A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: Perspectives of healthcare professionals

Abstract Introduction Healthcare inequalities and ethnicity are closely related. Evidence has demonstrated that patients from ethnic minority groups are more likely to report a long‐term illness than their white counterparts; yet, in some cases, minority groups have reported poorer adherence to prescribed medicines and may be less likely to access medicine services. Knowledge of the barriers and facilitators that impact ethnic minority access to medicine services is required to ensure that services are fit for purpose to meet and support the needs of all. Methods Semistructured interviews with healthcare professionals were conducted between October and December 2020, using telephone and video call‐based software. Perspectives on barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee. Results Eighteen healthcare professionals were interviewed across primary, secondary and tertiary care settings; their roles spanned medicine, pharmacy and dentistry. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medicine services for ethnic minority patients. These centred around patient expectations of health services; appreciating cultural stigma and acceptance of certain health conditions; and individually addressing communication and language needs. Conclusion This study provides much‐needed evidence relating to the barriers and facilitators impacting minority ethnic communities when seeking medicine support. The results of this study have important implications for the delivery of person‐centred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services. Patient or Public Contribution The Patient and Public Involvement and Engagement (PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.

The results of this study have important implications for the delivery of personcentred care. Involving patients and practitioners in coproduction approaches could enable the design and delivery of culturally sensitive and accessible medicine services.

Patient or Public Contribution: The Patient and Public Involvement and Engagement
(PPIE) group at Newcastle University had extensive input in the design and concept of this study before the research was undertaken. Throughout the work, a patient champion (Harpreet Guraya) had input in the project by ensuring that the study was conducted, and the findings were reported, with cultural sensitivity.  [4][5][6] Healthcare inequalities and ethnicity are closely related, and yet, patients from ethnic minority groups have not been involved in health and social care research to the same extent as those from predominantly white groups. 7 Evidence has shown that individuals from minority ethnic backgrounds report poorer general health when compared to their white counterparts. 8 In addition, evidence has also demonstrated that patients from ethnic minority groups are more likely to report a long-term illness than their white counterparts. 9 Yet, these patients are reportedly less likely to engage in regular medicine reviews and have reported poorer adherence to prescribed medications to manage long-term illness. 10,11 Regular reviews of patient medications, which include highquality information at the point of prescribing and considerations around deprescribing inappropriate medicines, are essential to support medicine effectiveness and prescribing safety. [12][13][14] Medicine review services delivered in primary care settings (like New Medicine Services conducted by community pharmacists or structured medicine reviews performed by general practice pharmacists) are one method that exists within the United Kingdom's National Health Service (NHS). [15][16][17] The focus of such services centres on improving the clinical effectiveness of medicines being taken, by addressing issues relating to medicine optimization and medicine adherence. [18][19][20] The economic effectiveness of these interventions has also recently been explored, where Elliott et al. 21 suggested that New Medicine Services would deliver better patient outcomes than normal practice at reduced costs to the health service in the long term. It is important to consider the accessibility of these services for patients to access and use these effectively, in particular, those patients from ethnic minority groups. 22 Variation in healthcare access can be associated with social and cultural determinants creating inequality for ethnic minority patient groups. 23 In previous medical literature across the globe, reduced access to healthcare for ethnic minority populations has been well reported, 8,[24][25][26] and groups have been previously referred to as medically underserved across a range of health conditions. [27][28][29] In recent studies, patients from minority ethnic groups were reported less likely to access and attend medicine-based services. 30 33 as well as the inequitable access to healthcare services, including pharmacies. 29 Gaining knowledge of the barriers and facilitators that impact ethnic minority groups accessing medicine services is required to ensure that services are fit for purpose to meet and support the medicine-centred needs of all patient populations.
In the United Kingdom, as demonstrated in other countries, the growth of various ethnic communities and linguistic groups, each with their own cultural traits and health profiles, presents a complex challenge to healthcare practitioners and policy makers in terms of achieving equitable access to healthcare. To shed light on the inequalities that impact the accessibility of medicine services, a greater understanding is required about the perceptions of healthcare professionals involved in the delivery of the services. By sharing the views of this cohort of healthcare professionals, this study aims to go beyond the existing patient-centred research to better learn about ways to improve access for minority groups themselves. Limited studies are available that apply this lens, with even fewer focusing on the challenges of medicine-specific contexts. 10,25,34 This study investigates the details surrounding the barriers and facilitators to access for these patient groups and seeks to build on existing evidence to ask the following question: 'What do healthcare professionals believe are the barriers and facilitators for patients of minority ethnic groups when accessing medicines services?' ROBINSON ET AL. | 629 2 | MATERIALS AND METHODS

| Recruitment and sampling
The consolidated criteria for reporting qualitative research (COREQ) checklist were followed for this study, according to EQUATOR guidelines (see Supporting Information File, Item 1). 35 Immediately before study commencement, COVID-19 restrictions were enforced across the United Kingdom. This meant that the planned face-to-face recruitment and data collection could no longer be undertaken in person. Instead, an amendment to University Ethics meant that participant recruitment could be conducted using remote methods.
Purposive sampling was used to recruit participants from a range of healthcare professional groups, who were of mixed in terms of age ranges, ethnic backgrounds, clinical expertise and years of experience. Publicly available data were used to access email addresses, and all participants were invited to participate via an email invitation (which included a study information sheet and consent form). Participants who expressed an interest and provided their informed written consent were enrolled into the study. No prior relationship was established between the researcher and participants before study commencement or recruitment. Participants were also given the opportunity to ask questions before signing the consent form and were informed that they were free to withdraw from the study at any time. Inclusion criteria were as follows: participants working in a UK-based healthcare professional role and those who perform medicine review services as part of their professional role.

| Semistructured interviews
In depth, semistructured interviews were conducted by one researcher (M. E., a female undergraduate researcher with experience of qualitative research) between October and December 2020. Interviews were conducted with participants over the telephone or by using video call-based software, such as Zoom ® and Microsoft Teams ® ; all participants were offered the choice of which platform they prefer. The semistructured interview topic guide was developed based on two pilot interviews and covered key issues identified within the current literature focusing on ethnic minority groups (see the Supporting Information File, Item 2). 8,24,25,36 These issues included participants' experiences of performing medicine review services with ethnic minority patient groups and their perceptions of barriers and facilitators that may impact the service. Interviews were conducted until theoretical data saturation was reached, that is, upon author consensus that subsequent interviews yielded no new information. 37-39

| Data analysis
All interviews were audio-recorded and transcribed verbatim by one researcher (M. E.). All data were anonymized at the point of transcription; participants did not provide comments on the transcripts or feedback on the results. A reflexive thematic analysis approach was performed by two researchers (M. E., a student pharmacist, and A. R., a pharmacist and qualitative researcher).
Following reflexive thematic analysis processes, as defined by Braun and Clarke, 39

| Ethical approval
The study received full ethical approval from the Newcastle University Faculty of Medical Sciences Ethics Committee, with an ethical reference number of 5314/2020.

| RESULTS
Eighteen participants were recruited and interviewed as part of this study (there were no refusals to partake, participant dropouts or repeat interviews). The characteristics of the healthcare professional participants are described in Table 1. The average age of the participants was 38 years (SD: 11.97), and the most common healthcare professional group interviewed was pharmacists (n = 9, 50%). Eleven interviews were conducted over the telephone and seven were performed using the video call-based software, Zoom ® .
Three key themes were developed from the data to highlight the perceived barriers and facilitators that affect access to medicine review services for ethnic minority patients. These themes centred around (1) healthcare professionals bridging the cultural divide; (2) appreciating cultural stigma and acceptance of certain health   seek medical advice, further hindering the ability to communicate and build a rapport between the healthcare professional and the patient. 60,61 The use of an independent translator could circumvent the language barrier issue. 62 The study by Karliner et al. found that professional interpreters were associated with improved quality of care and reduced differentials in access to care. 63 Participants in this study also cited the importance of translators as a facilitator for minority patient access; however, they also cited the challenges associated with accessing interpreters in a timely manner to support consultations. The lack of availability of interpreters in pharmacybased settings has been a recognized source of patient safety concern in the wider literature, 64 seek to utilize coproduction approaches that involve patients from underrepresented ethnic minority groups alongside healthcare professionals. 75 Latif et al. described coproduction approaches as a reflective opportunity for community pharmacy professionals to review services offered to medically underserved groups, including those from ethnic minority backgrounds. 33 Previous studies have also implemented coproduction approaches to tailor health services to the needs and preferences of service users. [76][77][78] Done in partnership with patient representatives from the communities being researched, coproduction can better extend the understanding of the lived experiences of ethnic minority groups in terms of accessibility. As a result, further investigation may enable the recognition and resolution of barriers and facilitators that would enable improved accessibility and inclusivity for ethnic minority communities.

| CONCLUSION
Acknowledging the barriers and facilitators to ethnic minority groups is an important step towards ensuring equality in access to medicine services. Before this study, limited data existed that explored the perspectives of healthcare professionals involved in delivering medicine review services, particularly in relation to barriers and facilitators affecting ethnic minority patient access. This study seeks to address this gap and provides much-needed evidence implicating the delivery of person-centred care and considering changes based on a systems-level and an individualized person level. Coproduction approaches should be adopted to support better understanding of ethnic minority cultures and thus inform the design and delivery of culturally sensitive, medicine review services. Findings from this qualitative study should be used alongside patient-informed research to work to achieve equal access to medicine services for all.