Audience Response System LEARNING OBJECTIVE • Describe the importance of communication in patient-centered care. 7 8 Why? (continued) Why Teach This Stuff?  Communication errors Surviving Pharmacy School  Working well with your peers  Cannot be avoided  Contributing to a comfortable learning environment  Lead to misunderstandings  Appreciating and understanding diversity  Contribute to dissatisfaction 9 10 Why? (continued) ♦ Clear, concise communication in pharmacy practice  Reduces medication errors Why? (continued) ♦ The Future  MTM  Increases adherence  Provider Status  Critical in primary prevention / public health  ACA  Public Health  Pharmacogenomics 11 12 2 In Practice and the Academy  Communication is among highest priorities  A prominent feature of professional development  Accreditation guidelines stress its importance  This is not new  From 1970’s  now  Increasing in importance  It is a major part of how our academy defines the role of pharmacy 13 14 How has Pharmacy looked at its future? 15 SYSTEM NOW 16 Geriatrics Rehab Pharmacy Prevention Nursing Critical Care Pediatrics 17 18 3 Unprecedented Access  Nearly 9 out of 10 adults have insurance  Greatest declines in the uninsured:  Young adults (ages 26 – 34)  Hispanics  Lower-income Americans 19 20 Unprecedented Costs  ~$2.8 Trillion (~16% of GDP)  80% of every healthcare dollar is spent on chronic, preventable diseases 21 22 Audience Response System 23 24 4 Covenant  Phenobarbital 15 mg  How did we get to where we are? LEARNING OBJECTIVE  Who is truly important?  How do we take care of our privilege to practice? • Explain the covenant between pharmacists and patients.  Call Me Pharmacy :> http://www.youtube.com/watch?v=td3VFPzK1OM 25 26 Pharmacists Code of Ethics Covenantal Relationships A covenant is :  Promise  Gift I. A pharmacist respects the covenantal relationship between the patient and pharmacist.  Considering the patient-pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust  Something owed  Expertise  Sufficient energy  Sufficient time  Current, evidence-based information 27 28 Developmental Model Characteristics of a Professional  Expertise  Autonomy  Standards  Ethics  Commitment  Career oriented  Lifelong learning 29 Professionalism  Interview:  Onset of training:  Mid-training:  Advanced training: - Eager - Grateful - Over confident - Realistic self-appraisal 30 5 ‘tude! What?  Overly deferent; passive; avoidant  Are your strengths?  Entitlement  Do you know?  Disrespect (for person or position)  Aspects of practice do you not like?  Making inaccurate assumptions  The “N = 1” effect  Blaming others 31 32 On Rotations … In Your Experience … Have you observed communication errors such as:      How will you ask for help?  What do you do if you are asked about something Upset patient encounter Pharmacy employee saying something wrong Disagreements between supervisor / staff Misunderstanding between patient and pharmacist 33 you do not know?  Do you know when you are “out of your depth”?  Will you ask for experience in counseling patients? 34 Interpersonal Communications Message Transmitted LEARNING OBJECTIVE Received • Interpret components of the Interpersona l Communications Model.  Translated Message => ideas, thoughts, emotions, information Transmitted => verbally, nonverbally, actions Translated => encoding, decoding 35 36 6 Responsibilities Analyzing Communications Transmitter =>  Clear signals, at proper literacy level, with fewest barriers Meaning?  Not complete until message is understood by receiver  Words  Football Receiver =>  Medical Terminology  Listen  Can be scary  Provide feedback  Idiopathic  Ask clarifying questions 37 38 Barriers Arising from the Pharmacy Barriers Arising from the Pharmacist Barriers Environmental Barriers • Distractions – Lack of privacy – Ringing phones – Clerks/other customers – Interruptions • Fixed objects – Counter – Glass partition – Displays – Distance from patient area Corrective Actions • Instruct employees on when not to interrupt – Move to a private space – Move out from behind barrier – Maintain eye contact – Maintain appropriate interpersonal space Corrective Actions • Inappropriate use of interpersonal space (being too close or too far) • Stay within 1½ to 4 feet of patient • Inappropriate body movement (nervous habits, “cold shoulder,” inappropriate touch, backward lean, slouching, lack of eye contact, crossed arms and legs) • CLOSER* – Control distractions, such as nervous habits – Lean toward patient – Open body posture – Squarely face patient – Eye contact 50%-75% of time – Relax! • Inappropriate vocal characteristics (disinterested, rushed, abrupt, too loud for privacy • Level tone, using appropriate vocabulary (patient level) *Muldary TW. Interpersonal Relations for Health Professionals: A Social Skills Approach. 1983. 39 40 Barriers (continued) Barriers Arising from the Patient Emotional Barriers  Anger  Embarrassment  Sadness  Distraction  Fear  Arrogance  Depression  Suspicion Functional Barriers  Comprehension difficulties  Language differences  Low health literacy  Functional illiteracy Strong feelings interfere with communization 41  Alternative health beliefs  Personal health beliefs  Cultural influences  Sensory deficits Impede receipt and interpretation of Pharmacist’s communication 42 7 Audience Response System LEARNING OBJECTIVE • E xp l a i n t h e re l a t i o n s h i p a m o n g l i s t e n i n g, e m p a t h y, a n d p a t i e n t p ro b l e m s o l v i n g . 43 44 Functions of Interpersonal Communication 1. 2. 3. 4. 5. Listening Facts  People listen at 125-250 wpm, Meet social needs Maintain sense of self Fulfill social obligations Exchange information Influence others  We think at 1,000-3,000 wpm  We are preoccupied ~75% of the time Ref: Powershow.com 45 46 Listening Facts (continued)  Remember what we hear = 20% of the time  > 35% of pharmacy employers think listening is a necessary skill for success Definition Receiving, constructing meaning from, and responding to messages whether spoken and/or nonverbal  “Listening creates reality”  Enacts, develops, and maintains a variety of social & personal relationships  Most of our time is spent listening 47 48 8 Listening If we speak powerfully and distinctly, is this “effective communication?” NO  Equally important is good listening skills Requires:  Understanding patient’s thoughts and feelings  Understanding must be conveyed back  So he / she knows you understand  Showing of genuine care and concern 49 Listening Interference  Multi-tasking  Jumping to conclusions  Focusing only on content  Judging 50 Interference (continued) Listening Well  Faking interest  Involves understanding BOTH the content and feelings expressed  Distractions  Listening skills include:  Lack of focus  Summarizing  Paraphrasing  Empathic responding  More important than verbal skills 51 52 Attending Listening involves: A–U–R–E–R  Be physically and mentally ready  Attending  Shift from speaker to listener completely  Understanding  Listen before you react  Remembering  Evaluating  Responding 53  Prepare to listen  Hear a person out  Adapt to the situation  Adjust the listening goals  Different listening types 54 9 Understanding Attending Listening Types Accurately decoding the message you share with the speaker  Appreciative  Determine the organization  Goal is enjoyment  Attend to nonverbal cues  Discriminative  Ask questions  Understanding the message  Paraphrase silently  Comprehensive  Learn, remember, and recall  Critical-Evaluative  Judge and evaluate 55 56 Mnemonics Remembering  Repeat information A technique used to aid memory  Create mnemonics  Take notes  Take notes when you are listening to complex • Take the first letter of a list you are trying to remember and create a word HOMES (the five Great Lakes) • Huron, Ontario, Michigan, Erie, Superior information  Key-word outline   Main points Supporting evidence On Old Olympian Towering Tops A Finn And German Viewed Some Hops => 57 58 Evaluating Critical Listening Fact  A verifiable statement Inference  A conclusion drawn from You are Listening Critically, When You Question Whether  The inference is supported with meaningful factual statements  The reasoning statement that shows the relationship between the support and the inference makes sense  There is any other known information that lessens the quality of the inference facts 59 60 10 Listening Guidelines Responding  Let your patient know you are interested  Focus fully on what is occurring  Give appropriate vocal responses  Adapt your listening skills and style  Accommodate differences in listening purposes and  Demonstrate that you care about the other individuals person and what he or she says  Listening is an active process You must invest energy and effort 61 62 Audience Response System LEARNING OBJECTIVE • Explai n th e relat ion sh ip amon g li sten in g, empathy, an d pati en t pro b lem solv in g. 63 64 Empathy Understanding and Comforting For what characteristics do you seek in someone to whom you will confide?  Understanding of another's feelings  Ability to identify with and understand somebody else's feelings or difficulties • • • • •  Experiencing an understanding of another person’s condition from their perspective  Walking a mile in someone’s shoes https://www.youtube.com/watch?v=cDDWvj_qo8&feature=youtube_gdata_player 65 Trustworthiness Confidential Listening Anonymous Others? 66 11 EMPATHY Empathic Responding  Many patient messages communicate how they feel  Letting patient know you understand these feelings is Identifying with or vicariously experiencing the feelings, thoughts, or attitudes of another person a key ingredient in a trusting, caring relationship.  Awesome way to establishing a rapport  Increases pro-social behaviors (helping)  “Mirror neurons” react to other’s expressed emotions and reproduces them!! Empathic response Emotional response parallel to patient’s actual or anticipated display of emotion 67 67 68 Example Responding (continued) Patient:  People are better able to express themselves in an “I’m so glad I moved into a retirement village. Every day, there is something new to do. There are lots of things going on accepting, caring environment  “Listening ear” to help elucidate feelings  Entering the private, conceptual world of another  It is:  Nonjudgmental Pharmacist:  “So there a lot of activities to chose from” {paraphrase}  “You seem to love living there” {empathic}  Accepting  caring 69 70 Positive Effects Building Trust  Patients trust you as one who cares  Helps patients understand their own feelings  Be genuine  Can set limits  Respect for and acceptance of patient  Autonomous, worthwhile person      Clinically significant relationship between empathy and positive therapeutic outcomes  With empathy = “therapeutic alliance” more clearly Facilitates patient’s own problem-solving abilities Feel more in control in “safe” environment May explore different coping mechanisms “Sounding Board” It is okay to tell a patient you do not have time at present to discuss something in detail; better than multitasking 71 72 12 Advising Response Judging Response  We have tendency to give advice “You shouldn’t worry”  We are the Experts / Professionals after all “You shouldn’t feel discouraged”  Good for medication regimens or OTC selections  These responses indicate that it is not safe to confide  Bad for helping patients deal with emotional or in you personal problems*  Do NOT judge as wrong OR right  Implies it is appropriate for you to judge person’s feelings 73  e.g., depression 74 Placating Response Advising Response (continued) “I am sure your procedure will turn out just fine”  Even “perfect” advice works best if arrived at by the     patient  Can help them identify resources  Can refer them 75 How is this different than “You shouldn’t worry?” Used to stop patient from being upset It “protects” us from emotional involvement Falsely reassures them => how do you know? 76 Generalizing Response Probing Response “I’ve been through the same thing and I’ve survived”  Asking question can take focus away from patient’s feelings and onto the message’s content  Takes focus away from patient’s feelings  Meet the needs of a “listening ear” as part of the  You may stop listening as you jump to the conclusion helping process that the patient’s would be feeling as you did  Could make patient feel less unique 77 78 13 Distracting Response Understanding Response  Used to alter the situation by changing the subject  Shows you understand patient’s concerns  Patients receives NO indication you have heard them or  Builds a pharmacist-patient relationship understood them  Assists the patient “Let me talk to you about your new prescription” “You seem to feel that there is something missing in your relationship with Dr. Johnson”  Patients may need to know that others understand “How about the Heat last night?” 79 80 How Can I Do This?      Audience Response System Empathy can be learned Can alter your existing habits Practice with family and friends It will become more “natural” Must value the importance of establishing a therapeutic relationship with patients 81 82 Possible Distortions • LEARNING OBJECTIVE • Describe potential barriers to communication. • • • • • 83 Health Literacy Perceptions Common Barriers Administrative Barriers Cultural Barriers S-B Barriers 84 14 Health Literacy Elements of Communication Process 85 86 Perceptions Perceptions (continued)  Patient’s personal perception  Critical to establish communication rapport  Knowledgeable & trustworthy  Approachable  Pharmacist’s personal perception of the value of patient communication  “talking to patients is not a high priority”  Impersonal healthcare system  “patients don’t want me to talk to them”  Patients perception of their medical condition  Do not value patient interaction  Not eager to participate in patient counseling  Eliminating this barrier requires personal analysis and motivation 87 88 Common Barriers  Environmental  People  Music  Hospital shared rooms Common Barriers (continued)  Administrative polices and procedures  Lack of time  Glass partitions  Intimidates patients  Personal issues  Perception that pharmacist does not want to speak to patient  Low self confidence  See pharmacy staff as not approachable  Shyness  Lack of objectivity  Emotional objectivity  Internal conversations  Cultural differences  “How can I get rid of this patient?”  Discomfort in sensitive situations 89 90 15 Administrative Barriers  Uncompensated education / communication  MTM  Studies have shown that many consumers are willing to pay for such services  Impact on readmissions Environmental Barriers  How visible is the pharmacist?  How easy is it to get pharmacist’s attention?  Does it appear that the pharmacist wants to talk to patients?  Responsibilities  Difficult to complete all job responsibilities and still communicate effectively with patients  Using a messenger  Support staff reduction / turnover  Adequate training 91 92 Cultural-Based Barriers Environmental (continued)  Is the prescription area conductive to private conversation?  Do you have to speak to the pharmacist through a third party (e.g., cashier)?  Are there a lot of background noises  What other distractions are present? 93  Definitions of illness  Perception of how to act when ill  Health-related customs  Perception of healthcare providers 94 Reconciliation (continued) Medication Reconciliation Process Medication errors and adverse events are common during and after hospitalization Financial burden on both healthcare organizations and patients (2005) The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No.8 95  Medication reconciliation should be performed each time the patient  Transfers to a new setting, or  New level of care  Admission: • Reconcile the patient’s medication taken at home or at a prior care setting • With any new prescription orders to be prescribed by an admitting clinician 96 16 Reconciliation (continued) Transfer:   Intra- or inter-facility Change of clinician or site of care LEARNING OBJECTIVE • Re c o g n i z e n o n ve rb a l q u e s.  Discharge: • Id e n t i f y ve rb a l a n d n o n ve rb a l f a c t o r s t h a t i m p a c t communicati on. • D i s c u s s s t ra t e g i e s t o i m p ro ve ve rb a l a n d n o n ve rb a l c o m m u n i c a t i o n .  Review all medications the patient was taking prior to being hospitalized  Incorporate new prescriptions from the hospitalization  Determine whether any medication should be added, discontinued, or modified 97 98 Nonverbal vs. Verbal Communication Nonverbal Communication o Mirrors innermost thoughts and feelings o Difficult to “fake” Verbal Communication o Nonverbal communication must be consistent; o Speaking o Writing otherwise, people will be suspicious of the intended meaning of your message o “What is not said” o Are you aware of what you project? Nonverbal Communication o o o o Behaviors Psychological responses Environmental interactions 55%-95% of all communication 99 100 Reading Nonverbals You can do well, if you concentrate!  Primary Emotions • Nonverbal expressions for happiness, sadness, surprise, anger, and fear are recognized with greater than 90% accuracy  Embedded Emotions • Nonverbal expressions for contempt, disgust, interest, determination, and bewilderment are recognized with 80-90% accuracy 101 Functions of Nonverbals Present an image Express power and control • Express or hide emotion and affect • Provide information • Regulate interaction • • 102 17 Present an Image  Body language • Can be used to establish an image 103 Express Power and Control  Posture or gestures • • • • Can be used to intimidate To be hierarchical To be paternalistic Opposite 104 Express Emotion or Affect  Facial expressions and gestures • • Augment verbal expressions of feelings Generally provide an accurate gauge of emotion 105 Provide Information  Facial expressions • 106 Regulate Interaction  Nonverbal messages • 107 Can provide much information Can be used to control or regulate the flow of a conversation Elements of Nonverbal Communication o o o o o o o Kinesics Paralanguage Vocal Inferences Spatial Usage (Proxemics) Self-presentation cues Environmental Barriers Distracting Factors 108 18 Kinesics Eye Contact Facial expressions Emoticons (human) Body movements (gestures) Posture Touch Handshake • • • • • • • Kinesics (continued) • Eye Contact     Connect with patient Look them straight in the eye Don’t stare, hold for 3-5 seconds Exemptions? • Facial Expressions  To gain and increase respect, first establish your presence with patient, then smile  Don’t overuse your smile 109 110 Kinesics (continued) • Emoticons   Kinesics (continued)  Opened or Relaxed Posture o Smiles show interest, excitement, empathy, concern Smiles create an upbeat, positive environment • Gestures  Observe in clusters => provides more accurate depiction  Each gesture is like a sentence  Sum total tell the non-verbal story 111 listen and speak  Closed Posture o 112  Touch Essential to a healthy life • Can communicate  Power  Empathy  Understanding • When is it inappropriate? 113 Arms folded in front of your chest o Legs crossed at the knees o Head facing downward o Eyes looking away Kinesics* (continued) • Standing or sitting with a full frontal appearance o Legs and arms comfortable apart (not crossed) o Facial expression relating interest and desire to Kinesics* (continued)  Handshake • Can be used to transmit attitude Dominance Submission  Equality   114 19 Vocal Inferences Paralanguage Pitch •  Vary tone; sound compassionate, caring Volume • Rate •   Not too slow (patients are not “stupid”) Not too fast (patients are not Pharmacists) Quality Intonation • • 115 Extraneous sounds or words that interrupt the flow of a conversation  “um” / “ah”  “like” / “ya know” • Place markers • Filler (meaningless phrases) • 116 Proxemics Spatial Usage Proxemics •      Structure and use of space o Intimate Distance Intimate distance Personal distance Social distance Public distance o < 18 in. (~ 45 cm) o reserved for close, intimate relationships o Personal Distance Territory •   o 18 - 48 in. (~46 - 120 cm) o Communication comfort zone for most non-related Americans Defensive positioning Use of barriers 117 118 Proxemics (continued)  Structure and use of space  Social Distance o 4 - 25 ft. ( 1.2 – 3.7 m) o Communication comfort zone for most non-related Americans Self-Presentation Cues •  • 119 • What message do you wish to send with your choice of clothing and personal grooming? Chronemics    Public Distance o > 25 ft. (> 3.7 m) o Public rather than private communication Physical Appearance Are you on time? How long did patient wait? Olfactory Communication   How strong is your perfume / cologne? Personal hygiene 120 20 Barriers Environmental Factors o Barriers to communication o Presence of a private consulting areas o General appearance of the pharmacy o Cleanliness o Clutter o Lighting o Pharmacy staff dress code o Pharmacist appearance 121 122 Distracting Factors Distracting Factors (continued) o Lack of eye contact o Looking at the prescription, vial, computer o Limits your ability to assess patient understanding o Body position o Closed stance with folded arms o Slouched forward o Tilted to one side o Listening to other “noises” o Tone of voice o Avoid sarcastic communication o Monotone voice o Show caring o Humor o Hard to pull-off o Often misunderstood o Telephones o Co-worker conversations 123 124 Nonverbal Cues o Interpretation of nonverbal communication Importance of Cues o Harris Survey (1997) found that embarrassment was the most common reason why consumers did not approach their health care provider o Perceived in a personal manner o Interpretation depends on background: o Social o Psychological o Cultural o Incontinence o Sexual dysfunction o Depression o Menopause o Hemorrhoids o Contraception o Breast or prostate cancer o Non-adherence o Focus on multiple cues o Ask questions to clarify 125 126 21 Intuition Proper Eye Contact o “Gut feeling” that verbal and nonverbal messages are “When the eyes say one thing, and the tongue another, a practiced man relies on the language of the first.” not congruent  o Result of your subconscious ability to read another person’s body language - Ralph  Pay attention to your gut 127 128 Eye Contact (continued) Eye Contact (continued) Make it and keep it! Focused eye contact displays confidence Helps you understand what the patient is really saying • Shows you are paying attention to others • • • 129 • • Conveying your interest in others Begin as soon as you engage patient in a conversation • May wish to start earlier if you are trying to get someone's attention • Continue it throughout the consultation 130 Eye Contact (continued) Maintain direct eye contact as you are saying "goodbye" • Leaves a positive, powerful lasting impression • Imagine an inverted triangle on your face •   131 Waldo Emerson Base of it just above your eyes Other two sides come to a point between your nose and your lips Eye Contact (continued) • Suggested area to "look at" during business conversations Socially, the point of the triangle drops to include the chin and neck areas • When people look you "up and down," it's probably more than business or a casual social situation they have in mind! • 132 22 Eye Contact (continued) Maintain about 80% - 90% of the time* < can be interpreted as discomfort, evasiveness, lack of confidence or boredom • > can be construed as being too direct, dominant, or forceful and make the other person uncomfortable • • Eye Contact (continued) Okay to glance down occasionally => as long as your gaze returns quickly to the other person • Avoid looking over the other person's shoulders => as if you were seeking out someone more interesting with whom to talk • *Can vary 133 134 Pharmacy Good Body Language for RPhs • Move smoothly  “The survival of pharmacy as a profession • When introduced to patient, be aware of their space may depend more upon our collective ability to communicate … than on our knowledge of diseases and therapeutics.” • Stand straight; no slouching • Stand with feet 4 to 8 inches apart, directly facing the person with whom you are speaking  Srnka QM, Ryan MR. Active listening: a key to effective communication. American Pharmacy 1993; NS33(9): 43-6 135 136 Good Body Language (continued) • • Keep your arms at your side Do not put your hands     • 137 In your pockets Behind your back On your hips Cross your arms Keep your chin parallel to the ground, do not lower your head or look at the ground Good Body Language (continued) • Nod your head in acknowledgment of what is said  Signals you are listening  Do not over do it • Gesture with hands open • Sit up straight Do not plop down into the chair • 138 23 Improving Your Skills  When sending messages Be conscious of your nonverbal behavior Be purposeful in using nonverbal cues Do not be distracting Match nonverbal and verbal communication Adapt as situation develops • • • • • 139 Improving Skills (continued)  When receiving messages Do NOT assume • Consider cultural, gender, and individual differences • Pay attention to all aspects of nonverbal messaging • Use perception checking • 140 Improving Skills (continued) Get CLOSER       Control distractions Lean in Open posture Smile Eye contact Relax 141 Pharmacists  Should be aware of nonverbal behaviors because: It helps you become a better receiver of patient’s messages 2. You will become a better sender of signals that reinforce your message 3. It increase the degree of perceived psychological closeness between pharmacist and patient 1. 142 AUDIENCE RESPONSE SYSTEM LEARNING OBJECTIVE • De scri b e te c hni que s to de cre a se com m unic a ti on a p p re h e nsi o n a m o ng p h a rm a c ists. 143 144 24 Definition Pharmacists*  Tend to struggle with communication  One’s level of fear (or anxiety) associated with communication with another person(s)  Have a higher rate of communication apprehension than other health professionals  Value the Communications and other Social-Behavioral  High levels => avoids communicating => talks less with patients content AFTER graduation A funny thing happens when clinicians start talking to people!! 145  Not just about the lack of skills!! 146 Symptoms Feelings of:  Tension Symptoms (continued) Manifested as:  Fear of public speaking  Anxiety  Apprehension  Nervousness  Withdrawal during group learning activities  Lack of skills in one-on- one situations  Worry  Shyness 147 148 Associated With …  Lack of confidence Consequences  Student Pharmacists with high communication apprehension will carry this trait into practice  Lack of training  Gender differences  Patients will probably question the credibility of information provided by RPh’s with high communication apprehension  Cultural influences  Personality traits 149 150 25 Apprehension Cascade Overcoming Apprehension Pharmacists with communication apprehension may be viewed negatively (poor "bedside manner")  Behavioral correction Patients are less likely to ask questions regarding their medication regimen  Systematic desensitization  Seek opportunities to work on the areas causing anxiety => consistent work on anxiety-inducer => ↓ ↓ levels of apprehension Missed opportunities for important patient counseling Practice , Practice, Practice, Practice Significant negative impact on patient outcomes 151 152 Thoughts (continued) Power of Thoughts Challenging your compelling thoughts  Is it true?  How many of our thoughts are simply not true?  Can you absolutely be sure that it is true?  If the thought has that much influence on you, it’s worth verifying 153  How do you react when you believe that thought?  Become aware of your thoughts and step outside of them for a moment  Who would you be without that thought?  Breathe  Observe yourself having negative thoughts  Proceed 154 HAPPY TRAILS TO YOU UNTIL WE MEET AGAIN 155 26 CHAPTER 6 CULTURAL PERSPECTIVES IN PUBLIC HEALTH Barry A. Bleidt, PhD, PharmD, RPh* Professor, Sociobehavioral and Administrative Pharmacy College of Pharmacy Nova Southeastern University Ft. Lauderdale, FL Carmita A. Coleman, PharmD, MAA Dean and Associate Professor College of Pharmacy Chicago State University Chicago, IL The World Health Organization (1948, p. 1) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Public health is “the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (Winslow, 1920, p. 30). In general, public health is concerned with issues that impact the health outcomes of a population in contrast to the health of an individual. The population in question can be a small handful of people within a community or as widespread as the people living in one or more countries. Today, the burden of preventable, chronic diseases and the existence of global communicable diseases significantly affect and challenge public health and health care. In order to deliver effective health care and public health services, an awareness of and appreciation for culture’s influence on the social determinants of health is fundamental. Figure 1 illustrates how and where culture has a significant influence on a patient’s health beliefs and health. Health disparities among different groups is attributed to poorer overall health and decreased health outcomes. Culturally competent delivery of care is a primary contributor to reducing the more expansive concern of health disparities (U. S. Department of Health and Human Services, 2010). There are many facets to understanding the concept of culture and its influences. First, each person is a member of multiple cultures. Second, some aspects of culture may be visibly obvious on an individual (such as ethnicity, gender, or religion), while other aspects may not be as readily apparent at all (such as sexual orientation). Third, another less-discussed aspect of culture is there can be tremendous diversity within a defined culture. For example, the Hispanic or Latino culture is very diverse, representing customs, beliefs, and values from different 2 hemispheres and many countries. Fourth, there are numerous cultures to which a patient could identify that may not be immediately recognizable as a distinct culture by a novice in his or her cultural-integration journey, such as: • Generational (to which generation does a patient belong); • Disability (physical, psychological, emotional); • Health professional (versus patient); • Primary spoken language (e.g., French, Creole, Arabic, Spanish); • Lifestyle (vegan, cross fit); and • Gender (transsexual, questioning). Figure 1 Culture’s Influence on a Patient’s Health Beliefs and Health In this chapter, the authors will define culture, its role and influence as a social determinant of health, and discuss the concepts of cultural awareness and cultural competency, which are the foundation of a patient-centered approach to better health outcomes and wellness. We will also discuss the current status of cultural consideration in health care as a public health problem and present the need for culturally competent services delivery, along with an exploration of what is involved in the cultural integration journey. 3 When public health issues arise to affect health negatively, it becomes imperative to identify and prioritize these concerns using a pragmatic framework that leads to positive action. Silvia Rabionet, Associate Professor of Public Health at Nova Southeastern University College of Pharmacy, established eight criteria that must be met for an issue to be defined as a public health problem. Professionals involved in addressing the public’s health can use the following framework to define, advocate, and articulate when to approach an issue from a public health perspective: 1. Does it affect the health and well-being of the population? 2. Is it widespread and increasing in scope and magnitude within a population or in a subgroup of a population? 3. Does it affect health-related and other societal resources (e.g., economic and social impacts)? 4. Does it challenge cultural norms and/or raise questions about values of life? 5. Does its solution rest in collective measures and interventions based in disease prevention, health promotion, and education? 6. Does it require interprofessional collaboration? 7. Does it call for organized government intervention? and 8. Does it merit urgent action? The complexity of delivering culturally competent care that is respectful of a heterogeneous patient population will multiply as the U.S. and world populations become more diverse. Past failures to recognize the role of culture significantly affected the health and well- 4 being of the populace; these failures also drastically influenced the utilization of resources and challenged how we value the individuality of a patient. Actions undertaken to resolve the lack of culturally competent care include interprofessional collaboration and governmental action. Therefore, culturally competent care meets these criteria to be classified as a public health problem. Modern public health practice requires inter-professional and transdisciplinary teams of public health workers and health care professionals including pharmacists, physicians, dentists, psychologists, epidemiologists, biostatisticians, physical therapists, medical assistants, nurses, environmental scientists, dietitians and nutritionists, veterinarians, public health engineers, public health lawyers, sociologists, community development workers, communications experts, and bioethicists, among others. The ethnic make-up of the population of the United States is continuously evolving and rapidly expanding. By 2050, the nation’s population is expected to increase to over 438 million people, a 48% growth since 2005. At that time, it is projected those that are now considered minorities will be a collective majority. Figure 2 shows a graphic representation and ethnic breakdown of the U.S. population for the years 1960, 2005, and 2050 (Passel & Cohn, 2008, February 11). Figure 2 Population by Ethnicity 1960, 2005, 2050 (Passel & Cohn, 2008, February 11) 5 Note: All races modified and not Hispanic (*); American Indian/Alaska native not shown These substantial changes shown over a 90-year timeframe demonstrate clearly how and why culture has become a huge influence on health. Interestingly, 20% of that population will include new immigrants to the U.S. Both Hispanic and Asian populations are expected to triple in size, increasing to 29% and 9% of the population, respectively. Purnell and Paulanka (2012, p. 2) defined culture as “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life-ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision-making.” It is important to understand as ethnic diversity continues to expand within the U.S., cultural considerations must be recognized as an integral factor in patient care to a greater extent than now. Cultural values and norms can determine health-seeking behaviors, selfmanagement of a disease, and certainly cross-cultural communication with health care providers. Public health practitioners that do not recognize that culture is the background for many of the decisions made relating to health, will most likely encounter mistrust from the patient, but also, professional frustration from the lack of impactful patient outcomes regardless of the intervention. Purnell and Paulanka (2012) further identified 12 domains of culture that could impact how a patient would approach an issue such as health care. In Table 1, the Chapter’s authors adapted these 12 domains of culture with a situational aspect related to patient care in the Pertinent Health Care Scenario column. 6 Table 1* Health Care Scenarios Affected by Culture Cultural Domain* Overview, Inhabited Localities, and Topography Communication Family Roles and Organization Workforce Issues Biocultural Ecology High-Risk Behaviors Nutrition Pregnancy and Childbearing Practices Potential Domain Components Heritage, residency, migration patterns, educational status, occupation Language, dialects, cultural interaction patterns, temporal relationships, format for names Decision-makers, matriarchal vs. patriarchal priorities, alternative lifestyles Conflicts in the workplace, professional autonomy Client’s physical, biological, and physiological variations Use of alcohol, tobacco, and recreational drugs Meaning of food, dietary practices, food rituals, nutritional deficiencies Sanctioned v. unsanctioned fertility practices, prescriptive, restrictive, and taboo practices related to pregnancy, birthing and postpartum, nursing Death, euthanasia, burial practices, bereavement Death Rituals Spirituality Healthcare Practices Healthcare Practitioners Religious practices, use of prayer, meaning of life, individual sources of strength, healthcare practices related to these beliefs Health-seeking behaviors, folklore practices, beliefs regarding blood transfusions, organ donation, responsibility for healthcare Status, use and perceptions of traditional, magico-religious 7 Pertinent Healthcare Scenario A group of people of a similar culture could live an area that has “food deserts”, areas where residents may not have easy access to fresh food or local grocers. Colloquial sayings may not be familiar to the healthcare provider causing the provider to have difficulty perceiving common social cues from their patients. Gender roles may dictate who receives patient counseling information or who the caregiver is for a patient. Immigration status may be questionable for the patient rendering them ineligible to receive employee health benefits. A particular ethnic group may have an increased risk to be afflicted by a certain disease state, such a hypertension or cancer. It may permissible to engage in promiscuous heterosexual encounters, but unacceptable to have a monogamous homosexual partner in a certain culture. It may be seen as a sign of affluence or good health to be morbidly obese in some cultures. Certain cultures may have no concept of prenatal or postnatal care. Certain cultures may require remains to be buried or cremated quickly before a cause of death could be found. Some cultures may require touching of remains although highly communicable disease could be present (Winslow). A patient could require the presence of a spiritual advisor as a member of their health care team or see their illness as part of God’s plan. A patient could employee alternative healing practices such as cupping or coining instead of or in addition to Western medicine modalities. Some cultures may consult advisors or healers prior to or instead of seeking treatment from health care practitioners. practitioners, and biomedical healthcare professionals *Cultural Domain headings expanded from: Purnell L, & Paulanka B. (2012). Transcultural health care: A culturally competent approach. Philadelphia: F.A. Davis. The Need for Cultural Competence in Health Care Delivery Findings reported in a 2016 Roundtable on Population Health Improvement workshop on health equity indicated that it is important to increase the racial and ethnic diversity among health care providers (National Academies, 2016) . Although studies have found that racial and ethnic minority practitioners are significantly more willing to serve in minority and medically underserved areas than their majority counterparts (Smedley, Butler, & Bristow, 2004), there are a number of medically underserved populations and communities across the United States. Many reported health disparities and health inequities are found in medically underserved populations (MUPs) in medically underserved areas (MUAs) and in areas that are designated “health professional shortage areas” (HPSAs) (Health Resources and Services Administration, 2016, July 1). Medically underserved populations include groups of persons who face socioeconomic, cultural, or linguistic barriers to health care. Medically underserved areas range in size and designation from a whole county or a group of contiguous counties, a group of county or civil divisions, or a group of urban census tracts. Health professional shortage areas are defined as the shortage of primary medical care, dental or mental health providers in urban or rural areas, across a variety of population groups, or across medical or other public facilities (Health Resources and Services Administration, 2016, July 1). However, the defining factor is that residents have a shortage of personal health services. 8 Greater diversity among health care professionals is associated with increased patient choices of clinicians, satisfaction, improved patient-practitioner communication, and better access to care for minorities (LaVeist & Pierre, 2014; Smedley et al., 2004; Williams, Walker, & Egede, 2016). The profession of pharmacy is fortunate to have at one professional student society whose primary mission is to improve the health of the medically underserved and increase the number of minority pharmacists: the Student National Pharmaceutical Association (SNPhA, 2016). In 1972, the SNPhA was formed in order to promote these interests among student pharmacists. As illustrated by its mission shown in Figure 3, SNPhA develops and implements programming and clinical initiatives that target improving minority health outcomes. Figure 3 SNPhA Mission Statement Student National Pharaceutical Association (2016) SNPhA is an educational service association of pharmacy students who are concerned about pharmacy and healthcare related issues, and the poor minority representation in pharmacy and other healthrelated professions. The purpose of SNPhA is to plan, organize, coordinate and execute programs geared toward the improvement for the health, educational, and social environment of the community. SNPhA has at its core six patient outreach initiatives, inlcuding HIV/AIDS; chronic kidney disease; and diabetes (SNPhA, 2013, October). Annually, SNPhA measures the number of initiative events and patient interventions. There were more than 108,000 patient encounters. These astounding numbers show that student pharmacists can have significant impact on the public health of a nation. Cultural Competence Delivering efficient and effective health care and public health services require an understanding of the differences among various cultures to which a patient identifies. Figure 4 9 outlines the steps involved in the journey towards Cultural Integration (Bleidt, 1992). An individual practitioner can be at many points along this continuum depending on which culture(s) he or she is encountering at the time. There is no set starting point either, as proper attitudes and learned techniques and practices advance the clinician along the continuum with each new cultural engagement. Although the continuum applies to both individuals and organizations, the primary purpose of this chapter is to discuss individual journeys. Figure 4 Journey towards Cultural Integration based upon the Cultural Competency Continuum (Bleidt, 1992) ETHNOCENTRICITY Cultural Insensitivity ➔ ➔ Cultural Awareness ➔ ➔ Cultural Sensitivity ➔ ➔ ETHNIC DIVERSITY Cultural Competency ➔ Cultural Integration With each new cultural experience, a person evolves toward cultural integration. The four benchmarks on the continuum address insensitivity, awareness, sensitivity, and integration. Cultural Insensitive is defined as not being aware of or having knowledge of cultural differences or their impact and/or lacking the desire to learn about various cultures. Cultural Awareness is the stage that involves self-examination of one’s own cultural background, what makes it unique, and what bearing these discoveries may have. In Cultural Sensitivity, public health professionals have an awareness and begin to develop a deeper cultural knowledge about others, but have not assimilated this knowledge into practice successfully. In the last step, Cultural Integration, cultural knowledge is placed into practice in order to communicate better and serve the patient more effectively. A culturally competent practitioner possesses the knowledge, skills, attitudes, and abilities to provide optimal health care services to patients from a wide range of cultural and 10 ethnic backgrounds. In a culturally competent organization, clinicians can move through the steps fairly rapidly and the patient feels comfortable as this learning process occurs. In the absence of cultural competency, miscommunication between clinician and patient can occur leading to medical misadventures, misdiagnosing, and failure to consider differing responses to medications. Skills in seeking, interpreting, and understanding relevant personspecific nuances are valuable to serving patients or those who seek services. Resources, especially time, must be given to those who serve other so that they may obtain these needed abilities. Cultural competence comprises the collective knowledge, abilities, attitudes, and aptitudes of practitioners to provide optimal services to a broad variety of culturally and ethnically different patients. Competence begins with having skills to assemble pertinent cultural information. It is a critical step in the patient’s care to determine if a cultural assessment is needed to be conducted. A culturally skilled practitioner is able to collect pertinent cultural data and perform a culturally appropriate physical assessment from a patient. Culturalkinetics Culturalkinetics is a process (Bleidt, 1992); it is defined as the movement along the Cultural Integration Continuum as new patients or cultures are seen. It involves understanding that other cultures may not share your views or values. Baseline assumptions are established and used with each new encounter until enough relevant data has been obtained from a cultural assessment. Then, the more specific, pertinent information is used with the patient. With each meeting, more data is gathered until as complete of an understanding of who he or she is can be achieved. 11 Through Culturalkinetics, culturally competent behavior is a continuous process of selfawareness and self-improvement as more detailed knowledge is gained about each culture or patient learning about cultural nuances and how they affect attitudes and health behaviors. Through this process one becomes more sensitive, understanding, and empathetic about these variances. Finally, cultural integration is reached when a practitioner is truly skillful in adapting and responding to those differences within appropriate contexts and circumstances. The process of Culturalkinetics involves a utilizing a set of skills needed to culturallyassess a patient. According to Bleidt (1992), these skills include: • identifying and appreciating ethno-specific problems (such as bigotry); • respecting the person as a human being and their rights to be treated as one; • accepting those who may be different as equals; • communicating in a cross-cultural fashion at the patient’s (consumer’s) literacy level without being condescending; • being a good listener, being empathetic, and being polite; • understanding, without prejudice, differing value systems and beliefs the patient may hold; • connecting with the underserved; • identifying with a patient’s background and using this to link with them; • using innovative approaches from other cultures to solve individual problems; • learning constantly about other cultures; and • appreciating the differences among cultures. 12 From this list of essential skills core, we can determine which values and behaviors are most relevant to create culturally competent organizational policies and processes that can be embodied within standards and guidelines. Such standards, by definition, would employ broader definitions of culture that went beyond traditional frames of race, ethnicity, health, and services provision and settings. This is reflected by the following recommendations of the National Center for Cultural Competence (NCCC, 2016, para. 3), For an organization to achieve cultural competence, they must: • “have a defined set of values and principles and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally”; • “have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of the communities they serve”; and • “incorporate the above in all aspects of policymaking, administration, practice, and service delivery and involve systematically consumers, key stakeholders, and communities.” The CLAS Standards Since their release by the Office of Minority Health (OMH) in 1999, the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) have been the foundation of health and health care organizations’ efforts to improve health equity, reduce health disparities, and improve quality of care (Office of Minority Health, 1999, 2001). In the introduction to the CLAS standards, OMH emphasizes the relationship 13 between health and the social determinants of health, that is “those conditions in which individuals are born, grow, live, work and age” (WHO, 2016), such as socioeconomic status, education level, and the availability of health services. Although the original 14 guidelines have been modified over time, the intent of the guidelines is still the same: to facilitate health care delivery for minority populations. They are aimed at health care organizations and the services that these organizations should provide. Specific services include: • education of their staff in cultural and linguistic service delivery; • provision of language assistance services and interpreters; • promotion of a strategic plan outlining goals and policies in this area; and • development of collaborative partnerships with the community. In 2012, the Office of Minority Health (OMH) updated the CLAS Standards to clarify the meaning of the Standards and broadening their scope. Standard 1 was made the Principal Standard. If all 14 standards are adopted, successfully implemented, and sustained with fidelity over time, then the Principal Standard is achieved “Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs” (OMH, 2013, p. 31). The remaining standards were regrouped under three categories: 1) governance, leadership, and workforce; 2) Communication and Language Assistance; and 3) Engagement, Continuous Improvement, and Accountability. Table 2 shows the standards for each theme. 14 Table 2 National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (OMH, 2013, pp. 30-32, reprinted with permission). Principal Standard: Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Theme 1: Governance, Leadership, and Workforce 2. Advance and sustain governance and leadership that promotes CLAS and health equity 3. Recruit, promote, and support a diverse governance, leadership, and workforce 4. Educate and train governance, leadership, and workforce in CLAS Theme 2: Communication and Language Assistance 5. Offer communication and language assistance 6. Inform individuals of the availability of language assistance 7. Ensure the competence of individuals providing language assistance 8. Provide easy-to-understand materials and signage Theme 3: Engagement, Continuous Improvement, and Accountability 9. Infuse CLAS goals, policies, and management accountability throughout the organization’s planning and operations 10. Conduct organizational assessments 11. Collect and maintain demographic data 12. Conduct assessments of community health assets and needs 13. Partner with the community 14. Create conflict and grievance resolution processes 15. Communicate the organization’s progress in implementing and sustaining CLAS It is the primary goal of Western medicine to provide optimal care for ALL patients. In order to realize this goal, providers must acknowledge and understand the existence of cultural variations and beliefs. The ethos of pharmaceutical care (or pharmacy care or patient care in pharmacy practice) is congruent with delivering the best possible individualized care, which requires taking into consideration the impact of a patient’s culture on his or her illness, on the In the late 1990s, the U.S. Department of Health and Human Services (US DHHS) government prepared a report on national goals for a more healthy population entitled Healthy People 2000 (US DHHS, 1991). Since that initial document, Healthy People 2010 and now 15 Healthy People 2020 have been developed and implemented federally (US DHHS 2000, 2010) . One of primary goals of Healthy People 2000 was to reduce health disparities among Americans. Healthy People 2010 went further to set the goal of eliminating health disparities. Now, Healthy People 2020 seeks to achieve health equity. This new concept of health equity is its loftiest undertaking in that it compels practitioners to assist patients in the “attainment of the highest level of health for all people” (National Partnership For Action To End Health Disparities, 2016, March 26, p. 9). Interestingly, these reports do not equate a patient’s health to a singular rationale of the lack of a disease process, but to broader determinants of health espoused by United States (Secretary’s Advisory Committee, 2010, July 6) and the World Health Organization (2016). Table 3 offers a brief review of these determinants from Healthy People 2020. Implications for Public Health and Pharmacists/Pharmacy Practice As we end this chapter, we would like to present recommendations on how to facilitate and promote cultural competence in an organization. Adapted from Brown and Nichols-English (1999), these suggestions, if followed, would help to build a more culturally-competent environment within a healthcare institution. They represent an excellent starting place to begin the continuous journey toward Cultural Integration: • Create a supportive environment for practicing multicultural patient care; • Allocate adequate resources to purchase culturally consistent patient-education materials, to attend workshops and courses, and to train staff and professional personnel; 16 • Accept diversity in the approaches and techniques used for different patient populations, and be able to adapt and change your practice in reference to the changing environment and differences in patient-population needs; • Respect the differences in people; and • Strengthen collaborative relationships with other health care providers. By recognizing and understanding health disparities, pharmacists can effectively change practice and service delivery to ensure culturally competent care to all their patients. Simply by practicing culturalkinetics, changing the pharmacy environment to be more welcoming for different groups, and incorporating health promotion and disease prevention initiatives, pharmacists can improve the overall health of local communities. Minimizing or eliminating communication barriers contributes to quality of care (Vanderpool & Ad Hoc Committee on Ethnic Diversity and Cultural Competence, 2005). In Appendix A, the policies of the American Society of Health-System Pharmacists (ASHP) that directly relate to cultural competence are presented. The reader is directed to the American Pharmacists Association manual for their policies that directly relates to cultural competence (https://www.pharmacist.com/policymanual). The authors have introduced the process of culturalkinetics and of how to take the journey toward Cultural Integration. From an early age, most of us have learned the Golden Rule, which is “do unto others as you would have done unto you”. However, in a fully culturallyintegrated scenario, the Platinum Rule would be followed, which is do unto others as they want done unto them. There is a very important distinction between these two guidelines. The Platinum Rule recognizes that the other individual has the right to be treated as he or she feels is appropriate. 17 The highest level of cultural awareness, Cultural Integration, is when one considers the individual difference in us all worthy of recognition. This aspect of providing care becomes very important to patients we may see from other countries and to the Lesbian, Gay, Bisexual, and Transgender (LBGT) community that has been largely ignored by many health care practitioners for far too long. It is hoped that this chapter will provide a roadmap for greater understanding of how to provide better care for all. 18 Appendix A ASHP Cultural Competence Policy [Reprinted with permission of ASHP] 1613 Cultural Competency Source: Council on Education and Workforce Development To foster the ongoing development of cultural competency within the pharmacy workforce; further, To educate healthcare providers on the importance of providing culturally congruent care to achieve quality care and patient engagement. This policy supersedes ASHP policy 1414. Rationale The United States is rapidly becoming a more diverse nation. Culture influences a patient’s belief and behavior toward health and illness. Cultural competence can significantly affect clinical outcomes. Research has shown that overlooking cultural beliefs may lead to negative health consequences.1 According to the National Center for Cultural Competency, there are numerous examples of benefits derived from the impact of cultural competence on quality and effectiveness of care in relation to health outcomes and well-being.2 Further, pharmacists can contribute to providing “culturally congruent care,” which can be described as “a process of effective interaction between the provider and client levels” of healthcare that encourages provider cultural competence while recognizing that "[p]atients and families bring their own values, perceptions, and expectations to healthcare encounters which also influence the creation or destruction of cultural congruence.”3 The Report of the ASHP Ad Hoc Committee on Ethnic Diversity and Cultural Competence4 and the ASHP Statement on Racial and Ethnic Disparities in Health Care5 support ways to raise awareness of the importance of cultural competence in the 19 provision of patient care so that optimal therapeutic outcomes are achieved in diverse populations. 1. Administration on Aging. Achieving cultural competence. A guidebook for providers of services to older Americans and their families. Available at: http://archive.org/details/achievingcultura00admi (accessed October 17, 2013) 2. Goode TD, Dunne MC, Bronheim SM. The evidence base for cultural and linguistic competency in health care. The Commonwealth Fund; 2006. Available http://www.commonwealthfund.org/usr_doc/Goode_evidencebasecultlinguisticcomp_962.pd f (accessed October 17, 2013) 3. Schim SM, Doorenbos AZ. A Three-dimensional Model of Cultural Congruence: Framework for Intervention. J Soc Work End Life Palliat Care. 2010; 6:256–70. 4. Report of the ASHP Ad hoc committee on ethnic diversity and cultural competence. Am J Health-Syst Pharm. 2005; 1924-30. 5. ASHP Statement on Racial and Ethnic Disparities in Health Care. Am J Health-Syst Pharm. 2008; 65:728–33. 20 References Bleidt, B. (1992). Understanding multicultural pharmaceutical education. In B. Bleidt (Ed.), Multicultural pharmaceutical education (pp. 141-150). New York, NY: Pharmaceutical Products Press. Brown, C. M., & Nichols-English, G. (1999). Dealing with patient diversity in pharmacy practice. Drug Topics, 143(17), 61–70. Coleman, C. A., & Bleidt, B. (2002). Considering the whole patient with hypertension: the ethos of pharmaceutical care. Ethnicity & Disease, 12(4), S3-72-75. Health Resources and Services Administration. (2016, July 1). Lists of designated primary medical care, mental health, and dental health professional shortage areas. Federal Register, 81(127), 43214-43215. LaVeist, T. A., & Pierre, G. (2014). Integrating the 3Ds--social determinants, health disparities, and health-care workforce diversity. Public Health Reports, 129 Suppl 2, 9-14. National Academies of Sciences Engineering and Medicine. (2016). Framing the dialogue on race and ethnicity to advance health equity: Proceedings of a workshop (9780309445733 0309445736). Washington, DC: Retrieved from http://www.nationalacademies.org/hmd/Reports/2016/Framing-the-Dialogue-on-Raceand-Ethnicity-to-Advance-Health-Equity-Proceedings-of-Workshop.aspx National Center for Cultural Competence. (2016). Conceptual frameworks/models, guiding values and principles. [Web page]. Washington, DC: Georgetown University. Retrieved from: http://nccc.georgetown.edu/foundations/framework.html National Partnership For Action To End Health Disparities. (2016, March 26). Health equity & disparities. In Glossary of terms. [Web page]. Washington, DC: U.S. Department of 21 Health and Human Services Office of Minority Health. Retrieved from: http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34 Office of Minority Health. (1999). Assuring cultural competence in health care: recommendations for national standards and an outcomes-focused research agenda. Washington, DC: Retrieved from http://minorityhealth.hhs.gov/Assets/pdf/checked/Assuring_Cultural_Competence_in_He alth_Care-1999.pdf Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care: Final report. Washington, DC: Retrieved from http://www.omhrc.gov/assets/pdf/checked/executive.pdf Office of Minority Health. (2013). National standards for culturally and linguistically appropriate services in health and health care: A blueprint for advancing and sustaining CLAS policy and practice. Washington, DC: Retrieved from https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf Passel, J. S., & Cohn, D. V. (2008, February 11). U. S. population projections: 2005-2050. Washington, DC: Retrieved from http://pewhispanic.org/files/reports/85.pdf Purnell, L. D., & Paulanka, B. J. (2012). Transcultural health care: a culturally competent approach (4th ed.). Philadelphia, PA: F.A. Davis. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. (2010, July 6). Healthy People 2020: An opportunity to address societal determinants of health in the U.S. Washington, DC: U. S. Department of Health and Human Services. 22 Smedley, B. D., Butler, A. S., & Bristow, L. R. (2004). In the nation's compelling interest : ensuring diversity in the health-care workforce. Washington, DC: National Academies Press. Student National Pharmaceutical Association. (2013, October). Initiative protocols Retrieved from http://snpha.org/wp-content/uploads/2014/08/Initiative-Protocols-20141.pdf Student National Pharmaceutical Association. (2016). Mission statement. [Web page]. San Antonio, TX: Author. Retrieved from: http://snpha.org/about/ U. S. Department of Health and Human Services. (1991). Healthy people 2000. Washington, DC: U S Dept of Health and Human Services, Public Health Service. U. S. Department of Health and Human Services. (2000). Healthy people 2010 Retrieved from http://purl.access.gpo.gov/GPO/LPS8595 U. S. Department of Health and Human Services. (2010). Healthy People 2020. Washington, DC: Retrieved from http://www.healthypeople.gov/2020/ Vanderpool, H. K., & Ad Hoc Committee on Ethnic Diversity and Cultural Competence. (2005). Report of the ASHP Ad Hoc Committee on Ethnic Diversity and Cultural Competence. American Journal of Health System Pharmacy, 62(18), 1924-1930. doi:10.2146/ajhp050100 Williams, J. S., Walker, R. J., & Egede, L. E. (2016). Achieving equity in an evolving healthcare system: Opportunities and challenges. The American Journal of the Medical Sciences, 351(1), 33-43. doi:10.1016/j.amjms.2015.10.012 Winslow, C.-E. A. (1920). The untilled field of public health. Modern Medicine, 2, 183-191. World Health Organization. (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 23 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Geneva, Switzerland: Author. World Health Organization. (2016). Social determinants of health. [Web page]. Geneva, Switzerlands: Author. Retrieved from: http://www.who.int/social_determinants/sdh_definition/en/ 24 *Note One of the co-authors, Dr. Bleidt, does not believe in race as a subdivision of mankind. When asked, he identifies himself as a member of the human race. Race is an artificial construct developed by British sociologists to justify slavery and treating others with less dignity than deserved. This chapter reflected these views. 25 The World Health Organization (1948, p. 1) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Public health is “the science and art of preventing disease, prolonging life and promoting health through organized efforts and informed choices of society, organizations, public and private, communities and individuals” (Winslow, 1920, p. 30). In general, public health is concerned with issues that impact the health outcomes of a population in contrast to the health of an individual. The population in question can be a small handful of people within a community or as widespread as the people living in one or more countries. Today, the burden of preventable, chronic diseases and the existence of global communicable diseases significantly affect and challenge public health and health care. In order to deliver effective health care and public health services, an awareness of and appreciation for culture’s influence on the social determinants of health is fundamental. Figure 1 illustrates how and where culture has a significant influence on a patient’s health beliefs and health. Health disparities among different groups is attributed to poorer overall health and decreased health outcomes. Culturally competent delivery of care is a primary contributor to reducing the more expansive concern of health disparities (U. S. Department of Health and Human Services, 2010). There are many facets to understanding the concept of culture and its influences. First, each person is a member of multiple cultures. Second, some aspects of culture may be visibly obvious on an individual (such as ethnicity, gender, or religion), while other aspects may not be as readily apparent at all (such as sexual orientation). Third, another less-discussed aspect of culture is there can be tremendous diversity within a defined culture. For example, the Hispanic or Latino culture is very diverse, representing customs, beliefs, and values from different 2 hemispheres and many countries. Fourth, there are numerous cultures to which a patient could identify that may not be immediately recognizable as a distinct culture by a novice in his or her cultural-integration journey, such as: • Generational (to which generation does a patient belong); • Disability (physical, psychological, emotional); • Health professional (versus patient); • Primary spoken language (e.g., French, Creole, Arabic, Spanish); • Lifestyle (vegan, cross fit); and • Gender (transsexual, questioning). Figure 1 Culture’s Influence on a Patient’s Health Beliefs and Health In this chapter, the authors will define culture, its role and influence as a social determinant of health, and discuss the concepts of cultural awareness and cultural competency, which are the foundation of a patient-centered approach to better health outcomes and wellness. We will also discuss the current status of cultural consideration in health care as a public health problem and present the need for culturally competent services delivery, along with an exploration of what is involved in the cultural integration journey. 3 When public health issues arise to affect health negatively, it becomes imperative to identify and prioritize these concerns using a pragmatic framework that leads to positive action. Silvia Rabionet, Associate Professor of Public Health at Nova Southeastern University College of Pharmacy, established eight criteria that must be met for an issue to be defined as a public health problem. Professionals involved in addressing the public’s health can use the following framework to define, advocate, and articulate when to approach an issue from a public health perspective: 1. Does it affect the health and well-being of the population? 2. Is it widespread and increasing in scope and magnitude within a population or in a subgroup of a population? 3. Does it affect health-related and other societal resources (e.g., economic and social impacts)? 4. Does it challenge cultural norms and/or raise questions about values of life? 5. Does its solution rest in collective measures and interventions based in disease prevention, health promotion, and education? 6. Does it require interprofessional collaboration? 7. Does it call for organized government intervention? and 8. Does it merit urgent action? The complexity of delivering culturally competent care that is respectful of a heterogeneous patient population will multiply as the U.S. and world populations become more diverse. Past failures to recognize the role of culture significantly affected the health and well- 4 being of the populace; these failures also drastically influenced the utilization of resources and challenged how we value the individuality of a patient. Actions undertaken to resolve the lack of culturally competent care include interprofessional collaboration and governmental action. Therefore, culturally competent care meets these criteria to be classified as a public health problem. Modern public health practice requires inter-professional and transdisciplinary teams of public health workers and health care professionals including pharmacists, physicians, dentists, psychologists, epidemiologists, biostatisticians, physical therapists, medical assistants, nurses, environmental scientists, dietitians and nutritionists, veterinarians, public health engineers, public health lawyers, sociologists, community development workers, communications experts, and bioethicists, among others. The ethnic make-up of the population of the United States is continuously evolving and rapidly expanding. By 2050, the nation’s population is expected to increase to over 438 million people, a 48% growth since 2005. At that time, it is projected those that are now considered minorities will be a collective majority. Figure 2 shows a graphic representation and ethnic breakdown of the U.S. population for the years 1960, 2005, and 2050 (Passel & Cohn, 2008, February 11). Figure 2 Population by Ethnicity 1960, 2005, 2050 (Passel & Cohn, 2008, February 11) 5 Note: All races modified and not Hispanic (*); American Indian/Alaska native not shown These substantial changes shown over a 90-year timeframe demonstrate clearly how and why culture has become a huge influence on health. Interestingly, 20% of that population will include new immigrants to the U.S. Both Hispanic and Asian populations are expected to triple in size, increasing to 29% and 9% of the population, respectively. Purnell and Paulanka (2012, p. 2) defined culture as “the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life-ways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision-making.” It is important to understand as ethnic diversity continues to expand within the U.S., cultural considerations must be recognized as an integral factor in patient care to a greater extent than now. Cultural values and norms can determine health-seeking behaviors, selfmanagement of a disease, and certainly cross-cultural communication with health care providers. Public health practitioners that do not recognize that culture is the background for many of the decisions made relating to health, will most likely encounter mistrust from the patient, but also, professional frustration from the lack of impactful patient outcomes regardless of the intervention. Purnell and Paulanka (2012) further identified 12 domains of culture that could impact how a patient would approach an issue such as health care. In Table 1, the Chapter’s authors adapted these 12 domains of culture with a situational aspect related to patient care in the Pertinent Health Care Scenario column. 6 Table 1* Health Care Scenarios Affected by Culture Cultural Domain* Overview, Inhabited Localities, and Topography Communication Family Roles and Organization Workforce Issues Biocultural Ecology High-Risk Behaviors Nutrition Pregnancy and Childbearing Practices Potential Domain Components Heritage, residency, migration patterns, educational status, occupation Language, dialects, cultural interaction patterns, temporal relationships, format for names Decision-makers, matriarchal vs. patriarchal priorities, alternative lifestyles Conflicts in the workplace, professional autonomy Client’s physical, biological, and physiological variations Use of alcohol, tobacco, and recreational drugs Meaning of food, dietary practices, food rituals, nutritional deficiencies Sanctioned v. unsanctioned fertility practices, prescriptive, restrictive, and taboo practices related to pregnancy, birthing and postpartum, nursing Death, euthanasia, burial practices, bereavement Death Rituals Spirituality Healthcare Practices Healthcare Practitioners Religious practices, use of prayer, meaning of life, individual sources of strength, healthcare practices related to these beliefs Health-seeking behaviors, folklore practices, beliefs regarding blood transfusions, organ donation, responsibility for healthcare Status, use and perceptions of traditional, magico-religious 7 Pertinent Healthcare Scenario A group of people of a similar culture could live an area that has “food deserts”, areas where residents may not have easy access to fresh food or local grocers. Colloquial sayings may not be familiar to the healthcare provider causing the provider to have difficulty perceiving common social cues from their patients. Gender roles may dictate who receives patient counseling information or who the caregiver is for a patient. Immigration status may be questionable for the patient rendering them ineligible to receive employee health benefits. A particular ethnic group may have an increased risk to be afflicted by a certain disease state, such a hypertension or cancer. It may permissible to engage in promiscuous heterosexual encounters, but unacceptable to have a monogamous homosexual partner in a certain culture. It may be seen as a sign of affluence or good health to be morbidly obese in some cultures. Certain cultures may have no concept of prenatal or postnatal care. Certain cultures may require remains to be buried or cremated quickly before a cause of death could be found. Some cultures may require touching of remains although highly communicable disease could be present (Winslow). A patient could require the presence of a spiritual advisor as a member of their health care team or see their illness as part of God’s plan. A patient could employee alternative healing practices such as cupping or coining instead of or in addition to Western medicine modalities. Some cultures may consult advisors or healers prior to or instead of seeking treatment from health care practitioners. practitioners, and biomedical healthcare professionals *Cultural Domain headings expanded from: Purnell L, & Paulanka B. (2012). Transcultural health care: A culturally competent approach. Philadelphia: F.A. Davis. The Need for Cultural Competence in Health Care Delivery Findings reported in a 2016 Roundtable on Population Health Improvement workshop on health equity indicated that it is important to increase the racial and ethnic diversity among health care providers (National Academies, 2016) . Although studies have found that racial and ethnic minority practitioners are significantly more willing to serve in minority and medically underserved areas than their majority counterparts (Smedley, Butler, & Bristow, 2004), there are a number of medically underserved populations and communities across the United States. Many reported health disparities and health inequities are found in medically underserved populations (MUPs) in medically underserved areas (MUAs) and in areas that are designated “health professional shortage areas” (HPSAs) (Health Resources and Services Administration, 2016, July 1). Medically underserved populations include groups of persons who face socioeconomic, cultural, or linguistic barriers to health care. Medically underserved areas range in size and designation from a whole county or a group of contiguous counties, a group of county or civil divisions, or a group of urban census tracts. Health professional shortage areas are defined as the shortage of primary medical care, dental or mental health providers in urban or rural areas, across a variety of population groups, or across medical or other public facilities (Health Resources and Services Administration, 2016, July 1). However, the defining factor is that residents have a shortage of personal health services. 8 Greater diversity among health care professionals is associated with increased patient choices of clinicians, satisfaction, improved patient-practitioner communication, and better access to care for minorities (LaVeist & Pierre, 2014; Smedley et al., 2004; Williams, Walker, & Egede, 2016). The profession of pharmacy is fortunate to have at one professional student society whose primary mission is to improve the health of the medically underserved and increase the number of minority pharmacists: the Student National Pharmaceutical Association (SNPhA, 2016). In 1972, the SNPhA was formed in order to promote these interests among student pharmacists. As illustrated by its mission shown in Figure 3, SNPhA develops and implements programming and clinical initiatives that target improving minority health outcomes. Figure 3 SNPhA Mission Statement Student National Pharaceutical Association (2016) SNPhA is an educational service association of pharmacy students who are concerned about pharmacy and healthcare related issues, and the poor minority representation in pharmacy and other healthrelated professions. The purpose of SNPhA is to plan, organize, coordinate and execute programs geared toward the improvement for the health, educational, and social environment of the community. SNPhA has at its core six patient outreach initiatives, inlcuding HIV/AIDS; chronic kidney disease; and diabetes (SNPhA, 2013, October). Annually, SNPhA measures the number of initiative events and patient interventions. There were more than 108,000 patient encounters. These astounding numbers show that student pharmacists can have significant impact on the public health of a nation. Cultural Competence Delivering efficient and effective health care and public health services require an understanding of the differences among various cultures to which a patient identifies. Figure 4 9 outlines the steps involved in the journey towards Cultural Integration (Bleidt, 1992). An individual practitioner can be at many points along this continuum depending on which culture(s) he or she is encountering at the time. There is no set starting point either, as proper attitudes and learned techniques and practices advance the clinician along the continuum with each new cultural engagement. Although the continuum applies to both individuals and organizations, the primary purpose of this chapter is to discuss individual journeys. Figure 4 Journey towards Cultural Integration based upon the Cultural Competency Continuum (Bleidt, 1992) ETHNOCENTRICITY Cultural Insensitivity ➔ ➔ Cultural Awareness ➔ ➔ Cultural Sensitivity ➔ ➔ ETHNIC DIVERSITY Cultural Competency ➔ Cultural Integration With each new cultural experience, a person evolves toward cultural integration. The four benchmarks on the continuum address insensitivity, awareness, sensitivity, and integration. Cultural Insensitive is defined as not being aware of or having knowledge of cultural differences or their impact and/or lacking the desire to learn about various cultures. Cultural Awareness is the stage that involves self-examination of one’s own cultural background, what makes it unique, and what bearing these discoveries may have. In Cultural Sensitivity, public health professionals have an awareness and begin to develop a deeper cultural knowledge about others, but have not assimilated this knowledge into practice successfully. In the last step, Cultural Integration, cultural knowledge is placed into practice in order to communicate better and serve the patient more effectively. A culturally competent practitioner possesses the knowledge, skills, attitudes, and abilities to provide optimal health care services to patients from a wide range of cultural and 10 ethnic backgrounds. In a culturally competent organization, clinicians can move through the steps fairly rapidly and the patient feels comfortable as this learning process occurs. In the absence of cultural competency, miscommunication between clinician and patient can occur leading to medical misadventures, misdiagnosing, and failure to consider differing responses to medications. Skills in seeking, interpreting, and understanding relevant personspecific nuances are valuable to serving patients or those who seek services. Resources, especially time, must be given to those who serve other so that they may obtain these needed abilities. Cultural competence comprises the collective knowledge, abilities, attitudes, and aptitudes of practitioners to provide optimal services to a broad variety of culturally and ethnically different patients. Competence begins with having skills to assemble pertinent cultural information. It is a critical step in the patient’s care to determine if a cultural assessment is needed to be conducted. A culturally skilled practitioner is able to collect pertinent cultural data and perform a culturally appropriate physical assessment from a patient. Culturalkinetics Culturalkinetics is a process (Bleidt, 1992); it is defined as the movement along the Cultural Integration Continuum as new patients or cultures are seen. It involves understanding that other cultures may not share your views or values. Baseline assumptions are established and used with each new encounter until enough relevant data has been obtained from a cultural assessment. Then, the more specific, pertinent information is used with the patient. With each meeting, more data is gathered until as complete of an understanding of who he or she is can be achieved. 11 Through Culturalkinetics, culturally competent behavior is a continuous process of selfawareness and self-improvement as more detailed knowledge is gained about each culture or patient learning about cultural nuances and how they affect attitudes and health behaviors. Through this process one becomes more sensitive, understanding, and empathetic about these variances. Finally, cultural integration is reached when a practitioner is truly skillful in adapting and responding to those differences within appropriate contexts and circumstances. The process of Culturalkinetics involves a utilizing a set of skills needed to culturallyassess a patient. According to Bleidt (1992), these skills include: • identifying and appreciating ethno-specific problems (such as bigotry); • respecting the person as a human being and their rights to be treated as one; • accepting those who may be different as equals; • communicating in a cross-cultural fashion at the patient’s (consumer’s) literacy level without being condescending; • being a good listener, being empathetic, and being polite; • understanding, without prejudice, differing value systems and beliefs the patient may hold; • connecting with the underserved; • identifying with a patient’s background and using this to link with them; • using innovative approaches from other cultures to solve individual problems; • learning constantly about other cultures; and • appreciating the differences among cultures. 12 From this list of essential skills core, we can determine which values and behaviors are most relevant to create culturally competent organizational policies and processes that can be embodied within standards and guidelines. Such standards, by definition, would employ broader definitions of culture that went beyond traditional frames of race, ethnicity, health, and services provision and settings. This is reflected by the following recommendations of the National Center for Cultural Competence (NCCC, 2016, para. 3), For an organization to achieve cultural competence, they must: • “have a defined set of values and principles and demonstrate behaviors, attitudes, policies, and structures that enable them to work effectively cross-culturally”; • “have the capacity to (1) value diversity, (2) conduct self-assessment, (3) manage dynamics of difference, (4) acquire and institutionalize cultural knowledge, and (5) adapt to diversity and the cultural contexts of the communities they serve”; and • “incorporate the above in all aspects of policymaking, administration, practice, and service delivery and involve systematically consumers, key stakeholders, and communities.” The CLAS Standards Since their release by the Office of Minority Health (OMH) in 1999, the National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS Standards) have been the foundation of health and health care organizations’ efforts to improve health equity, reduce health disparities, and improve quality of care (Office of Minority Health, 1999, 2001). In the introduction to the CLAS standards, OMH emphasizes the relationship 13 between health and the social determinants of health, that is “those conditions in which individuals are born, grow, live, work and age” (WHO, 2016), such as socioeconomic status, education level, and the availability of health services. Although the original 14 guidelines have been modified over time, the intent of the guidelines is still the same: to facilitate health care delivery for minority populations. They are aimed at health care organizations and the services that these organizations should provide. Specific services include: • education of their staff in cultural and linguistic service delivery; • provision of language assistance services and interpreters; • promotion of a strategic plan outlining goals and policies in this area; and • development of collaborative partnerships with the community. In 2012, the Office of Minority Health (OMH) updated the CLAS Standards to clarify the meaning of the Standards and broadening their scope. Standard 1 was made the Principal Standard. If all 14 standards are adopted, successfully implemented, and sustained with fidelity over time, then the Principal Standard is achieved “Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs” (OMH, 2013, p. 31). The remaining standards were regrouped under three categories: 1) governance, leadership, and workforce; 2) Communication and Language Assistance; and 3) Engagement, Continuous Improvement, and Accountability. Table 2 shows the standards for each theme. 14 Table 2 National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (OMH, 2013, pp. 30-32, reprinted with permission). Principal Standard: Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Theme 1: Governance, Leadership, and Workforce 2. Advance and sustain governance and leadership that promotes CLAS and health equity 3. Recruit, promote, and support a diverse governance, leadership, and workforce 4. Educate and train governance, leadership, and workforce in CLAS Theme 2: Communication and Language Assistance 5. Offer communication and language assistance 6. Inform individuals of the availability of language assistance 7. Ensure the competence of individuals providing language assistance 8. Provide easy-to-understand materials and signage Theme 3: Engagement, Continuous Improvement, and Accountability 9. Infuse CLAS goals, policies, and management accountability throughout the organization’s planning and operations 10. Conduct organizational assessments 11. Collect and maintain demographic data 12. Conduct assessments of community health assets and needs 13. Partner with the community 14. Create conflict and grievance resolution processes 15. Communicate the organization’s progress in implementing and sustaining CLAS It is the primary goal of Western medicine to provide optimal care for ALL patients. In order to realize this goal, providers must acknowledge and understand the existence of cultural variations and beliefs. The ethos of pharmaceutical care (or pharmacy care or patient care in pharmacy practice) is congruent with delivering the best possible individualized care, which requires taking into consideration the impact of a patient’s culture on his or her illness, on the In the late 1990s, the U.S. Department of Health and Human Services (US DHHS) government prepared a report on national goals for a more healthy population entitled Healthy People 2000 (US DHHS, 1991). Since that initial document, Healthy People 2010 and now 15 Healthy People 2020 have been developed and implemented federally (US DHHS 2000, 2010) . One of primary goals of Healthy People 2000 was to reduce health disparities among Americans. Healthy People 2010 went further to set the goal of eliminating health disparities. Now, Healthy People 2020 seeks to achieve health equity. This new concept of health equity is its loftiest undertaking in that it compels practitioners to assist patients in the “attainment of the highest level of health for all people” (National Partnership For Action To End Health Disparities, 2016, March 26, p. 9). Interestingly, these reports do not equate a patient’s health to a singular rationale of the lack of a disease process, but to broader determinants of health espoused by United States (Secretary’s Advisory Committee, 2010, July 6) and the World Health Organization (2016). Table 3 offers a brief review of these determinants from Healthy People 2020. Implications for Public Health and Pharmacists/Pharmacy Practice As we end this chapter, we would like to present recommendations on how to facilitate and promote cultural competence in an organization. Adapted from Brown and Nichols-English (1999), these suggestions, if followed, would help to build a more culturally-competent environment within a healthcare institution. They represent an excellent starting place to begin the continuous journey toward Cultural Integration: • Create a supportive environment for practicing multicultural patient care; • Allocate adequate resources to purchase culturally consistent patient-education materials, to attend workshops and courses, and to train staff and professional personnel; 16 • Accept diversity in the approaches and techniques used for different patient populations, and be able to adapt and change your practice in reference to the changing environment and differences in patient-population needs; • Respect the differences in people; and • Strengthen collaborative relationships with other health care providers. By recognizing and understanding health disparities, pharmacists can effectively change practice and service delivery to ensure culturally competent care to all their patients. Simply by practicing culturalkinetics, changing the pharmacy environment to be more welcoming for different groups, and incorporating health promotion and disease prevention initiatives, pharmacists can improve the overall health of local communities. Minimizing or eliminating communication barriers contributes to quality of care (Vanderpool & Ad Hoc Committee on Ethnic Diversity and Cultural Competence, 2005). In Appendix A, the policies of the American Society of Health-System Pharmacists (ASHP) that directly relate to cultural competence are presented. The reader is directed to the American Pharmacists Association manual for their policies that directly relates to cultural competence (https://www.pharmacist.com/policymanual). The authors have introduced the process of culturalkinetics and of how to take the journey toward Cultural Integration. From an early age, most of us have learned the Golden Rule, which is “do unto others as you would have done unto you”. However, in a fully culturallyintegrated scenario, the Platinum Rule would be followed, which is do unto others as they want done unto them. There is a very important distinction between these two guidelines. The Platinum Rule recognizes that the other individual has the right to be treated as he or she feels is appropriate. 17 The highest level of cultural awareness, Cultural Integration, is when one considers the individual difference in us all worthy of recognition. This aspect of providing care becomes very important to patients we may see from other countries and to the Lesbian, Gay, Bisexual, and Transgender (LBGT) community that has been largely ignored by many health care practitioners for far too long. It is hoped that this chapter will provide a roadmap for greater understanding of how to provide better care for all. 18 Appendix A ASHP Cultural Competence Policy [Reprinted with permission of ASHP] 1613 Cultural Competency Source: Council on Education and Workforce Development To foster the ongoing development of cultural competency within the pharmacy workforce; further, To educate healthcare providers on the importance of providing culturally congruent care to achieve quality care and patient engagement. This policy supersedes ASHP policy 1414. Rationale The United States is rapidly becoming a more diverse nation. Culture influences a patient’s belief and behavior toward health and illness. Cultural competence can significantly affect clinical outcomes. Research has shown that overlooking cultural beliefs may lead to negative health consequences.1 According to the National Center for Cultural Competency, there are numerous examples of benefits derived from the impact of cultural competence on quality and effectiveness of care in relation to health outcomes and well-being.2 Further, pharmacists can contribute to providing “culturally congruent care,” which can be described as “a process of effective interaction between the provider and client levels” of healthcare that encourages provider cultural competence while recognizing that "[p]atients and families bring their own values, perceptions, and expectations to healthcare encounters which also influence the creation or destruction of cultural congruence.”3 The Report of the ASHP Ad Hoc Committee on Ethnic Diversity and Cultural Competence4 and the ASHP Statement on Racial and Ethnic Disparities in Health Care5 support ways to raise awareness of the importance of cultural competence in the 19 provision of patient care so that optimal therapeutic outcomes are achieved in diverse populations. 1. Administration on Aging. Achieving cultural competence. A guidebook for...
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