A Call to Action for a Programmatic Approach to Addressing Health Disparities and Cultural Competency in Pharmacy Education

DISCUSSION

Over the last decade, the profession of pharmacy has increasingly called for enhanced training of graduates in HDCC concepts. Most professional organizations have developed white papers, published commentaries and viewpoints, and issued statements on the importance of these topics.^2,3 For example, the Accreditation Council for Pharmacy Education (ACPE) Standards 2016 and AACP Center for the Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes included cultural sensitivity as a component of a team-ready, practice-ready pharmacist.^2,3 Cultural competency is defined as the attitudes, knowledge, skills, behaviors, and values that an individual can develop over time and use to work in a cross-cultural environment.⁶ The ACPE Standards also require education regarding the social determinants of health and include many elements of HDCC concepts as part of the Pharmacists’ Patient Care Process.^4,7 While these concepts can be delivered in the curriculum, co-curriculum, and experiential learning, lack of detailed guidance may not adequately prepare students for required exposure to diverse patient populations as part of advanced pharmacy practice experiences (APPEs).

What exactly should be included in curricula related to HDCC and how can it be integrated? Institutions face challenges in finding room in the curriculum to embed encounters that could develop affective domain behavioral characteristics and move the students up the hierarchy of Krathwohl’s Taxonomy of Learning, such as CC topics that require, immersion experiences, guided discussions, and reflections.⁹ Characteristics such as self-awareness, accountability, acting based on moral and ethical principles, and respect for diversity are essential for becoming a conscientious steward of the profession, for valuing the inalienable worth of each individual, and for exhibiting a commitment to work for social justice. Previous publications have highlighted concern about the depth and breadth of what is being taught in the PharmD curriculum regarding HDCC concepts.⁹ As of 2007, 51% of responding pharmacy institutions had made curricular changes to introduce CC, and 49% planned to implement new topics or new courses on the topic.⁹ Two American College of Clinical Pharmacy (ACCP) white papers that assessed the integration of instructional strategies and resources were published in 2013 and included a preliminary list of learning objectives and methods for assessing cultural competency/sensitivity curricula.^10,11 Additionally, these white papers advocated for curricula to include culture concepts; patient, practitioner, and health system perspectives on health disparities; and patient-centered culturally sensitive health care, all of which could have aided in integration efforts.

Chen and colleagues recently conducted a recent survey to determine how US and Canadian pharmacy schools integrated HDCC content in their curriculum revealed that it was primarily taught in silos and not thoughtfully implemented across the entire program.¹² Additionally, the study found that HDCC was commonly taught at the introductory or reinforcement level by a small group of core faculty in varying courses across years in the didactic PharmD curriculum. Data were collected regarding which patient populations were covered in the curriculum. Interestingly, less than 80% of institutions reported covering racial/ethnic groups, poverty/low-income groups, and issues of sexuality, gender identity, gender expression in their curriculum.¹² The investigators concluded that opportunities remain for improving the extent to which HDCC is covered and integrated in the co-curriculum and experiential training. Thus, despite a myriad of publications on these concepts and their inclusion in key accreditation standards, gaps remain in pharmacy institutions’ ability to integrate this essential content throughout curricula. Prior pharmacy literature has certainly underscored the importance of integrating HDCC content within curricula, and providing frameworks for integration, assessment tools, experiential training, addressing the needs of certain diverse populations, and recommendations for increasing diversity within the profession.¹³ ⇓⇓⇓^-17 However, there remains limited research on implementing a holistic, programmatic approach to HDCC education. A literature search was previously conducted to explore implementation of HDCC in other disciplines, but few successes were described in the literature. Thus, embedding HDCC throughout the PharmD curriculum is essential to provide a comprehensive set of concepts and skills and to challenge students to exhibit the specific attitudes and characteristics needed to deliver culturally sensitive patient care. Also, the Academy needs to expand their efforts to make integration of HDCC comprehensive, particularly since components such as the co-curriculum and experiential education have enhanced focus in Standards 2016.^3,12

By incorporating a holistic, programmatic approach, HDCC content is not placed within single activities or courses. Instead, it is introduced, reinforced, and integrated throughout the curriculum in the didactic, co-curricular, interprofessional, and experiential areas by faculty, staff, and preceptors who have embraced the importance of integrating HDCC content and undergone training to improve their own competency. Further, all disciplines of pharmacy (pharmacy practice, social and administrative sciences, and pharmaceutical and biological sciences) should contribute to the integration of content in the curriculum. This method will require additional resources and extensive training of faculty, which is often a barrier to such initiatives. However, if integration is expected of students, each faculty member should also take accountability for his/her own development in this area and to find ways to integrate such knowledge into their courses.¹⁸ This will honor guideline 10.2 of the standards, which asks for faculty members to be aware of each other’s courses, including the content, depth, methodologies used, and relationship to adopted curricular competencies and outcomes.³ Given the focus on having the didactic, experiential, and co-curriculum components reinforce one another to build practice-ready, team-ready pharmacists, and the inclusion of HDCC-related standards, a programmatic approach appears to be the ideal approach to meet the standards and begin to train healthcare professionals that can promote health equity.

There is currently no consensus on how HDCC education should be integrated in health professions curricula, and, as a result, there is significant inconsistency in implementation. As such, this paper serves as a call to action for health professions to integrate HDCC education holistically in their curricula. Although this approach may be more challenging to implement, it is more likely than traditional siloed approaches to have impactful results. This requires a collegial and collaborative effort among faculty and a culture of EDI at the institution level. As the pharmacy profession continues to advance in HDCC education, further data will be needed to validate the success of this approach as we seek to improve patient health outcomes and reduce inequities. To meet this challenge, the AACP HDCC-Special Interest Group determined, as part of their strategic plan, that it must address this gap by calling our Academy to action. The Academy is encouraged to move past siloed HDCC curricula towards a programmatic approach and to create guiding principles and examples for a holistic, programmatic approach to HDCC education in which concepts and skills are introduced and reinforced, and students are constantly challenged to demonstrate the knowledge, skills, and behavioral characteristics of a pharmacy professional.⁸ This would require faculty to be sensitized to and aware of the role their colleagues are playing in meeting educational outcomes for the program and to communicate and collaborate with them with collegiality and humility to meet the educational outcomes for students related to HDCC and other key aspects of the curriculum.¹⁸ Previous publications and proposed frameworks should be updated and moved to a programmatic level. Institutions that have a holistic, programmatic approach to integration, particularly those that have mastery-level integration and inclusion in co-curricular, interprofessional, and experiential components, should engage in scholarship to provide the Academy with examples of approaches, especially those that include assessment of students’ skills, knowledge and attitudes.