Cultural Sensitivity and Global Pharmacy Engagement in the Caribbean: Dominica, Jamaica, Puerto Rico, and St. Kitts

Influence of Colonization on Caribbean Economies.

When pursuing reciprocal relationships with Caribbean partners, individuals must first understand the region’s past. This includes the historical influence of colonization by the British, French, and Spanish. After these settlers arrived, natives often were enslaved or killed.⁹ Conquering nations then forged economies largely based on slavery and the plantation system.⁹ The British colonized Dominica, which was considered to be “the last of the Caribbean islands colonized by European influence,” perhaps because of its mountainous terrain.^10,11 Here, the indigenous population, known locally as the Kalinago or Caribs, continues to reside in the Northeast part of the island.¹² Similar to Dominica, in St Kitts and Nevis, the islands were ruled by the British, with a portion being ruled temporarily by the French.¹¹ In Jamaica, Spanish settlers exterminated the native islanders or Taino, and brought African slaves to produce crops within a plantation system. The British later took control of the island until the time of independence. Under their rule, slave labor eventually was abolished and replaced by workers, primarily imported from China and India. The workers were employed at minimal wages and given long-term contracts, which were described as lower wage apprenticeships.^13-15

In Puerto Rico, as in Jamaica, the Spanish decimated the native population (Indios Tainos) and replaced them with African slave labor.^16-18 Spanish influence predominated until 1898 when the island became a US territory. Later in 1917, islanders were granted US citizenship. However, Puerto Ricans are still subject to rules and governance that differ from those of the mainland United States. For example, residents are subject to US Federal law but do not have voting representation in Congress. The island operates very similarly to a state but is instead a territory that is subject to the jurisdiction and sovereignty of the United States, but not able to vote on federal issues and does not have electoral votes in Presidential elections.^16-21

Colonization influenced the structure of the current day government of most Caribbean islands. The duration of government control may have impacts on partnerships, collaboration, or involvement of foreign practitioners, and funding challenges that can impact health care reform or limit health initiatives.^9,22 The government of those islands that more recently gained independence may have a structure that more closely resembles that of their former colonial powers.²² Many Caribbean islands have constitutions that are based on the parliamentary system of government. These constitutions were introduced by the British, with little input from the Caribbean people. Some islands have begun to undergo constitutional reform as their duration of independence lengthens.²³ Most Caribbean islands described in this paper gained independence in the past 50 years, with the exception of Puerto Rico, which remains a territory of the United States.^{10-12, 18, 21, 24-28} Democratic elections are held every five years in Dominica, Jamaica, and St. Kitts and Nevis.^10-12,24-28 Other ministers of government, such as Ministers of Health, are appointed on the advice of the Prime Ministers.^27-30

Beyond the development of infrastructure, colonial rule often affected the basis of the economies of the Caribbean. With freedom from colonial rule and the abolishment of slavery, the economies of islands such as Dominica, Jamaica, and St. Kitts and Nevis transitioned away from an almost complete reliance on agriculture to a focus on other opportunities such as tourism, offshore banking, programs where foreigners obtain citizenship by financial investment, exportation of bauxite/alumina, which is made into aluminum, and the formation of economic partnerships.^13,24,26-31 However, despite the shift in economies, the gross domestic product (GDP) per capita of many Caribbean nations remains substantially lower than that of the United States and other nations with which the islands have partnered and have diplomatic relations.^32-42

An increased need for support from other nation states has expanded in recent years because of natural disasters. In 2017, a category 5 hurricane directly hit Dominica and Puerto Rico. St. Kitts and Nevis were also struck by a hurricane in 2017 that caused severe damage and required multinational efforts (eg, medical relief, voluntourism) to restore infrastructure.^43-49 Natural disasters have underscored the need to develop climate resilient practices and disaster relief measures (eg, response and preparedness plans) into the health care infrastructure of these islands.^43-53 Islands were affected by these disasters to different extents based upon their economies, size, and infrastructure. Of the islands included in this paper, Dominica and Puerto Rico are discussed with regard to the impact of natural disasters on their health care infrastructures.^52,53

Influence of Colonization on Language.

The languages of the Caribbean as a region are unique to each island and based on dialects, which are a blend of local influences and the languages of the foreign colonizers.⁵⁴ In Puerto Rico, both Spanish and English are official languages. In contrast, in Dominica and Jamaica, English is their official language. Additionally, in some Caribbean islands, Dutch and Dutch Creole as well as Papiamentu (a mix of Portuguese and Dutch) are spoken, but islands that speak this mix of language were not included in this paper.

Beyond the formally recognized languages highlighted above, Creole or local patois, is spoken by more than 75 million people throughout the Caribbean. The majority of Caribbean people also speak a second language, typically that of the former colonial power.^55-59 Variations of Creole have existed in the Caribbean for over 200 years, but were mainly oral and not written languages.^59,60 Thus, a standardized orthography and consistent grammar is often not observed.⁵⁷ Creole has never been formally used in education in many of the islands. One of the reasons cited for this are the negative perceptions of the language by some educators, policymakers, and the public.^57,58 Thus, there are concerns that the indigenous languages are at risk of disappearing.^58,61 Orthography workshops have attempted to document the language to prevent this from occurring and have noted variances in dialects and phrasing between islands and also among villages within the islands.^54,59 For example, in St. Lucia, Dominica, and Haiti, the Creole language is very similar, although accents and some phrases differ.^61,62

In Puerto Rico, an innovative blend of Anglicized Spanish and English, the Costumbrismo dialect, may be interpreted as another Creole language.^19,63,64 This dialect was inspired by indigenous or Taino people and Africans, and emerged in the 16^th to 19^th centuries with new meanings, rhythms, and tones.¹⁸ As an example of this language, the letter ∼n and the “s” sound at the end of words are commonly omitted and the final “r” and “l” syllables are neutralized.^64,65 These differences in language are important to recognize in cultural collaborations as differences in pronunciations, slang, and derivation of meanings can result in miscommunication. In addition, language spoken by patients and collaborators may differ and the level of understanding of each language may vary.

Diet.

Food is an important social and cultural aspect of the Caribbean.^66,67 Cleanliness and hygiene in food service is now publicly regulated. Some subcultures (eg, Rastafarian culture) have special dietary needs. For example, a way of eating called ital includes a diet of fresh, organic, and homegrown foods. Additives are avoided and meat is not eaten due to respect for animal life.⁶⁷

The size and timing of meals in the Caribbean may differ from that in the United States. Breakfast is larger than that in the United States and dinner is often smaller. In Dominica, for example, breakfast and lunch are larger meals and may traditionally include salt fish and bakes (fried dough). Lunch dishes also include seafood or one-pot meals such as callaloo soup. Many meals feature what is referred to as provisions, which are root crops such as yams and tannias (a root vegetable with pear shaped tubers and arrow-shaped leaves). Typically, fresh juices, coconut water, and fresh water are readily available. For hot drinks, coffee, cocoa tea, and local bush teas are consumed. Dinner is generally a smaller meal.^66-72

Safety.

The safety of visitors in pursuit of engagements in the Caribbean is as important as it is in any other region of the world. For the majority of islands in the Caribbean, travel is generally safe. On the US Department of State website, out of the islands included in this paper, crime is only listed as a concern in Jamaica.⁷¹ However, prior to visiting any foreign country, travelers should exercise caution and consult resources such as the US Department of State website for current travel advisory warnings and the reasons for any alerts. Additionally, they should review the Center for Disease Control (CDC) website for health-related considerations which may impact the risk of illness or disease while traveling.^70,71

Health Issues/Health Care System.

Life expectancy in the Caribbean has risen over the past 35 years, but it remains below that of North America and Western Europe. Life expectancies in Dominica, Jamaica, and St. Kitts and Nevis are 77.2 years, 73.7 years, and 75.9 years, respectively, compared to that of Puerto Rico, a territory of the United States, at 80.9 years.^8,13,14,25 Economic indicators and growth are tied to resource availability and income, which can influence health.⁷² Health disparities still exist in use of services, with larger gaps present based on income.⁷²

Political infrastructure is recognized as an important influence on the health status of people in the Carribean.⁷³ The larger the share of government expenditures directed to health care, the lower the differences are between use of health care services and income level.⁷³ Infrastructure factors that impact health include policies affecting labor and housing, and public provisions that influence personal and household welfare. Challenges have existed with linking traditional epidemiological data sources (eg, vital records, health registry) with reliable data on infrastructure. An example of this would be linking living conditions, health, and health service use to further study their effects on health in the Caribbean.^72,74 The PAHO promotes studies and projects aimed at increasing knowledge of health inequalities, identifying determinants, and developing and evaluating interventions that address disparities.⁷²

The relationship between international migration and health status in the Caribbean is evident. Migrant populations have worse health outcomes and less access to health services.⁷² “Brain drain” among health care providers resulting from an insufficient number of health care workers has further affected the delivery of modern health care in the Caribbean.⁷ In Puerto Rico, economic hardships and high costs of living have reduced health professionals’ desire to remain on the island. An article Perreria discussed an estimated a 12% increase in the average cost of living as compared to living on the US mainland. The need to import products also may have contributed to the increased costs of health care supplies, equipment, and services in Puerto Rico.⁷⁵ Currency devaluation has created favorable export conditions, which in turn has affected the local price of goods, driving out local business and increasing unemployment.⁷

Soyibo and colleagues described chronic non-communicable diseases as a major financial challenge in the Caribbean. Thus, health care has historically focused on the delivery of preventative care. Examples of common non-communicable diseases prevalent in Dominica, Jamaica, Puerto Rico, and St. Kitts and Nevis include hypertension, diabetes, asthma, and chronic kidney disease.^75-77 Challenges also exist in the management of mental health conditions in many of the islands.^78-84

Infectious diseases also have affected Caribbean countries. In 2006, the Joint United Nations Program reported that the Caribbean had the second highest prevalence of Acquired Immunodeficiency Syndrome (AIDS) in the world.⁸⁵ In addition to the presence of AIDS, other notable communicable diseases include vector borne illnesses such as Zika, Chikungunya, and Dengue. Also, risks of infection from water or food contamination such as typhoid have been observed.^70,86-88 Post hurricane conditions exacerbate the prevalence of these diseases as well as that of chronic conditions.^50,53

A majority of the health care delivery to manage communicable and noncommunicable diseases, whether in disaster situations or more stable times, are overseen in most Caribbean islands by a ministry of health (MoH).^27-31 With regards to drug regulation, the Caribbean Regulatory System began operations in 2013 as a collaborative initiative of the Caribbean Community and Common Market (CARICOM) within the Caribbean Public Health Agency. Partners such as the PAHO and the World Health Organization (WHO), as well as private organizations such as the Bill and Melinda Gates Foundation, supported the development of this drug oversight entity. Legal authority was obtained by a public health mandate, a Caribbean Pharmaceutical Policy, and support from the MoH of each member island.⁸⁹ Further, the WHO monitors and reports on the status of the practice of pharmacy in the Caribbean.⁹⁰ A description of each country and factors that have implications for the respective health systems and pharmacy services for the islands highlighted in this paper are included in Tables 2-5.^{13,21,24,25,86,91-118,120}

Pharmacy Education and Organizations.

Approximately 10 pharmacy training programs and colleges exist in the Caribbean (Table 6).^112,121-129 Program offerings vary from technician training to masters or Doctor of Pharmacy (PharmD) training programs. Of the islands highlighted, Jamaica and Puerto Rico have the largest number of programs offered. The training program in Dominica has been offered occasionally when there is sufficient student interest and enrollment. No formal program was found for training of pharmacists or pharmacy technicians in St. Kitts and Nevis.^111,121-128 Tables 2-5 provide further details and information regarding US schools and colleges of pharmacy offering advanced pharmacy practice experiences (APPEs) through collaborations with partners on the islands highlighted in this article.^{94,95,112-115,118}

After completing their formal education, opportunities for regional involvement and continuing professional development exist for pharmacists throughout the Caribbean. The Caribbean Association of Pharmacists (CAP) began in Kingston, Jamaica in 1976. The organization has worked to “advance the development and empowerment of people of the Caribbean through excellence in the provision of all aspects of pharmacy practice.” The CAP has also sought to “unleash the potential of Caribbean pharmacists to contribute to the growth and development of the region.” An annual meeting for the organization is held within the Caribbean and a journal is published.¹²⁹ Notably, the CAP has advocated for shared minimum standards (degree based) across the Caribbean for pharmacist education in order to promote or establish free movement of pharmacists within the region.¹³⁰

The islands included in this paper have participated in efforts to centralize regional resources such as partnerships for delivery of higher education (eg, the University of the West Indies). These relationships have facilitated access to educational opportunities to pursue training that increases available care and development of infrastructure. Specific to pharmacy, access to training, has implications for the preparation of a global pharmacy workforce. Beyond education, these relationships historically emphasized the development of shared policies. They have facilitated cooperation and coordination of resources through organizations such as the CARICOM and the Organization of Eastern Caribbean States (OECS), formed in 1981. The OECS offers member islands a pooled procurement process for medications that increases the islands’ purchasing power and allows for greater access to and availability of medications.¹⁰

Influence of Hierarchy.

Hierarchical considerations exist regarding how health care is provided and how information is exchanged within the Caribbean. This is important because some patients may not readily question or correct health care practitioners.¹³⁶ Historically, feelings of mistrust of formalized health care in the Caribbean existed.^130,136 The origination of these feelings of mistrust may stem from previous interactions with other health care practitioners in which patients experienced disrespect or felt stereotyped or stigmatized.¹³⁶ Patients expressed further discomfort when personal questions (eg, regarding their sexual history) were asked using slang terms. However, despite the existence of some level of mistrust, health care practitioners are often held in a position of esteem and respect because of their knowledge.¹³⁶ To establish a mutual relationship, the health care providers should introduce themselves, listen and address patients’ needs, explain why sensitive questions are asked, and consider whether recommendations fit within patients’ existing health beliefs, preferences, and practices. Taking time to determine whether the patient agrees with or intends to adhere to the care plan is also important.

Identifying care recommendations can be complex and should include a partner knowledgeable in a patient’s circumstances and access to treatments and resources. For example, medication availability can differ between public and private sectors. In some countries, medication formularies and government supply may allow for only one medication per class (eg, atenolol as a beta blocker). In the private sector, multiple medications in a class would be accessible for a fee (eg, multiple beta blockers). However, just because a medication is available, it does not mean it is accessible or affordable. Thus, care should be directed at designing interventions that promote sustainability or ability to adhere to regimens.¹³⁷ Mutual respect and reciprocal exchange of knowledge and customs and incorporation of local preferences in health care provider and academic partnerships should seek to reduce health disparity. Seeking the involvement and support of key opinion leaders such as religious or community leaders in the creation and implementation of health interventions can greatly enhance inclusion of Caribbean beliefs and cultural considerations. Their involvement cannot be emphasized enough to ensure local buy in. These partnerships enrich the care provided and help to ensure the applicability of interventions.^135,138,139

Awareness of the Family Role.

Caribbean culture is a collectivist culture rather than individualistic. It places great importance on the group, especially the family, and as such, the family and extended family play an important role in decision-making including in decisions related to health.^82-140 This can also extend to providing financial assistance, emotional support when experiencing illness, and childcare for family members with children.⁸² Puerto Ricans have often lived by the tenets of familismo (social orientation towards family values), respect (respect towards family regardless of what one believes is right or wrong), simpatia (kindness, sympathy, or empathy towards others), and personalismo (formal friendliness). Interpersonal harmony, trust, warmth, and respect of others is fostered. Individuals also respect the authority of elders.^141,142 The elders pass on knowledge to younger generations about traditional remedies and proverbs to cure sickness. Thus, involvement of families and having an understanding of how remedies are passed down by elders are important in understanding patients’ preferences for how health information should be exchanged. This is important to recognize as patients may provide different details or express different preferences to a health care provider when alone than when in the presence of family members. Privacy within a family are central to family attitudes and behaviors.^143,144 As such, personal or family matters are considered private, and the revelation of family matters or private knowledge to strangers is viewed with disapproval.^145,146 Further, Caribbean people are strongly discouraged from dwelling on family or personal problems. Instead, the culture places an emphasis on perseverance and exercising control over emotions. This may be important for a visiting health care provider to know as a patient may not share relationship dynamics that are influencing their health. Furthermore, challenges the patient is having with adhering to or accessing care may not be mentioned or may be de-emphasized. Resiliency, self-reliance, and self-silencing are extensions of these cultural values.^147,148 Self-silencing involves concern for others over oneself, thus deemphasizing personal symptoms of depression. As a result, women in particular have been known to engage in self-devaluation, which leads to symptoms of depression.^75,143 Furthermore, patients may have fears about the negative stigma associated with seeking mental health services and receiving mental health treatment including medication. Patients may have concerns that their confidentiality may not be maintained.¹⁴⁶ When caring for women or men, these influences are important to appreciate as they can greatly impact disclosure of a patient’s medical history, particularly when mental health conditions are discussed. Further, this can influence a patient’s preferences about where help is sought and how care for these conditions is provided. The mental health services available to a patient may be limited, particularly those services that are preventative in nature. In many Caribbean health systems, the public hospital is the primary available location to seek mental health services. Additionally, stigma exists related to use of these mental health services. This is mentioned in the context of family dynamics as the family may be a support system in health or may hinder what information is provided and to whom. Many individuals and families have historically pursued help from religious advisors rather than seeking treatment in a health care facility or from a provider.^145,146

Influence of Spirituality and Traditional Healing on Health.

Religion and superstition are intertwined within many aspects of Caribbean life.^149,150 Strong beliefs related to religious coping such as prayer during hardships and seeking God’s guidance and strength are held by many and are especially common among women and married individuals who actively participate in religion.^151,152 Beliefs in evil spirits and that an “evil eye” can trigger the development of illness still persist. Solutions pursued by patients may include finding favor with spirits. Holistically, a person and his or her surroundings are viewed as interdependent. Therefore, natural remedies and environmental changes are believed to impact health as influenced by spirits and/or God.¹⁵³ In Jamaica, obeah is a set of spiritual beliefs and practices that originated in Western Africa and varies by locations. Obeah is not an organized religion. Obeah involves manipulation of supernatural forces, usually with material objects, recitation of spells, divination (eg, finding lost goods, finding the cause of illness), healing and bringing good fortune, and protection from harm. Both spiritual and religious approaches may be seen by Caribbean people as important to being healthy or achieving wellness.¹⁵⁴ An example may be demi savants, or persons, who combine herbal lore, massage, and other techniques, who may be consulted to provide natural healing. The remedies to illness or visions of events to come are believed to be presented in dreams to these traditional healers.^155,156

Many Caribbean people use herbal therapies as a resource in the pursuit of health. Some believe that herbs rubbed or ingested into the body have healing properties.^155,156 African knowledge related to herbs, plants, and foods has been passed down and is used in medicinal practices. This practice, sometimes referred to as “herbal medicine” or “bush medicine,” links plants to healing.^157,158 Common preparations include teas and essential oils. Some herbs are consumed directly.¹⁵⁷ Other traditional remedies such as bathing in hot sulfur springs are considered important to achieve good health. In addition, wellness pursued through physical activity and relaxation is often practiced.^159,160

Difference in Language and Definitions of Health.

When delivering care, the health care provider should consider the individual and the unique setting and situation. For example, begin by asking a patient for his or her personal definition of health and wellness. Care should be taken to ask this question as the initial step prior to setting goals for patient interventions.^161,162 Although this paper has highlighted shared similarities, differences do exist. Stereotypes or stigmatization may lead to feelings of disrespect or distrust of a health care provider by a patient. For the pharmacist and patient relationship, in the Caribbean, it is critical for the patient to trust that the pharmacist respects or acknowledges his or her health beliefs.¹³⁶ Although English is the primary language in many Caribbean islands, certain statements have other meanings and different phrasing may be used to describe health and health issues. Making an effort to learn some common Creole phrases and paying attention to slight variances in pronunciation are also important.

Factors Influencing Availability of Health Care Resources.

Many Caribbean islands encounter different challenges that may affect the delivery, access, and costs of health care. Tables 2-5 provide specifics about Dominica, Jamaica, Puerto Rico, and St. Kitts and Nevis. Important factors to consider in the delivery of care include clinic or health system structure, the availability of public or privatized insurers, the extent of coverage of care/medications, availability of a trained health care workforce, and the capacity to address population-based needs.^{13,23,24,74,77,85-87,90-119}

Establishing Connections.

In addition to valuing spirituality, Caribbean colleagues also value taking the time to establish connections or relationships. For the provider to be overly busy, multitasking, or to seem hurried or detached, as may be common in Western culture, may come across in Caribbean countries as not being invested in the patient.¹⁴¹ When meeting with colleagues or patients, visitors should be friendly but formal at the same time at the start of a relationship. Begin the day before transitioning into business with greetings like, “Good morning!” or “Good day!” In conversation, taking the time to be polite and present shows respect. However, until relationships are solidified, avoid overly personal topics or questions, as this may be considered intrusive. Address visiting individuals by their formal titles until the friendship has matured or a sense of partnership is established, at which point you may be able to address the person less formally. Offering a handshake is considered a display of warmth and respect and is a good gesture when greeting Caribbean colleagues.^163-165

Partnership Formations.

Hierarchy and formality considerations should be respected in the formation of relationships. This is especially important when interacting with government officials or health colleagues in the formation of more formal professional relationships as well. Visitors should dress professionally and be well groomed.

Avoidance of Assumptions and Sharing of Preferences.

Similar principles apply to the avoidance of assumptions when hosting students or faculty members from the Caribbean. Visiting individuals may not wish to make personal requests, but will emphasize the needs of the group instead.^82,138,139 However, the host should still attempt to ascertain individual preferences from guests to demonstrate respect. Further, related to self-silencing as described earlier in the paper, individuals may not share or express frustrations as it may be considered inappropriate to do so.^142-145 Concerning language, although many people from the Caribbean speak English, their word choices may be influenced by dialect or their language proficiency. Hosts should have patience when trying to understand their visitors. Accepting visitors’ alternative pronunciations or word choices as influenced by dialects is respectful.^1,54-66

Dietary Considerations.

Hosts should inquire about their guests’ specific dietary needs as the Caribbean diet differs significantly from the US diet and some restrictions may exist.^65,68 Avoiding foods with additives or preservatives, offering fresh produce or fruits, and even avoiding meats may be necessary in certain cases.^65,68

Concept of Time.

Some business guides exist although these guides contain few references or basis to support their recommendations related to concepts of time.^166,168 In general, the hosts should schedule appointments in advance and confirm their guests’ availability as the date approaches. When confirming or exchanging potential schedules or clarifying the needs of a group prior to their visit via email, the host should use semiformal language, addressing the person by titles such as “Honorable” if British or “Doctor.”