Cultural competency: Agenda for Cultural Competency Using Literature and Evidence

Article Outline

• Abstract
• 1. Introduction
• 2. Relevance of cultural competence to the pharmacy practitioner
• 3. A framework for cultural competency
• 4. Research Agenda
  • 4.1. Licensing, education, and CE requirements
    • 4.1.1. What's been done
    • 4.1.2. What needs to be done
  • 4.2. Patient care
    • 4.2.1. What's been done
    • 4.2.2. What needs to be done
  • 4.3. Scholarships, grants, and incentives
    • 4.3.1. What's been done
    • 4.3.2. What needs to be done
  • 4.4. Policies for funding services and access
    • 4.4.1. What's been done
    • 4.4.2. What needs to be done
• 5. Conclusions: summary of research agenda
• References
• Copyright

Abstract 

Background

Cultural competency has been recognized as an important issue relevant to all health professions. A research agenda is needed to establish a systematic approach to developing an understanding of factors relevant to the delivery of culturally competent health care.

Objective

Within the context of existing literature, evidence-based, concrete recommendations are developed as an Agenda for Cultural Competency Using Literature and Evidence (ACCULTURE).

Methods

First, key points representing opportunities for intervening in promotion of cultural competent health care are discussed. Following is a review of existing literature with a focus on identifying next steps for future research. Recommendations for licensing, education, and continuing education requirements suggest developing educational research establishing course content and delivery strategies that have measurable impact on improving cultural competency. In addition, existing initiatives need to be evaluated regarding effectiveness in recruiting, retaining, and preparing a diverse workforce. Patient care recommendations focus on further developing an understanding of the factors impacting health outcomes for culturally diverse patients.

Results

Further work is needed for translating theoretically-based research into concrete curricula maintaining evidence-based outcomes. It is important to continue with promoting policies ensuring that research and clinical trials include diverse samples and a broad range of variables implicated in differential outcomes.

Conclusions

Based on connections between cultural competency and workforce diversity established within existing literature, data are needed regarding the effectiveness of existing initiatives promoting scholarships, grants, and incentives for improving workforce diversity and funding research on diversity issues. Finally, additional research is needed to evaluate existing and new policies for funding services and access for health services.

Keywords: Cultural competency, Disparities, Workforce development, Pharmacist, Diversity, Communication

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1. Introduction 

There exists a growing body of literature regarding the role that cultural issues play within the health care system. Many culturally diverse patients have inadequate health literacy to benefit from public health campaigns, to access health care services, and to understand directions from health care providers. Health disparities exist in which the prevalence of some diseases (such as diabetes and sickle cell anemia) is higher for diverse populations. Culturally diverse populations may have a more difficult time accessing health services and are less likely to use the health services available to them. Even when accessing services, diverse populations may be more likely to experience communication barriers. Clinical practice is typically culturally blind, applying services in an uniform manner without regard to cultural variation, and clinical research tends to be uninformative regarding culturally sensitive indications.

A review of the literature in health care professions indicates that incentives and initiatives are needed for recruiting a diverse workforce, which is important for establishing culturally competent patient care practices and for improving access for underserved populations. There is increased recognition that a culturally competent workforce is vital in decreasing racial and ethnic health disparities, especially in cases where the impact of culture intersects with low education, low literacy skills, limited English proficiency, and poor assertiveness skills.¹, ²

Currently, there are few incentives or initiatives promoting cultural competency within the pharmacy profession. Just as the pharmacy profession can learn from other professions successes, pharmacy also has the opportunity to influence and perhaps take a lead role in pervading cultural competency among its practitioners.

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2. Relevance of cultural competence to the pharmacy practitioner 

“Some recipients who speak little or no English are coming away from drugstores without their medicine, one volunteer says, because they do not understand the complicated language tied to the new Medicare prescription drug program. In California, efforts are under way to find beneficiaries who speak other languages and explain to them how to sign up for coverage.”³

The scenario presented above hints at the myriad problems that could spiral out of a language barrier. Lack of a common medium of communication between patient and provider has far-reaching implications for patient care and for appropriate medication use. Cultural competence from the pharmacist's perspective begins with 2-way communication with the patient, beginning with basic information such as eligibility and coverage and expanding to medication-related counseling. Lack of communication or miscommunication is a problem in itself, and when compounded by cultural issues, has the potential for medication misadventures.⁴, ⁵, ⁶

As the profession shifts its practice to more patient-focused services where continual communication is necessary for ensuring outcomes, the significance of cultural competence becomes more pronounced. The need for cultural competence in the pharmacist workforce is even more apparent and imminent given the outcomes proposed for the recently established Medication Therapy Management Programs (MTMs) under Medicare Part D.⁷ Pharmacists have been named as providers of MTM for targeted Medicare enrollees toward improving enrollee adherence with regimens and decreasing medication-related adverse events.⁸ Involved patient care such as MTM necessitates a relationship between the pharmacist and patient based on mutual trust and respect that ultimately help motivate the patient to be adherent and persistent with therapy. An obvious antecedent to this relationship is communication, to which there could be barriers based on various factors.

“Culture is the medium through which people interpret their world and the tool individuals use to guide decisions.”⁹ Similarity between patients and providers in cultural background, be it race, ethnicity, language, or other factors, tends to facilitate a positive relationship.¹⁰ In a muliticulturally diverse population, identifying a common cultural tie to unite provider and patient is a challenge. Moreover, gaining knowledge of the many cultural nuances and their implications to health issues, may be quite arduous; however, a willingness to learn about cultures, respect for other cultures, and working with persons from different backgrounds is critical to providing culturally competent care.¹¹ Additionally, the patient-pharmacist relationship thrives if the provider has an understanding of the cultural value systems/beliefs/attitudes of the patients or can obtain that information in an appropriate manner.¹²

The first implication that emerges from this discussion is that communication is the basis for culturally competent patient care that can be provided by a pharmacist or any health care provider.¹³ The second and related implication is that education of all providers regarding cultural sensitivity and communication skills is vital to patient care, whether in dispensing, counseling, education, or monitoring. The pharmacist can then work in partnership with patients on how to fit therapy regimens into their lifestyle as mediated by cultural attitudes and beliefs, rather than taking an authoritative or patronizing approach that raises a barrier.⁹

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3. A framework for cultural competency 

Because the ultimate outcome of a culturally competent health system is effective and efficient services for diverse populations and, consequently, the best health-related quality of life for diverse populations, the authors have focused on developing evidence-based recommendations. This model is intended to establish a framework for concrete strategies to promote cultural competency of the workforce. Each point within the model represents an opportunity for intervention. The elements of the model provide specific and practical opportunities for improving cultural competency coming out of current policies, literature, and practices. However, establishing which interventions are most effective requires the development of a research agenda. Research is needed to document strategies that have already been attempted and the effectiveness of the strategies so that the profession can make evidence-based decisions.

Figure 1 illustrates an Agenda for Cultural Competency Using Literature and Evidence (ACCULTURE). The various components within Figure 1 should not be considered constructs for predicting other constructs later in the model. The components should be considered specific opportunities for concrete policy intervention. Policies promoting earlier components should help promote later components but may require additional policies. This is different from traditional, academic, theoretic models because this figure delineates specific policy opportunities. These components are not necessarily continuous variables useful for correlating with or predicting other continuous variables. The model should be considered more like an organizational flow chart rather than a model of causal predictors.

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• Fig. 1 

  ACCULTURE—Agenda for Cultural Competency Using Literature and Evidence.

One of the fundamental problems with promoting cultural competency relates to the inherent conceptual, abstract nature of the concept. Existing knowledge is continually evolving, thus making it difficult for a definitive understanding of the needs of diverse populations. Any attempt at addressing cultural competency must first establish a concrete agenda regardless of ongoing development of factual knowledge.

Although workforce diversity and cultural competency have nonoverlapping components, the consensus is that workforce diversity has an important role in promoting cultural competency. Existing literature supports a strong relationship such that a diverse workforce is more effective at providing culturally competent services. Ultimately, culturally diverse patients experience better health outcomes when served by diverse providers.¹⁴, ¹⁵, ¹⁶

The 2 primary outcomes of ACCULTURE are quality care and quality of life, whereas other areas within the model represent potential points for intervention throughout the health care system. At the top center is “policy,” referring to the potential for distributing resources to impact all possible levels of policy decision making, such as local community policies, national policies, and international policies. Policies can impact practitioner licensing requirements, educational requirements, and continuing education (CE) requirements, which are all potential opportunities for interventions.¹⁷

In examining 1 component of the model, educational curricula focus on patient care and aim to develop culturally appropriate knowledge, skills, and values establishing an understanding of patient culture and sensitivity to cultural differences and strengths. A major goal of developing this knowledge is effective communication between health care providers and their patients facilitating accurate diagnosis, treatment decision making, and treatment adherence. This suggests 2 primary goals in culturally competent communication: (1) understanding a patient's current situation and (2) communicating back to the patient to ensure patient adherence to prescription regimens and counseling.¹⁸, ¹⁹

Policy also influences strategies for establishing scholarships, grants, and incentives (center of Figure 1), which all facilitate enriching workforce diversity.²⁰ A diverse workforce more adequately integrates with a diverse patient population, especially in light of a consistent body of research indicating that ethnic concordance results in better health outcomes.²¹ In other words, patients from diverse groups and perspectives benefit more from health care providers with shared characteristics of diversity. Additionally, a diverse health care workforce is more likely to have the linguistic ability to effectively communicate in the patients' most comfortable language (with the caveat presented previously that this ability cannot be all encompassing with multiple languages in the population), further ensuring the outcomes of effective communication: accurate diagnosis, treatment decision making, and treatment adherence.¹³, ¹⁸

Policy decisions also impact the funding of services (far left of Figure 1). Funding policies impact organizational licensing and can facilitate incentives to influence service providers to serve diverse geographic locations. It is important that the provision of services is injected to diverse communities, often requiring incentives in areas with reduced economic strength.²⁰

Patient education and prevention can provide adequate empowerment and health literacy to know how to obtain access to health services.²² Evidence suggests that a diverse workforce is more likely to serve diverse patient populations, maybe because they understand the needs of the communities from which they come.²³, ²⁴

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4. Research Agenda 

So far, everything discussed in ACCULTURE relates to all health professions. The application of this model to pharmacy provides specific ideas for interventions aiming to improve pharmacist cultural competency, which are organized here into 4 categories: (1) licensing, education, and CE requirements, (2) patient care, (3) scholarships, grants, and incentives, and (4) policies for funding services and promoting access.

4.1. Licensing, education, and CE requirements 

One way policy can influence the development of a culturally competent workforce is through licensing requirements, educational requirements, and CE requirements.

Existing university accreditation requirements included requirements relating to cultural competency as it relates to establishing policies for improving the diversity of the students and faculty recruited by academic institutions. The inclusion of these issues in accreditation discussions is an important first step. However, the implementation and interpretation of requirements may result in inadequate means for addressing the full range of diversity issues. Accreditation standards need to more precisely define what is meant by diversity; and there may be differences in the extent to which individual universities' interpretations will include characteristics such as acculturation, age, sexual orientation, socioeconomic differences, education/literacy differences, gender, religious beliefs, and health issues relevant to disabled individuals. It is also important that during accreditation these issues receive more than lip service and that there is clear accountability. The newly published accreditation standards by the Accreditation Council for Pharmacy Education (ACPE) recognize the importance of culturally diverse populations and include content knowledge and skills in cultural competence as one of the goals in the PharmD curriculum. It states, “The college or school must ensure that the curriculum addresses patient safety, cultural competence, health literacy, health care disparities, and competencies needed to work as a member of or on an interprofessional team.”²⁵ Thus, the requirements are aimed at ensuring that the curriculum adequately prepares graduates to be able to provide culturally competent care to a diverse population.

Across the range of professional associations for health service providers, cultural competency has been included as a key agenda item;²⁶ however, there are no specific recommendations on implementation. At this point, individual schools must determine their own standards for relevant course content. The best available guidelines come from reviewing the literature for educational curricula that have been developed, evaluated, and published. In addition to lecture(s) whom instructors may have inserted in their individual courses, there is also some evidence that courses on this topic exist that have attempted to assess their outcomes in students.¹⁹, ²⁷ There exists a need for collective assessment of these courses' merit in improving cultural competency in the practicing workforce.²⁸, ²⁹ Successful initiatives in other professions have focused on developing specific guidelines for educational content.³⁰

Further, faculty development programs need to focus on developing culturally competent faculty who can (1) communicate appropriately with a growing multicultural student body and (2) in turn, bring in cultural competency in their instruction modules to ensure students are ingrained with these skills.³¹

Other professions have successfully implemented initiatives integrating cultural competency into licensing examinations and have begun implementing CE requirements in this area.³², ³³ Learning from other professions, pharmacist licensing examinations could include testing of cultural competency, thus ensuring that individuals entering the workforce understand standards of care for diverse populations. Adding a specific CE requirement in cultural competency could ensure that the existing workforce is equipped to work within diverse populations.

Based on the authors' experience with local government agencies' plans for implementation of cultural competency initiatives in California, there are 3 potential models for implementing a CE diversity requirement. First, these initiatives could be implemented as specific requirements, for example, a requirement that all licensed providers must complete CE related to working with older adults. Second, implementation might require CE with diversity issues, more generally. In this scenario, individual providers could choose whichever CE courses provide the most benefit based on their relevant patient populations. Finally, a CE diversity requirement might also be implemented by requiring all accredited CE courses to include material regarding diversity within the context of the individual course's focus. This option would require that courses include cultural competency content relevant to the various courses' topics prior to receiving accreditation.

Regardless of how this is implemented, the challenge will be oversight to ensure minimum standards regarding the accuracy and quality of the material to ensure improvement in care and not just a list of traits specific to a population that may reinforce the propagation of stereotypes. Additionally, a major challenge will be developing guidelines for the specific topics that should be covered within educational curricula for the pharmacy profession, but the profession can benefit from prior work in this area.⁴, ⁵, ⁶, ¹⁴, ¹⁵, ³⁰, ³⁴

In addition, cultural education at the practitioner level (continuing or otherwise) needs to be addressed to serve diverse populations. Although there is evidence that community pharmacies place multilingual pharmacists in areas where there is need, more needs to be done in educating the workforce in culturally appropriate communication—obtaining and delivering information. National organizations such as the National Association of Chain Drug Stores and the National Community Pharmacists Association would be well served to make this a priority, given their impact on employment of the workforce and on prescription volume.

4.2. Patient care 

An important parallel process is the development of culturally competent standards for patient care. Within ACCULTURE, it is clear that the factor most proximal to patient outcomes relates to patient care, resulting from appropriate professional knowledge, skills, and values. As mentioned previously, a most important element that always surfaces in effective patient care is communication. Communication permits accurate assessment of a patient's current situation and permits accurate patient education and instruction to improve treatment adherence relating to medications, diet, and other health behaviors.¹⁸

This is the area that has received much attention, yet still requires considerably more in the future. Here are some of the lessons learned that have been documented in pharmacy literature.

Although it appears that we learn more each day about how to improve patient care for diverse populations, there is still more that we do not know relating to how ethnicity influences pharmacokinetics, strategies to effectively communicate with diverse individuals, public health strategies for improving health literacy within diverse communities, factors impacting adherence, and increasing the availability/utilization of professional interpretation services as a part of service delivery.⁵, ¹⁴, ¹⁵, ¹⁶

Up to this point, many initiatives focusing on patient care typically emphasize the importance of avoiding the exclusion of various populations from studies on the basis of ethnicity, age, or gender. These initiatives should not be undermined; however, additional initiatives and resources are needed in studying the relevancy of the existing literature for diverse populations. Research initiatives are needed to revisit the existing literature that excluded culturally diverse populations to confirm that the results replicate in diverse populations. In addition, because the concept of diversity must be expanded beyond ethnicity, age, and gender, it is necessary for specific initiatives exploring other populations of diverse persons.⁶, ¹⁴, ¹⁵, ¹⁶, ¹⁷

As we consider these points, the implications of the above to each branch of pharmacy—basic, clinical, and social sciences—seem apparent. There is an ongoing need for a more thorough understanding of diversity in pharmacokinetics. Research is needed to explore variations in factors affecting treatment success, toxicity, and adverse events. In addition to exploring strategies for maximizing clinical outcomes, research within clinical contexts needs to focus on barriers to adherence and strategies for improving communication.

Disease management programs with a heavy focus on major lifestyle changes, such as diet and activity level, need to be customized and evaluated within diverse populations. For example, many of the standard diet materials and educational curricula focus on diets that will seem extremely foreign to Hispanic/Latino and Asian individuals. Without the inclusion of culturally appropriate diet suggestions, adherence to lifestyle changes becomes even more difficult and less likely.⁹

Communication is an overarching issue that covers print media (prescription label, patient education leaflets, direct-to-consumer advertising [DTCA]), oral (provider patient), broadcast media (DTCA and public health awareness programs), and the Internet. Each of these media presents its own challenge in communicability with diverse populations from the perspective of the patient and the creator or transmitter of the communication. Thus, although there is some research conducted on communication in general and in diverse populations, communication as a patient care issue presents a rich avenue for research.⁶², ⁶³

Suggestions in the literature include a cultural broker or a health facilitator who works as a liaison between patient and provider. This model is currently a central component of innovation in psychiatric care being implemented in California as a part of the Mental Health Services Act.⁶⁴ The intention is that these “personal service coordinators” will facilitate continuity and be a key contact for patients to consult with questions. Future research will be helpful in determining whether evidence supports this model.¹, ⁶⁵

4.3. Scholarships, grants, and incentives 

This section focuses on financial incentives promoting cultural competency within practitioners. There are basically 2 main goals of these incentives: promoting diversity of the workforce and creating incentives for practitioners to serve underserved populations. There is a substantial body of literature indicating that workforce diversity is important for promoting culturally competent health services due to familiarity with the health needs and cultural considerations important for diverse populations. Ethnic concordance has been associated with better health outcomes.⁴, ⁵, ¹³, ⁵⁶

Currently, it seems that each health profession has established its own strategies for promoting diversity. Responsibility for spearheading and funding diversity initiatives is often dispersed (perhaps better represented as fragmented) throughout various professional organizations. For example, for the medical profession, the American Medical Association, and the American Association of Medical Colleges have both worked to establish their own independent diversity initiatives.⁶⁶, ⁶⁷ The American Pharmacists Association (APhA), the American Association of Colleges of Pharmacy (AACP), and the ACPE have all developed diversity initiatives.⁶⁸, ⁶⁹ Likewise, the nursing profession appears to be suffering from fragmented diversity policies.⁷⁰, ⁷¹, ⁷², ⁷³ Separate associations exist for ethnic minority, Hispanic, and black nurses.⁷⁴ The National Coalition of Ethnic Minority Nurse Association has developed its own scholarship program.⁷⁵

Some of the most impressive initiatives in promoting the diversity of health professionals have been implemented by the National Institutes of Health (NIH) that promote diversity across all health professions. Among their exemplary efforts, one of the more cutting edge programs at NIH includes the Loan Repayment Program repaying educational loans for researchers who commit 2 years researching topic areas such as health disparities, women's health (such as contraception and infertility), and children's health. Another track of this NIH program supports clinical researchers from disadvantaged backgrounds.⁷⁶

To a large extent, foundation funding agencies and individual donors are potential partners for supporting activities improving health workforce diversity and for providing incentives for health professionals to meet the needs of underserved populations. For example, while focusing primarily on developing the physician workforce, the Robert Wood Johnson Foundation and Herbert N. Hickens programs have made significant contributions.⁶⁶, ⁷⁷

The primary message for what needs to be done relating to cultural competency is that (1) various professional associations within and across medical professions must collaborate to establish transdisciplinary agendas to promote a diverse workforce and equitable care for underserved populations and (2) statistics and studies are needed regarding trends in scholarships, grants, and financial incentives for promoting a diverse workforce and meeting the needs of diverse populations and evaluations of whether these resources result in their intended outcomes.

Although the APhA, AACP, and ACPE support and advocate for diversity, primary responsibility remains unclear. Without overt, public collaboration, this could potentially result in fragmented or duplication of efforts and less than optimal results. NIH initiatives primarily emphasize research efforts rather than diversity in practitioners. Professional associations need to advocate for broadening initiatives to practitioners and need to develop their own initiatives and resources potentially including private foundation support.

Basic descriptive data are needed regarding the impact and range of existing resources for scholarships, grants, and other financial incentives specifically focusing on developing the pharmacy workforce. Agencies across all medical professions need to publish and disseminate results regarding the effectiveness of relevant activities. Basically, evidence-based standards need to be developed, and those documented as effective need to be replicated. Studies focusing on trends within pharmacy education could be modeled after the National Postsecondary Student Aid Survey sponsored by the National Center for Education Statistics (NCES), which tracks trends across programs.⁷⁸ NCES statistics are based on a national probability sample; however, their data do not provide statistics specific to pharmacy students. Future projects require focused data collection regarding financial aid, scholarships, and student financial need.

4.4. Policies for funding services and access 

Existing policies regarding the funding of services play a major role in establishing historic patterns of inequity.

There is considerable research establishing inequities between various ethnic and underserved populations. Inequities include differences in health literacy or ability to understand health information, understand disease, and understand treatment instructions, and health disparities, regarding both the prevalence of disease and services received. Disadvantaged populations include (1) ethnic minorities, (2) the economically disadvantaged, (3) women, (4) individuals in rural communities, and (5) those who experience difficulties advocating for their needs.⁷⁹, ⁸⁰, ⁸¹, ⁸², ⁸³ Among others, some of the populations that experience dramatic challenges simply advocating for their needs include the mentally ill, the physically disabled, the visually impaired, and the hearing impaired.⁴, ⁵, ¹⁴, ¹⁵, ⁸⁴, ⁸⁵, ⁸⁶, ⁸⁷, ⁸⁸

The Medicare Prescription Drug Improvement and Modernization Act of 2003 that proposed comprehensive prescription drug benefit for the elderly is a positive example of an attempt to improve access to medications for the elderly and disabled.⁷

These are complex problems needing complex solutions relevant to current debates on national health care policy to be determined through ongoing debates including government agencies and other politically oriented organizations. Health care practitioners need to conduct research focusing on the development of realistic recommendations. Considering the complexity of the funding and access problems plaguing health care systems, it is important to prioritize initiatives based on resource requirements. There are a number of initiatives that likely require little to no additional resources that might provide initial improvements in decreasing funding barriers and increasing access. Actions requiring little to no resources should be implemented immediately while initiatives requiring substantial investment are pursued over longer periods of time. Quite simply, “small steps' are okay, especially considering the associated complexity, which rules out any single ‘quick fix.’”

For example, some of the most innovative and cost-effective methods for short-term improvement include partnering with organizations representing underserved populations, enlisting consumer advocates, patient advocates, existing community leaders, and other volunteers to work with patient populations to apply, establish, and maintain health benefits. These concerned community members also frequently provide ideas about innovative solutions to health system challenges.⁸⁹

In addition, research is needed to understand the extent to which existing services are physically or geographically accessible to underserved populations. This would include studies exploring factors creating incentives for practitioners to serve these communities and incentives for diverse practitioners to return to their underserved home communities after completing their education.

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5. Conclusions: summary of research agenda 

As indicated, the research agenda proposed here focuses on the need for studies of specific, practical strategies for improving the cultural competency of the pharmacy profession. Cultural competency must be embedded within the concept of evidence-based practices, and possibly a parallel process must be developed for evidence-based administration, which also must include cultural competency as a necessary element. This focus on pragmatic solutions is needed to move the concept of cultural competency from an abstract ideal toward a concrete initiative with observable and measurable outcomes.

Table 1 provides a summary of the research agenda derived from the ”What Needs to Be Done” sections previously. Within the area of licensing, education, and CE requirements, research needs include the evaluation and study of educational content that have clear connections to health outcomes. Predictably, educational content will need to detail specific practices that health care providers can understand how to implement. Research is also needed to inform educators and educational institutions regarding effective strategies for recruiting a diverse student body and ensuring their success.

Table 1. Research agenda for a culturally competent pharmacy workforce

CE, continuing education.

The research agenda focusing on promoting culturally competent patient care must include strengthening both basic and practical understanding of the mechanisms influencing individual and group-based differences in disease, pharmacokinetics, barriers associated with treatment adherence, and barriers to communication.

Within the context of scholarships, grants, and incentives, research is needed to determine which initiatives are most effective. Initiatives for study should include those emphasizing development of diversity within health care workforces, funding and developing research for understanding diversity issues, and creating incentives for providers to serve the underserved.

Finally, future research can improve understanding regarding which policies for funding services and access are most effective for facilitating access and promoting the utilization of health services. Application of geospatial/modeling methodologies is likely to further our understanding of population-based patterns within health service data. In addition, additional funding and dissemination of research on health policy analysis should inform decisions regarding future public health concerns both expected and unexpected. As the compositions of various populations continue to experience dramatic change, there will likely be growing need for assessing and reassessing existing policies.

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