An Introduction to Cultural Sensitivity and Global Pharmacy Engagement

Culture

Culture has been defined in many different ways, but in general it is identified as “a dynamic system of rules, explicit and implicit, established by groups in order to ensure their survival, involving attitudes, values, beliefs, norms, and behaviors, shared by a group but harbored differently by each specific unit within the group, communicated across generations, relatively stable but with the potential to change across time.”³⁰ This definition encompasses key aspects that are critical to successfully engage with any group of people. Even when culture is shared by a group and relatively stable, it is important to recognize that there are variations over time and certainly at the individual level. Thus, it should not be assumed that everyone within a culture will have the same attitudes, beliefs, norms, and behaviors. However, at the same time, knowledge of key aspects of shared culture is important because it affects how people within a culture think and act. Developing respect and understanding of the components of a culture among different groups, as in the case of global engagements, is critical to establishing sustainable relationships.

Cultural Sensitivity

Cultural awareness or sensitivity is the first step towards cultural competency. It is the recognition of and respect for the different cultures that exist within a society and across the globe. Further, it recognizes that differences between cultures do exist and are based on many factors including religion, race, ethnicity, gender, education, nationality, politics, and geographic origin.³¹ Knowledge of and respect for these differences is key in all interactions and in the development of cultural skills. This foundation will challenge readers to address their own biases towards others. As a result, the sense of superiority over the others and the attitude that “my way is the only way” disappears. Consequently, cultural humility becomes part of interacting with people in an egoless way. It requires acceptance of the limitations of one’s knowledge and expertise, acknowledgment that everyone can make mistakes and has flaws, and recognition that much is gained by respecting each other as equals.^32,33 As a result, people who exhibit cultural awareness towards others will develop a positive attitude toward people who are different, and as a result, enjoy more effective and enriching communication and experiences. In fact, literature has emphasized the importance of cultural sensitivity to enable better communication and team building.³⁴ Cultural sensitivity also is identified as one of the core values of an effective health care team.³⁵ While cultural sensitivity is important in all encounters within a society, an awareness of the different beliefs, values, and customs of others becomes critical when dealing with cultures across the globe. This also becomes paramount for health care professional students and faculty members engaged in educational activities abroad and in the delivery of care to diverse patient populations.

Global Engagement

While cultural sensitivity is important at the individual level, general logistical aspects of any global engagement also are important to demonstrate cultural sensitivity. These include a structured program beginning with greeting and welcoming guests at the airport; providing an orientation session; coordinating local transportation and housing; training personnel on how to behave appropriately around guests; addressing health and safety issues and what to do in an emergency; attending to guests’ spiritual needs and food preferences; and providing meaningful cultural and social activities.^4,5,9 These structured activities demonstrate a genuine concern for developing a well-planned and purposeful relationship with the guests, and shows hospitality and an awareness of many of the issues that may concern the guests to ensure they have a positive experience. Logistics related to the educational experience also should be addressed including scheduling, types and scope of experiences, communication, site details, and preceptor training and qualifications.^5,8 Cultural competency has been discussed in much detail within the context of general global engagement;^6-38 however, training students in the host country in cultural competency is critical, as well. Also, of equal importance is that consideration of cultural humility and assessment of cultural competency should include an awareness of the limitations to current instruments for measuring cultural competency such as differing definitions of culture.³⁹

Another important aspect in fostering cultural sensitivity is to consider the challenges experienced by students and faculty members in global engagement activities. The literature has identified communication, cultural differences, and discrimination as challenges experienced by international students in general and specifically by those studying in the United States.^40-43 Thus, collaborative experiences should address such challenges to ensure a successful social and academic experience during the time the students stay in the host country. Support from peers, instructors, and the university are key to helping the students adjust during their stay. Language can be a major barrier and can result in excluding students from participation, loss of confidence, feelings of inequality, worsening mental health, and knowledge translation barriers.^44-46 Because English is the dominant language in many of the locations where there are global engagement opportunities, having limited English proficiency is a disadvantage for an international student or educator. Efforts should be made by both the sending institution and host partners to help in this regard.⁴⁷ However, attempts by the visiting party to learn aspects of the local language are also important. Some institutions, for example, offer a Spanish class for students on exchange programs in Spanish-speaking countries. In addition, host students and faculty members need to be cognizant of communication barriers and help support and encourage visiting guests to overcome language barriers, so they will feel comfortable to speak and share their opinions and knowledge. Speaking at a slower pace, providing thorough and clear explanations, and using different tools to communicate, including written and visual materials, may help in this regard. Also, the emphasis in communication should be placed on understanding and relaying of ideas rather than on correct grammar and accent. In addition, having limited language proficiency may also result in a student or faculty member having a tendency to copy other people’s work. In the United States, students are told to read published material and summarize it in their own words to include in a paper; however, in some cultures students are taught to respect and not question authorities and not to change an author’s words.^47,48 Thus, international students studying in the United States are often more likely to plagiarize.^47,48 To prevent this problem, an orientation to plagiarism and education about scientific writing, citation, and referencing should be presented. Providing visiting students with access to a university writing center would also be helpful if they will be required to submit written assignments or reports.

Stereotype, Discrimination

A stereotype is defined as “a fixed, over-generalized belief about a particular group or class of people.”⁴⁹ The assumption becomes that the stereotype is true for individuals within that group. Stereotypes can be explicit because the individual is willing to verbalize and acknowledge them, or implicit, existing in the individual unconsciousness. Regardless, the concern is when people start having or exhibiting negative feelings and emotions based on these stereotypes. This may result in prejudicial misconceptions about the group and can lead to discrimination. The resulting danger occurs when people with prejudicial feelings become unwilling to rethink their attitudes and behaviors. As a result, they can easily justify these prejudicial attitudes and behaviors and do not even consider their consequences.⁵⁰ This may result in disastrous relationships, conflicts, and harm to targeted groups. Thus, addressing stereotypes on a collective or individual level with the people of the host or sending country is key to building fruitful and healthy relationships.

Acculturation

Cultural differences often play a major part in alienating the visiting guest, and purposeful efforts on the part of the hosts are needed to establish a feeling of social belonging. This is important because acculturation stress, culture shock, lack of self-esteem, lack of social support, and discrimination are factors identified in the literature that may deter from a positive cultural and educational experience.^51-53 When individuals leave their home to live in another culture, they encounter many obstacles. Traditionally, the term “culture shock” has been applied to this experience. However, psychologists prefer acculturative stress, providing for a broader definition that includes both positive and negative impacts.⁵¹ The earliest model of culture shock, developed by Oberg⁵² and Lysgaard,⁵³ described a U-shaped model of cultural adjustment developing over four phases. Initially, the honeymoon phase occurs where a person is fascinated by the new culture and excitement is the dominant feeling. A crisis or hostile stage occurs next in which the person becomes irritated by the differences between the new culture and their own, often reacting out of proportion to the incident that brings on these feelings. Eventually, as an individual learns more and becomes increasingly comfortable in the new culture, he or she enters the recovery or adjustment phase. The final phase of cultural adjustment is adaptation of the person to the new culture and acceptance of the place as their alternate home.^52,53 However, evidence to support this model has been contradictory.⁵⁴ Regardless of whether cultural adjustment occurs in these stages, the person can develop an uprooting disorder, leading to physical and psychological symptoms.⁵⁵

As expected, a person’s response to a change in culture is highly dependent on their personality, with six traits in particular showing a correlation to cultural adaptation: openness, conscientiousness, extraversion, agreeableness, neuroticism, and honesty-humility.⁵⁴ In addition, the similarity of the home and host cultures also plays a role in promoting a smooth transition. Thus, understanding the diverse cultural skills and identities of the participating students and faculty members is important. Measures should be put in place to increase acculturation of the students, minimize acculturative stress, and socialize the students to help them become more integrated into the cultural and educational aspects of their experience. While American culture has spread to many parts of the world, this is not true everywhere. In countries like China, where there are currently increased opportunities for engagement with the United States, more cultural effort might be needed when hosting Chinese students because of the heightened language barriers, different cultural values, unfamiliarity with American culture, and overall diverse worldviews based on the countries’ contrasting political systems.^56-58 This can also be a factor for US students and faculty members travelling overseas and encountering cultures they are not familiar with. In both situations, efforts should be made to adapt to the local culture instead of expecting hosts to adapt to the culture of the visiting students or faculty members.

Differences in the education culture between countries also should be addressed to ensure the guest feels a sense of academic belonging. Learning styles can play a role in this, depending on the culture. In a collectivist culture, the instructor imparts information in a concise and direct manner. Students are expected to only listen during class, and memorization is emphasized.⁵⁹ Thus, a teacher-centered approach dominates. In an individualistic culture, such as the American culture, critical thinking, active learning, and problem solving are stressed. Thus, a student-centered approach is expected. This variation has implications in verbal and written interactions including the important issue of questioning authority or inadvertently committing plagiarism as mentioned above.^47,48 For example, in the United States, developing critical thinking, encouraging questions by students, engaging in experiential learning, and challenging established knowledge and concepts are emphasized.⁵⁹ Visiting students who were not trained in this approach to education and are accustomed to being passive learners who simply reproduce information may struggle with giving their opinion and criticizing current knowledge and practices.^59-61 In fact, in some cases, when attempting to question teachers or preceptors, they may be perceived as rude or not being tactful. Therefore, creating a welcoming educational experience when visiting students are oriented to the expectations of the educational process is important. For a student-centered interaction, this should include informal interactions where teachers take time to talk to the student before and after the educational experience or to participate in social activities with them so that the students become more comfortable and free to ask questions, share opinions, demonstrate initiative, and communicate in a culturally sensitive way.^56-61 Instructor role modeling by stating, for example, “I do not know” when the student asks a question about something they are not familiar with, can demonstrate to the students that it is acceptable that one does not know everything, and that it is alright if a student attempts a question and ends up giving the wrong answer. This will facilitate better engagement with students, giving them a sense of belonging, and can prevent misconceptions on the part of the teacher that the international student lacks motivation to learn or does not know the subject matter. It is also important to consider the learning style predominant in the country of the student or trainee. Resources for assistance in person or electronically from their teachers and preceptors, or help from academic and counseling services, also should be shared. As with any attempt to address cultural differences, it is important not to generalize the discussion above to all students from any culture and instead to look at commonalities to make the experience a more positive one for all. In addition, emphasizing the potential benefits for both cultures from the engagement, including open-mindedness, self-awareness, and cultural sensitivity, is critical. Further, in cultures where faculty-centered learning exists, and authority is emphasized, the hosts should orient visiting students to this. Visiting students should be trained to be tactful when communicating with faculty members, preceptors, and health care providers so as not to disturb the established hierarchy in a negative way, and to act professionally when providing opinions or questioning authority.^43,60,61

Both cultural and academic differences may potentially lead to hosts forming negative stereotypes about the students prior to, during, or after the experience. This may be because they have general stereotypes or bias about a certain group of students, students’ ethnic or religious background, or their respective country of origin.⁵⁰ There are strategies to address these issues, and partners on both sides of the engagement should be challenged to address their own biases and stereotypes.⁶² Holding a cultural sensitivity workshop that addresses general aspects and specifics related to the cultures of the visiting students or educators is crucial before the start of any engagement program. Being aware of existing stereotypes based on historical and political constructs is important, especially in engagements between “developed” and “developing” countries or individuals from home and host countries with a history of colonization. As shared above, many negative stereotypes do exist based on these types of historical and political factors, where, for example, one group had a history of being demonized and dehumanized by the other group and holds a belief that the other culture is superior. As shared above, this could be a factor when students and faculty members from Western countries engage with countries in Africa and the Arab world. This inferiority complex may make individuals from those regions feel that they do not have much to offer in such a relationship, when in fact they can enrich the relationship in many ways. On the other hand, those from Western countries may, overtly or covertly, abuse such relationships and play on such a belief to gain financial privileges and advantages, pretend to have expertise in areas in which they do not (something they may not be tempted to do in their home country), or feel that there is not much they can gain from the experience. As such, students and faculty members from Western countries should seek opportunities to engage hosts or guests in a positive way and keep an open mind regarding their experiences.

Ethics and Trust

Intertwined with the concept of cultural sensitivity and the success of global engagement is having a commitment to upholding key ethical principles, including autonomy, trust, veracity, beneficence, nonmaleficence, self-regulation, solidarity, sustainability, and capacity building. Building a trusting relationship based on these principles is essential, especially in global engagements with countries and regions of the world with a history of mistrust of the West because of colonization of their countries and the resulting deplenishment of resources and marginalized populations.⁶³ For example, while the principle of a nation having autonomy is very much emphasized in Western countries, because of a history of colonization and exploitation between the sending and host countries, the concept and other principles may be ignored when dealing with professionals or patients from those countries. An awareness of this anachronism is critical because Western guests may be seen as authority figures by local practitioners and patients. As a result, the hosts may not feel free to share their own opinions or preferences. Also, while the principles of autonomy, telling the truth, beneficence, and nonmaleficence, as defined by Beauchamp and Childress,⁶⁴ are critical, other ethical frameworks should be adopted because cultural differences do exist in how these principles are addressed or emphasized. Childress and colleagues proposed a framework for conducting global research in marginalized communities based on five principles: effectiveness, proportionality, necessity, least infringement, and public justification.⁶⁴ Although proposed for a research framework, these principles also apply to engagement in education to ensure that outreach activities are: purposeful; meet the educational and training needs of the partner; do not infringe in a negative way on local, educational, economical, and workforce factors; and meet the long-term health needs of the local communities. Exercising other ethical principles such as self-regulation would ensure that all partners were acting in the best interest of the relationship and meeting the agreed upon goals. This can only be achieved at the individual level through cultural humility, self-education, self-awareness, self-monitoring, self-evaluation, self-reflection, life-long learning, and self-reformation to maintain competence.^65-67 Likewise, to maintain solidarity, we must all recognize that we are interdependent and have complementary needs based on our individual strengths and weaknesses. Moreover, sustainability and capacity building should be at the heart of all engagements to ensure that the work that is started can continue by providing the education and training needed and creating a workforce that will sustain efforts for both partners, especially partners with limited resources. This too requires advocacy at the level of regulatory bodies and ministries, innovative mechanisms to address limited resources, outreach to the public, and addressing power dynamics and corruption.^68-71 All of the aforementioned principles and actions are key to building a trusting relationship and exhibiting cultural sensitivity in all interactions.

An overarching must for all the above guidelines, and especially as members of a profession, is the need to remember that we are bound by a code of conduct. In the United States, 2019 is the 25^th anniversary of the most recent revision to the Code of Ethics for Pharmacists.⁷² This code addresses many aspects regarding the conduct of a pharmacist and refers to pharmacists’ respecting the dignity of all persons. Students and practitioners should keep their country’s code of ethics in mind as they participate in global engagement to ensure that they do not conduct themselves in ways contrary to what is expected of them by their own country. In addition, pharmacists should familiarize themselves with any professional, religious, social, and/or political factors in the host country that may impact their ability to maintain their country’s code of conduct for pharmacists and those for other health care professionals.

Cultural Competency in Pharmacy Practice

Cultural competency is important when addressing the healthcare needs of a diverse population. The 2013 Center for the Advancement of Pharmacy Education (CAPE) educational outcomes,⁷³ ACPE standards,⁷⁴ and additional guidelines published by the American Association of Colleges of Pharmacy (AACP)⁷⁵ and other pharmacy organizations have emphasized the need to graduate culturally competent practitioners. The American College of Clinical Pharmacy (ACCP) has published a series of four white papers on cultural competency in health care and its implications for pharmacy.^76-79 The first paper is an overview of key concepts in multicultural health care that stressed the importance of cultural competency in reducing health care disparities; specifically, the importance of congruent beliefs and expectations between the patient and the pharmacist to avoid drug misadventures.⁷⁶ The second paper focuses on pharmacy systems and practice, and identifies seven components to improve culturally competent patient care: (1) analyzing self and system attitudes toward various cultures, (2) improving the knowledge of health care providers about the cultures of the people they serve, (3) engaging in effective cross-cultural communication, (4) accommodating cultural preferences in the provision of care, (5) fostering communication ties in the community, (6) adhering to regulatory requirements to enhance care for patients from various cultures, and (7) conducting quality assurance assessments.⁷⁷ The third and fourth AACP papers focus on pharmacy education and the importance of inclusion and diversity among students, faculty, staff, and administrators, as well as across all aspects of academic policies and procedures.^78,79 Furthermore, the papers provide guidance on teaching cultural sensitivity in pharmacy curricula to produce culturally competent pharmacists. These papers and others address cultural competency for students and practitioners within the United States.^73-79 However, the key concepts can be applied to students and faculty involved in international engagements as well as in training activities in the United States.

The cultural, educational, and ethical dilemmas that arise in global outreach activities create a necessity to foster sensitivity and respect for cultural, educational, religious, historical, political, regulatory, and practice issues in health care professional students and faculty members to optimize opportunities for positive engagement. In addition, an awareness of the health care system, pharmacy education and practice, disease burden, health, and healing practices of the people in the target areas is essential. This will facilitate in developing citizens who are aware of global issues, have a sense of interconnectedness across borders, and have an understanding of their role in building bridges among diverse cultures. Thus, this special issue will serve as a resource on culturally sensitive engagement for schools and colleges of pharmacy and for others who are currently involved in or considering becoming involved in outreach opportunities in many regions of the world including within the United States. Memorandums of understandings should address all of the above issues from the perspective of both parties to ensure a mutually respectful accountability on both sides.

Individual Papers

In this special issue, the title of each paper is similar, emphasizing the goal of addressing cultural sensitivity in global pharmacy engagement with the specific region. The abstract of each paper will emphasize the unique aspects of the region that are not addressed in the general abstract provided in this introduction. Authors for each paper set the stage for any unique aspects of how their paper is organized and the rationale for dividing their region into subregions. Although it was impractical for this theme issue to address all the countries in the regions of interest, attempts were made to address major and representative countries within each region including those with published literature on pharmacy education and practice that documented their engagement activities with the United States. When possible, references were given to access information related to other countries not discussed in this theme issue and included the country’s website and US Department of State links related to the region or a country.

The body of each paper also addresses general information such as demographics, pertinent history, religions, languages, spoken English, transportation, health care system, health and healing practices of the community, disease burden, status of pharmacy education and practice including clinical pharmacy, professional organizations, stereotypes and general guidelines for culturally sensitive practice. Where there is an indigenous culture or traditional practices, the influence these have on health and healing practices were addressed.

When addressing stereotypes, where applicable, those stereotypes related to the health care system were discussed and implications for interactions and what can be learned from the other culture are emphasized. Recommendations for culturally sensitive engagement were derived to counter identified stereotypes and any specific issues related to ethnicity, religion, country of origin, cultural norms, age and gender, family role, communication, food etiquette, concept of time, hierarchy, verbal and nonverbal communications, and other aspects that are critical for positive engagement including those related to educational differences. However, general recommendations, which are common to all regions including those for purposeful engagement for the benefit of both partners, are summarized in Table 3. In addition to the above, a section was added on recommendations for culturally sensitive engagement when hosting students and/or faculty members from respective regions in the United States.

DISCLAIMER

The purpose of included papers is to facilitate culturally sensitive communication by promoting mutual understanding of cultures in the United States and other regions of the world. While the content is based on resources from the United States, in some cases, the current political position of the United States might differ from what the discussed country or regions identify with and publicize. However, it is not within the scope of this theme issue to discuss any political controversies. The aspects that differ between the United States and the covered countries or regions were chosen and included by primarily targeting the US audience based on US resources. The included papers do not aim to discuss or present any of the authors’ political opinions or beliefs. Also, the papers should not be construed as an endorsement of any political opinion or position. The authors also do not claim to have covered all of the cultural sensitivity issues pertaining to each of the geographical regions discussed. However, with the support of local authors from the different regions, attempts were made to address, in an accurate way, some of the key issues. All the papers are meant to encourage those who are engaged in global outreach to put forth their utmost effort to educate themselves and to consult with local experts to ensure a culturally sensitive approach to their global outreach efforts.