Overcoming Bias: How Cultural Competence Improves Patient Care

The most recent US Census, conducted in 2020, delivered some interesting data: Since 2010, the overall US population has become more racially and ethnically diverse than it was just 10 years prior. For pharmacists, this means that the patient in front of them now is more likely to be of a different race, ethnicity, or religion or have a different sexual identity than previously.

Wooden blocks representing cultural diversity / Sascha - stock.adobe.com

“As a pharmacist, you want to be able to ask questions like, ‘Do you have any cultural, religious, or special preferences that you would like us to be aware of as we review your medications?’” said Angelina Tucker, PharmD, clinical director of Best Value Pharmacies in Texas; managing network facilitator for CPESN Texas, an integrated network of pharmacy providers; and assistant director for CPESN USA’s Community Connected, an initiative focused on preparing pharmacies to work within the diverse communities where patients live, work, play, and pray. Pharmacists can do this by practicing cultural competence––behaviors, attitudes, and policies that enable health care providers to work in cross-cultural situations.

What is Cultural Competence?

“Cultural competency is not just looking at somebody’s religion or ethnicity. It could be working with someone who is [hard of] hearing, or…a patient [who] is LGBTQ+, or perhaps someone who has autism,” Tucker explained. “The pharmacist needs to be aware of the population that they’re serving and understand what their needs are, so they can properly relate to that patient.”

Cultural competence has become so essential to health care that it is now taught in colleges and universities that educate health professionals. In a recent study, whose findings were published in the International Journal of Clinical Pharmacy, investigators evaluated how best to integrate cultural competency and humility into undergraduate pharmacy training.¹ In the study, undergraduate students from one UK-based pharmacy school were invited to participate in an in-person, semistructured interview to discuss cultural competency in the pharmacy curriculum. The findings demonstrated how and when cultural competency teaching should be embedded within the undergraduate pharmacy curriculum. Some students described cultural competency as “being centered in awareness” and “viewing others and society in a nonjudgmental way.” One student observed, “I can see why it [cultural competency] is important because it’s encouraging you to open your eyes and mind more, and if we’re going to be pharmacists, we need to show we care about other people’s beliefs.”¹

Three educational themes emerged from the study data, which researchers stated “appear fundamental in shaping the initial education and training of pharmacy students underpinned by cultural competency and cultural humility.” Those themes include:

• Recognizing and reflecting on cultural competency and cultural humility (within ourselves and others)
• Gaining exposure to and confidence in cultural competency training (When is the best time to teach cultural competency?)
• Thinking ahead as a culturally competent pharmacist of the future (cultural competency underpinning clinical decision-making)

When asked how they would like cultural competency to be taught, students suggested having seminars and smaller groups to discuss a patient case. They also suggested having scenarios with a mock patient, where students could talk through their diagnoses and medications and think about holistic lifestyle impacts, where culture (and cultural competency) come into play.

One student related how learning about cultural competency during his training was put into almost immediate use as a pharmacist: “A man of South Asian descent came to me on placement asking me about his medicines [and] the fact [that] he wants to miss taking his medicines when it’s Ramadan....I was able to help him because of what we’d covered in seminars.” Another said, “[For] hypertension, there [are] certain ethnic groups that you can’t give ACE [angiotensin-converting enzyme]–inhibitors to….That’s really important for us to know to make sure we’re keeping patients safe.”

Study participants also agreed that developing cultural competence will be an ongoing process, given how cultures and populations constantly grow and change. Tucker embraced this idea, explaining that educating yourself through reading and attending events is priceless. One participant noted he preferred learning he could do himself, “[such as] reading up on the news and social media about how people are speaking up for trans rights….That can all feed back into my job and patients I’m seeing.” Tucker added, “Many communities offer open mosque dinners during Ramadan that anyone can attend. I recently went to a Black History Month event at a bookstore. I wound up learning so much; I networked, I made new friends.” She feels such things will only enhance her value as a pharmaceutical professional.

Tucker also offered details from her own situation as an example of the importance of cultural competency. “I’m a Muslim woman who wears a hijab.…If I wanted to get an immunization, I would prefer to get an immunization from a female pharmacist because…our religion [has] a boundary between males and females,” she explained. “There’s no physical interaction with people that we’re unfamiliar with…outside our family bounds. To have to disrobe myself or pull my dress sleeves up in front of a male would [make me] feel extremely uncomfortable. But I wouldn’t want to say that necessarily to a pharmacist. A pharmacist who knows and understands that about my religion, instead of sending their male pharmacist for my immunization, would send a female pharmacist.”

Tucker offered other examples of how cultural competency pays off for a pharmacist. “During the month of Ramadan, a lot of Muslims are fasting from dawn till dusk. Many patients may not even be taking their medications at all,” she said. There are also certain Asian cultures where patients prefer alternative therapies and herbal medications. “Being able to ask your patient about this, and understanding that within their culture there are…alternative practices they prefer to use, will be helping these people enormously.”

Practicing Pharmacy With Cultural Competence

Cultural competence stretches beyond understanding lifestyle concerns: Some ethnicities may be predisposed to certain health conditions. “In the African American population, we know there’s an increased incidence of diabetes and cardiovascular disease,” Tucker said. “[For] patients [who are] coming in, just starting on their journey with diabetes, you need to understand that there may well be a family history…. Being able to have diabetes classes, where you can get to know these patients one-on-one and help impact health care outcomes by building that communication and bridging barriers, will be a great asset to them.”

Cultural competence can also help with employee retention in your own pharmacy, Tucker added. Knowing, for example, that one of your employees may be celebrating Rosh Hashanah or Chinese New Year and simply wishing them a happy holiday can go a long way to feeling recognized and respected within that person’s religious or ethnic group.

The Health Policy Institute at Georgetown University published a series of issue briefs entitled “Challenges for the 21st Century: Chronic and Disabling Conditions.” One brief addressed whether or not cultural competency was critical for a health care system treating chronic conditions. In the paper, the authors were adamant that cultural competency is crucial for all health care stakeholders: “A culturally competent health care system can help improve health outcomes and quality of care and can contribute to the elimination of racial and ethnic health disparities. Examples of strategies to move the health care system toward these goals include providing relevant training on cultural competence and cross-cultural issues to health professionals and creating policies that reduce administrative and linguistic barriers to patient care.”²

Indeed, with the United States becoming more diverse, the need for culturally competent health care professionals seems essential. According to APM Research Lab, which informs the public of challenges and opportunities facing the nation, by 2060, 1 in 3 children will be non-Hispanic White. By 2045, populations of color are expected to outnumber non-Hispanic Whites, who are expected to decrease by 19 million individuals between 2016 and 2060. The number of multiracial Americans is projected to grow faster than that of any other major racial or ethnic group over the next 4 decades.³

How can pharmacists begin bettering their skills in cultural competency? According to Tucker, there are 3 key steps: training, access to resources, and connecting with other essential community stakeholders. These include diverse business owners; leaders of temples, mosques, and churches; and nonprofit organizations.

Regarding education and training, communityconnected.us, the CPESN initiative, offers a resource library with videos, slides, and monthly webinars, and a newsletter. The American Association of Colleges of Pharmacy website, aacp.org, provides a list of resources to help improve cultural competence, and the American Pharmacists Association site, pharmacist.com, devotes a section to tools for culturally competent care. Pages include modules with various training methodologies. For example, one of these pages, “Social Context of Patients,” offers sample questions that pharmacists can use, including:

• Are you very involved in a religious or social group?
• What language do you speak at home?
• Do you ever feel that you have a hard time talking about your medicine with the doctor or pharmacist?
• Do you have trouble reading your medication bottles or appointment slips?
• Where are you from?
• What was medical care like there compared with here? How did you get your medication?

“It’s important for all of us to accept that we all have implicit bias. We don’t always recognize it; it can be on an unconscious level,” Tucker said, “but it’s important for us to understand that we still contain those biases. But being able to recognize [bias] and overcome it, and then not trip over it while interacting with our patients,…will make us better professionals.”

READ MORE: Public Health Resource Center

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References

1. Robinson-Barella A, Takyi C, Chan HKY, Lau WM. Embedding cultural competency and cultural humility in undergraduate pharmacist initial education and training: a qualitative exploration of pharmacy student perspectives. Int J Clin Pharm .2024;46(1):166-176. doi:10.1007/s11096-023-01665-y

2. Cultural competence in health care: is it important for people with chronic conditions? Georgetown University McCourt School of Public Policy. Accessed March 28, 2024. https://hpi.georgetown.edu/cultural/ 

3. The United States will soon be bigger, older, and more diverse. APM Research Lab. August 2, 2018. Accessed March 27, 2024. https://www.apmresearchlab.org/blog/the-united-states-will-soon-be-bigger-older-and-more-diverse