‘Creating a culturally competent pharmacy profession’: A qualitative exploration of pharmacy staff perspectives of cultural competence and its training in community pharmacy settings

Abstract Introduction Cultural competence is an important attribute underpinning interactions between healthcare professionals, such as pharmacists, and patients from ethnic minority communities. Health‐ and medicines‐related inequalities affecting people from underrepresented ethnic groups, such as poorer access to healthcare services and poorer overall treatment outcomes in comparison to their White counterparts, have been widely discussed in the literature. Community pharmacies are the first port of call for healthcare services accessed by diverse patient populations; yet, limited research exists which explores the perceptions of culturally competent care within the profession, or the delivery of cultural competence training to community pharmacy staff. This research seeks to gather perspectives of community pharmacy teams relating to cultural competence and identify possible approaches for the adoption of cultural competence training. Methods Semistructured interviews were conducted in‐person, over the telephone or via video call, between October and December 2022. Perspectives on cultural competence and training were discussed. Interviews were audio‐recorded and transcribed verbatim. The reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Ethics Committee (reference: 25680/2022). Results Fourteen participants working in community pharmacies were interviewed, including eight qualified pharmacists, one foundation trainee pharmacist, three pharmacy technicians/dispensers and two counter assistants. Three themes were developed from the data which centred on (1) defining and appreciating cultural competency within pharmacy services; (2) identifying pharmacies as ‘cultural hubs’ for members of the diverse, local community and (3) delivering cultural competence training for the pharmacy profession. Conclusion The results of this study offer new insights and suggestions on the delivery of cultural competence training to community pharmacy staff, students and trainees entering the profession. Collaborative co‐design approaches between patients and pharmacy staff could enable improved design, implementation and delivery of culturally competent pharmacy services. Patient or Public Contribution The Patient and Public Involvement and Engagement group at Newcastle University had input in the study design and conceptualisation. Two patient champions inputted to ensure that the study was conducted, and the findings were reported, with cultural sensitivity.


| INTRODUCTION
Cultural competence can be defined as an individual's ability to possess the skills and knowledge to effectively interact with people from different cultural backgrounds. 1 It involves the acknowledgement, understanding and appreciation of an individual's cultural identity such as their religion, ethnicity, nationality, gender and sexual orientation. 2,3 Evidence has demonstrated that being culturally competent promotes communication between individuals, 4 respect for other cultures, individual self-awareness 1 and support shared decision-making between individuals. 5 Therefore, it can be considered a key attribute to those working within the healthcare system. 6 The General Pharmaceutical Council Standards for Pharmacy Professionals report demonstrates the responsibility of pharmacy professionals to 'treat people as equals, with dignity and respect, and meet their own legal responsibilities under equality and human rights legislation, while respecting diversity and cultural differences… (and) assess and respond to the person's particular health risks, taking account of individuals' protected characteristics and background'. 7 Similar statements are acknowledged in the General Medical Council Equality, Diversity and Inclusion Policy, which ensures that the organisation and all medical professionals 'treat anyone who [we] interact with fairly, without bias or discrimination', 8 and in the principles of good practice for community pharmacy teams, to address health inequalities (point 1.2.6) in the National Institute of Health and Care Excellence Guidance. 9 Despite referring to cultural competence within the guidance from professional bodies, there remains evidence of healthcare and medical inequalities affecting patients belonging to ethnic minority communities. 5,10,11 Recent studies have identified several factors that may contribute to these health inequalities, including poorer health outcomes, lower reported health literacy levels, lower socioeconomic status and feelings of disempowerment and distrust within the healthcare system for those from underrepresented ethnic communities, compared to their White counterparts. 12,13 Evidence suggests that one approach to tackling the aforementioned health inequalities could relate to the education and training of healthcare professionals, particularly developing skills to become culturally competent. 11,[14][15][16] Govere et al. demonstrated that cultural competence training had a positive impact on cultural awareness and overall competence of healthcare professional consultations, hence improving rates of patient satisfaction. 14 Most knowledge around the training of cultural competency within healthcare settings currently focuses on the fields of nursing, medicine and dentistry. There have been variations in proposed strategies and frameworks for teaching cultural competence to these healthcare professionals 17 ; for example, including the provision of online, self-directed learning sessions for trainees, 18 as well as faceto-face workshops and seminars, delivered by trainers. [19][20][21][22] One setting within healthcare that encounters a wide range of culturally diverse patients is a community pharmacy. Community pharmacy is regarded as a vital and easily accessible healthcare setting to any patient who requires health advice and treatment. 23 A recent study proposed that cultural competence training should be implemented into the training curriculum of all staff working within community pharmacies 10 ; however, limited research exists on the optimal delivery methods of cultural competence training to meet this need. 24,25 By exploring the perspectives of community pharmacy staff members, this qualitative study aims to: (i) provide new insights that showcase beliefs and attitudes towards cultural competence within the pharmacy profession and (ii) identify strategies to implement and deliver training for community pharmacy staff to use within their culturally diverse places of work.

| Recruitment and sampling
The consolidated criteria for reporting qualitative research checklist was followed for this work (see Supporting Information: File). 26 Given the capabilities of digital strategies to support qualitative research, a blended strategy was applied to perform participant recruitment and data collection with pragmatism. Recruitment was facilitated by community pharmacies, community charities and professional networks based in the North East of England, as well as on the social media profiles of two members of the research team (J. McC and A. R.-B.). All interested participants who contacted the research team were emailed an information sheet and consent form detailing the purpose and aim of the research. Those who expressed an interest and gave their written consent were enroled in the study. There was no relationship established between the researcher and participants before study commencement or recruitment. Inclusion criteria comprised: participants over 18 years of age who held a role within a community pharmacy team working in the United Kingdom (including, but not limited, to: pharmacists, foundation trainee pharmacists, pharmacy technicians, dispensers/dispensing staff and counter assistants). Purposive sampling was used to recruit participants and ensure representation from a variety of typical job roles within community pharmacy teams; participants were also of mixed age ranges, had been qualified in their job roles for varying lengths of time and were from varying ethnic backgrounds.

| Semistructured interviews
In-depth, semistructured interviews were conducted by one researcher (J. McC, a female pharmacy student researcher with experience in qualitative research) between October and December 2022. Interviews were conducted either remotely, via Zoom ® or telephone calls, or in-person (face-to-face); all participants were offered the choice of which format they would prefer. The semistructured interview topic guide (see Supporting Information: File) was developed based on three pilot interviews and covered key issues identified in the existing literature, 5,10,11 including participants' knowledge of cultural competence within the pharmacy and wider healthcare settings; participants' perspectives and experiences of interacting with patients from ethnic minority communities and their views and suggestions on cultural competence training. In addition, the topic guide was informed by findings from a previous qualitative study conducted by the research team 5 and the lived experiences of patient champions involved as co-authors in this study (L. S. and A. K. D.).

| Data analysis
All semistructured interviews were audio-recorded to enable data analysis. The audio files were encrypted and transcribed verbatim by this reflective process and enabled the researchers to work iteratively and inductively between interviewing and data analysis. NVivo (version 12) software was used to facilitate data management. The research team was in agreement that data sufficiency and information power occurred after conducting 12 semistructured interviews and thus, study recruitment stopped following interview number 14. 29,30 To ensure confidentiality when using direct patient quotes within this research, nonidentifiable pseudonyms are used throughout, for example, participant 1 and participant 2, and so forth.

| Considerations when reporting participant demographics
The researchers wished to consider whether there were any connections or associations between perspectives shared by participants and their ethnicity. Collecting data on a person's ethnic group is complex since ethnicity in itself is a multifaceted and changing phenomenon. 31 Various ways of measuring ethnicity exist and could include a person's country of birth, nationality, religion, culture, language, physical appearance or a combination of all of these aspects. 3,32 Efforts have been taken in this study to report a multitude of these aspects, to demonstrate the multi-faceted layers that accompany discussions about ethnicity. The UK Office of National Statistics 'Ethnic group, national identity and religion', 3

| Participant demographics
Fourteen participants in total were recruited and interviewed for this study (participant characteristics are described in Table 1). Of the 14 participants interviewed; 8 described their job roles within community pharmacy as pharmacists (57%), 1 interviewee was a foundation trainee pharmacist (8%), 3 were dispensers/pharmacy technicians (21%) and 2 were counter assistants (14%). Ten participants selfreported their ethnicity to be White, with nine stating they were British and one stating they were Scottish; one participant identified as mixed-race British; two participants identified as Chinese, and one identified as Pakistani. The average age of the participants was 30 years (SD ±8.06). Participants worked within community pharmacy settings across the United Kingdom; specifically, nine participants worked across the regions of Northumberland, Tyne and Wear (England), three participants worked across Yorkshire (England), two participants stated they worked in London (England) and one participant worked in Glasgow (Scotland). Nine interviews were conducted over video call-based software (64%), four interviews were conducted over the telephone (28%) and one interview was carried out in person (8%). There were no refusals to partake, participant dropouts or repeat interviews.
Three overarching themes were developed to reflect the perceptions of community pharmacy staff on cultural competence and the delivery of cultural competence training within community pharmacy. These focused on (1) defining and appreciating cultural competency within pharmacy services; (2) identifying pharmacies as 'cultural hubs' for members of the diverse, local community and (3) delivering cultural competence training for the pharmacy profession ( Figure 1). The three themes, and their subthemes, are discussed in turn.

Definitions and understanding
Cultural competence was believed by most participants to relate to the awareness and appreciation of another person's culture, with one explaining that being culturally competent is 'about understanding and appreciating people from a lot of diverse backgroundsthat are different to yours. So that's whatever ethnicity you are, it's understanding about cultures and upbringing and all the things that make you, you' (Participant 8). In this sense, cultural competence was interpreted, in a wider social context, as a skill that an individual can develop through interactions with people from different cultures.
Other participants described cultural competence as a concept relative to health, and drew on their medicine expertise to address this; they described cultural competence as being 'inclusive in your treatment of those patients and being able to build that into the way we approach patient care and healthcare decisions' (Participant 6).
You've got to be aware of issues such as religion, race or cultural differences that may require a different approach to treating that patient… you know what they can and can't eat for example, you can offer them alternative medication with products that wouldn't be offensive or unacceptable to them. (Participant 5)

Cultural beliefs influencing decisions about medicines
Participants provided examples where it was important to be aware of formulation considerations and excipients within medications.
Specifically, the suitability of capsules containing pork products for someone practicing religions including Islam or Judaism was discussed, with one participant stating 'somebody who's Muslim wouldn't be happy with pork products, like gelatine, in their capsules'   within the community pharmacy described the potential for interactions with members of a diverse population accessing the pharmacy.
One participant viewed the potential for community pharmacies to be regarded as 'cultural hubs' that local communities can access, knowing they will 'be recognised and spoken to in way that accounts for them and their culture' (Participant 11). Approaches that could improve the inclusivity of pharmacy services were discussed, with many relating to language and the need for translators or interpreters to support conversations about medicines. Translation and interpreter services were recognised as a potentially beneficial pharmacy service for patients who do not speak English as 'a lot of information that we give across to patients i.e., patient information leaflets, which are inside and the boxes and everything, well the majority are just in English' (Participant 7).

Most
Another participant, who worked in an area with a higher level of deprivation, discussed strategies employed in their pharmacy which were managed by a pharmacist from an ethnic minority background.  Two participants contemplated that, rather than training students on cultural competence, the aim of the MPharm teaching should be to instill an open-minded and inquisitive attitude in students for whenever they engage with people from ethnic minority groups. These participants argued that giving cultural training would not be appropriate, with one stating 'to sit down and have a lesson and say, "This is how you speak to someone who's Muslim" or "This is how you speak to someone who is from this ethnicity" -I think that's patronising non-English speaking patients were also a major concern amongst other healthcare professional groups. 42

| CONCLUSION
Cultural competence is important for community pharmacy staff to develop, due to the increasing patient diversity they encounter. As