherence exist across diverse patient populations in the United States. Cultural competence of health system pharmacists is important to optimize medication use in diverse patient populations. The LARA (Listen, Affirm, Respond, and Add) methodology, Kleinman’s explanatory model, and the teach-back method are communication tools to facilitate culturally integrated discussions with patients. Health system pharmacists should be cognizant of cultural considerations that may emphasize spiritual care, nonpharmacologic therapy, patient privacy, and potential distrust of health care professionals. Conclusion: Health system pharmacists should strive to increase awareness of the impact that cultural beliefs and traditions have on patient care.

Key Points

• Health system pharmacist cultural competence is critical to aid reduction and elimination of health care disparities.

• Communication tools can create meaningful communication that facilitates personalized patient care.

• Health system pharmacists should strive to provide culturally competent care.

Introduction

Cultural competence is the recognition of cultural influence and interactivity that creates a trusting and respectful exchange.^1,2 Cross and colleagues postulated that culture “refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.”³ Multiracial and religious-based cultural segments, heritage, sexual orientation, gender, gender orientation, socioeconomic status, geographic location, and linguistics have also been included when identifying diverse groups.^4-6

In the United States, evidence exists that patient outcomes, health care utilization, and treatment adherence for patients of minority descent differ from the majority population.^7-9 Examples of these health care disparities include data indicating that Caucasians have a longer life expectancy than African Americans, African Americans and Hispanics have a 77% and 66% higher risk of developing diabetes, respectively, and Hispanic patients are 3 times less likely to have regular health care provider follow-up and twice less likely when compared with African American patients. Patients living below the federal poverty level have the highest rates of preventable hospitalization.⁷ Harm from adverse drug events (ADEs) is more common for patients with limited English proficiency and have been related to communication errors.⁷ Health system pharmacist cultural competence is critical to aid reduction and elimination of health care disparities.¹⁰

It is critical to note cultural competence efforts are not purposed to categorize or stereotype groups of people, but rather to recognize each patient interaction as cross-cultural and unique.^1-3 Cultural themes are provided in health care cultural competence learning to create awareness and sensitivity in approach to personalized patient care.

The health system pharmacist role demands culturally competent care to assure patients are able to manage their care plans as intended.¹⁰ Pharmacists are direct patient advocates responsible for the medication use process and are well positioned to make a significant impact on patient understanding of and adherence to medications.¹¹ Pharmacists can increase effectiveness of their interventions through exercise of cultural competence and assuring patient care plans align with cultural beliefs, customs, and overall lifestyle.

The purpose of this article is to equip health system pharmacists with a baseline understanding of cultural competence and to provide an introduction to personalized patient care considering respective culture and treatment goals.

Cross-cultural Communication

A majority of health systems fail to adapt to the communication needs of minority patient populations.¹² Chevannes surveyed health professionals about their knowledge and comfort level when caring for multiethnic patients. A significant finding of the survey found an unanimous response indicating that communication with minorities creates barriers that affect quality of care and therefore further increases health care disparities. Furthermore, 65% of survey respondents specified they lacked education in personalized care delivery to meet minority group health care needs.¹³ According to a 2014 Joint Commission Online report, communication was within the top 3 contributing factors to sentinel events which result in critical injury or even death.¹⁴

Communication tools that may be effective for the health system pharmacist to facilitate a culturally integrated discussion with patients include the LARA methodology,^15,16 Kleinman’s explanatory model,¹⁷ and the teach-back method.¹⁸

The LARA methodology is introduced in Gordan’s Leadership Effectiveness Training and other applications.^15,16 LARA is an acronym that stands for “Listen, Affirm, Respond, and Add.” The first element, “Listen,” incorporates a focus on needs, cultural values, interests, emotions, and meaning of word choice. “Affirm” is to acknowledge listening occurred by paraphrasing the patient communication. Agreement is not necessarily a part of affirmation. “Respond” includes clarification of information to assure understanding. “Add” is where additional views and context are shared in a nonconfrontational manner. The LARA methodology can provide an optimal environment for the health system pharmacist to share perspectives and understand patient beliefs.^15,16

Health system pharmacist patient counseling sessions may benefit from employing Kleinman’s explanatory model. This model provides specific questions to guide a patient interview which emphasize understanding of what creates a patient experience with their respective illness.¹⁷ The following example questions guide discovery of a patient approach to their own care:

• What do you think caused your problem? What name does it have?

• Why and when did it start?

• Why do you think it started when it did?

• What do you think your illness does to you? How does it work?

• How severe is your illness? Will it have a short or long course?

• What are the chief problems your illness has caused you?

• What do you fear most about your illness?

• What kind of treatment do you think you should receive?

• What are the most important results you hope to receive?¹⁷

Within the health system setting, the teach-back method is a process of asking a patient to communicate information provided back to the pharmacist. When patient comprehension has been studied after a physician encounter, approximately 40% to 80% of information communicated was immediately forgotten.¹⁸ Of the information retained, approximately 50% of content stated back was incorrect. The teach-back method has been shown to increase patient understanding and adherence, as well as improve patient satisfaction.¹⁹

Stimulating open conversations with patients of diverse cultures by employing the LARA method, recognizing how the patient perceives their care and illness, and confirming patient understanding using the teach-back method can create meaningful communication that facilitates personalized patient care.

Cultural Considerations

General cultural considerations detailed below highlight how health system pharmacist interventions may evolve to provide culturally competent care. These shared considerations are absolutely not intended to categorize patient populations, but rather to aid in enhancing health system pharmacist understanding of the role cultural beliefs can play within patient interactions.

Many cultures connect physical wellness with spiritual influence and conditioning.²⁰ For example, both medical intervention and spiritual care may be beneficial for ill patients within Muslim belief systems.²⁰ The health system pharmacist should explore spiritual care resources available within their organization to bridge physical and spiritual patient healing.

Some cultural themes motivate nonpharmacologic patient self-care. Polynesian communities hold physiotherapy in high regard. Physiotherapy includes healing dances, exercise, and massages.^21-23 Korean Americans may place increased emphasis on healthy lifestyle maintenance.^24-26 This emphasis further materializes with natural remedies, exercise, and strict medicinal adherence.^24,25 The health system pharmacist should strive for complete evaluation of self-care to assure drug interaction avoidance and safe use.

Respecting patient privacy may facilitate comfort for those with cultural beliefs appreciating modesty. In traditional belief systems of Somali women, desire for privacy may include providing time to replace traditional clothing removed for medical treatment before discussing care and time to finish prayers.¹² Health system pharmacists must be aware of time management strategies to provide a comfortable patient environment when providing culturally competent care.

Religious holiday observance may affect patient ability to adhere to prescribed medication administration and instructions. Ramadan, as an example, encompasses 30 days where individuals traditionally refrain from eating and drinking during day time hours.¹² Medications that require specific dietary requirements for absorption or interaction avoidance may become complex to manage for patients observing this holiday. Health system pharmacists need to thoughtfully educate patients on modifying treatment regimens to accommodate religious holiday observance.

Medication ingredients may conflict with religious beliefs and customs. Some cultures forbid consuming pork or alcoholic substances, as in Islamic culture.^12,20 Dietary constraints may have implications when medications are prescribed. Particular thyroid medications, porcine heparin, or medications with alcohol-based solvents are some examples of therapies that may need to be substituted or avoided. Defining cultural preferences during patient interaction can aid health system pharmacists in effectively tailoring medication therapy.

Historical tenets of culture may affect how patients engage with health care professionals. Significant events of medical oppression may create distrust, such as the Tuskegee experiments with African American patients.²⁷ Health system pharmacists should be cognizant of patient suspicion surrounding their care and can strive to build trust by providing supportive detail around care decisions which may develop meaningful rapport.

Conclusion

Health system pharmacists should strive to increase awareness of the impact that cultural beliefs, customs, and overall lifestyle have on patient care. Communication tools can facilitate culturally integrated discussions with patients. Consideration of cultural factors in patient interactions may create personalized care opportunity.