Cultural Competency in Health Care and Its Implications for Pharmacy

As the United States becomes more diverse, a patient's cultural influences on health outcomes and health care decision-making and delivery need to be considered. Cultural influences affect a patient's decision to take drug therapy and concomitant alternative therapies. Seven components have been identified to improve culturally competent care in a variety of practice sites. The first component to developing culturally competent practices involves the analysis of self and system attitudes and practices toward various cultures. In the second component, health care providers should increase their knowledge about the cultures they serve through different patient assessment techniques, readings, and community activities. The third component involves improving cross-cultural communication by being aware of differences in social norms, assessing health literacy, using interpreters, knowing another language, and using bilingual patient education materials. In the fourth component, pharmaceutical care plans should accommodate cultural preferences such as the use of herbs, spiritual healers, and additional family decision-makers. Therapeutic plans should be negotiated between patient and provider to optimize outcomes. The fifth component discusses health care provider and system involvement in the community through health fairs, ethnic festival participation, and communication with cultural decision-makers to help provide culturally competent care by fostering communication ties. In the sixth component, knowing and following regulations such as the federal Culturally and Linguistically Appropriate Services and the Joint Commission standards for organizational cultural competency can help enhance care for patients from various cultures. In the last component, quality assurance assessments of procedures to improve care for various diverse cultures should be conducted, with findings (in terms of strengths and areas of improvements) shared with other providers and systems. Pharmacists and pharmacy technicians in a variety of systems and practices can improve care to patients with differing cultures by using these seven components to enhance culturally competent care.     

An Opportunity to Integrate Cultural Sensitivity Training Into the Doctor of Pharmacy Curriculum

Instructors of pharmacy skills-based laboratory courses are positioned to prepare students to be practice-ready practitioners through use of hands-on instructional activities essential for pharmacists. This commentary explores an approach to developing cultural sensitivity in pharmacy students, a skill which is reflected in Accreditation Council for Pharmacy Education (ACPE) Standard 3.5 and viewed by the authors as a critical skill for all healthcare practitioners. This commentary challenges the Academy to develop best practices for promoting cultural sensitivity in student-learners with the goal of producing students aware of how their own experiences may influence health inequities. The authors propose, using the model of self-efficacy theory as a framework, that skills-based pharmacy education is an ideal platform for cultural sensitivity skill development and engagement because of its ability to go beyond knowledge attainment and influence student abilities, behaviors, and attitudes. The authors’ recommendations include that members of the Academy self-assess personal and institutional cultural sensitivity, ensure integration of cultural sensitivity in curriculum, use self-efficacy theory as a guide to integrate best practices for providing culturally sensitive care in laboratory activities, and develop best practices.     

Drinking to the limit: Alcohol,social status and health governance

The aim of this article is to analyse social status differences in alcohol norms and practices seen from the perspective of ‘health governance’. Survey data on 1442 employees in a middle-sized, Danish firm are used to construct a Bourdieu-inspired social space, tied to four forms of capital: economic, cultural, inherited and organisational. A range of variables measuring alcohol norms, drinking practices and alcohol-related problems are then inserted into the space. This article identifies status differences in the employees’ drinking patterns indicating that respondents with large amounts of economic, cultural and inherited capital are more responsive to alcohol-related health messages than respondents (and especially males) occupying positions low in the social space. This, however, does not mean that respondents from dominant groups have ‘safe’ drinking habits, as these are defined by the Danish National Health Board. Rather, this article identifies a relatively large group of high-positioned respondents balancing at the limits of risky drinking – or transgressing them, if measured by international standards.     

When is it appropriate to address patients' alcohol consumption in health care--national survey of views of the general population in Sweden

The aim of this study was to investigate the Swedish population's beliefs and attitudes on when it is appropriate to address patients' alcohol in health care services and to identify the characteristics of those who are most supportive of this alcohol-preventive work. A cross-sectional study of 5981 nationally representative individuals (18-64 years) was done using confidential mail questionnaires. Alcohol consumption was assessed with AUDIT-C and respondents were classified into four levels of drinking status. Sociodemographic data were also collected. Thirty-four percent completely agreed that health care providers should routinely ask patients about their alcohol habits and 33% completely agreed that providers should ask but only if patients have consulted them with alcohol-related symptoms. There was limited support for a statement that alcohol conversations should be premised on the patient bringing up the issue and even less support for the notion that alcohol habits are people's own business and not something that health care providers should address. Thirty-four percent believed that people did not answer honestly when asked about their alcohol habits in health care. There appears to be considerable support in the general population for alcohol prevention in Swedish health care services that involves questions being asked routinely about alcohol. This should be helpful in ongoing efforts to improve the implementation of alcohol screening and brief interventions in Sweden. Further studies on the views of hazardous and excessive drinkers appear particularly important.     

Issues of cultural competence in mental health care

As the United States’ population continues to grow in its diversity, health care providers, including pharmacists, need to be able to provide culturally competent care to their patients. Cultural competence allows patients to feel comfortable with their provider and leads to their continuing to seek out care. Mental health is one of the most underused services in health care, particularly in underrepresented minority communities. This review looks at different published literature that assessed the reasons why individuals from minority communities may avoid seeking mental health care, cultural competence in psychiatric care for underrepresented minority communities, strategies for implementation for training providers in cultural competency, and barriers to implementation in mental health services. Current ideas include providing cultural competency training to students in their respective professional school or residency, incorporating the cultural formulation interview into psychiatric sessions, or increasing minority representation in the psychiatric services. On the basis of the literature examined, research is still needed to identify the best approach to improve culturally competent care in psychiatric services in the United States.     

Organizational contexts of primary care approaches for managing problem drinking

Little is known about the organizational contexts associated with different primary care (PC) approaches to managing PC patients with drinking problems. Relying upon the Chronic Care Model and a theoretically based taxonomy of health care systems, we identified organizational factors distinguishing PC practices using PC-based approaches (managed by PC providers, mental health specialists, or jointly with specialty services) versus referral-based management in the Veterans Affairs health care system. Data were obtained from a national survey of 218 PC practices characterizing usual management approaches as well as practices' leadership, delivery system design, information system, and decision support characteristics and from a national survey of substance use disorder specialty programs. PC- and referral-based practices did not differ on the sufficiency of their structural resources, physician staffing, or on the availability of specialty services. However, PC-based practices were found to take more responsibility for managing patients' chronic conditions and had more staff for decision support activities.     

运用纽曼健康系统模式提高脑卒中合并高血压患者自我管理能力的成效

目的 探讨纽曼健康系统模式对老年脑卒中及高血压患者护理干预的方法及效果.方法 随机选取90例老年脑卒中高血压患者分为对照组和观察组各45例,对照组采取脑卒中常规护理;观察组在常规护理的基础上采用纽曼健康系统模式对患者进行三级预防护理,比较干预前后两组患者不良生活习惯、高血压控制情况和相关知识掌握情况.结果 观察组中不良生活习惯的患者例数明显少于对照组,血压控制情况明显优于对照组,对相关知识掌握情况明显优于对照组,两组比较差异有统计学意义（P＜0.05）.结论 将纽曼健康系统模式理论运用于老年脑卒中合并高血压患者,可提高患者对疾病相关知识的认知度,改变不良生活习惯,控制病情的发展,减少脑卒中高血压疾病的复发.     

Alcohol Habits and Health Care Use in Patients with Psychiatric Disorders

Objective: It is common for persons with psychiatric disorders to also have alcohol problems. Studies in the general population as well as in clinical samples have found hazardous or harmful alcohol habits to be particularly prevalent in the presence of psychiatric disorders. This study sought to explore the relationships between drinking habits and health care utilization (psychiatric as well as general medical) in persons seeking psychiatric treatment and to investigate the associations among age, sex, and type or number of diagnoses and health care use and costs. For the planning of targeted interventions, we also sought to identify subgroups with a high prevalence of hazardous drinking habits. Methods: From a psychiatric clinic for affective disorders at a university hospital in Sweden, patients who had been screened for hazardous drinking (N = 609) were selected. Patients with primary psychosis or substance use disorder receive treatment at other clinics and did not participate. Medical records data were grouped and compared. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) was used for diagnoses and the Alcohol Use Disorders Identification Test for screening. Patients were grouped by drinking habits and sex, age, and diagnosis group, and their psychiatric as well as general medical health care use was compared. Results: Abstainers used psychiatric care more than all other drinking groups (p < .001). Psychiatric health care costs were higher in abstainers and low-risk drinkers (1.64 to 1). No differences in general medical care could be identified between drinking groups. Specific subgroups with higher rates of hazardous drinking could not be identified (44% of all males and 34% of all females reported such habits). Inconclusive results from previous research are most likely due to different methods used to classify drinking problems. Conclusions: Abstainers and low-risk drinkers used psychiatric health care to a higher cost than the other drinking groups. Possible explanations are discussed from a clinical and scientific perspective. This study clarifies the need for uniform measures when classifying alcohol use in studies of relationships between alcohol use and health care use. There is also a need to separate former drinkers from abstainers in future studies.     

Novel database for exposure to fragrance ingredients in cosmetics and personal care products

Exposure of fragrance ingredients in cosmetics and personal care products to the population can be determined by way of a detailed and robust survey. The frequency and combinations of products used at specific times during the day will allow the estimation of aggregate exposure for an individual consumer, and to the sample population. In the present study, habits and practices of personal care and cosmetic products have been obtained from market research data for 36,446 subjects across European countries and the United States in order to determine the exposure to fragrance ingredients. Each subject logged their product uses, time of day and body application sites in an online diary for seven consecutive days. The survey data did not contain information on the amount of product used per occasion or body measurements, such as weight and skin surface area. Nevertheless, this was found from the literature where the likely amount of product used per occasion or body measurement could be probabilistically chosen from distributions of data based on subject demographics. The daily aggregate applied consumer product exposure was estimated based on each subject’s frequency of product use, and Monte Carlo simulations of their likely product amount per use and body measurements. Statistical analyses of the habits and practices and consumer product exposure are presented, which show the robustness of the data and the ability to estimate aggregate consumer product exposure. Consequently, the data and modelling methods presented show potential as a means of performing ingredient safety assessments for personal care and cosmetics products.     

Reclaiming our roots: accomplishments and challenges

Best practices for Native Americans are rooted in culture. However, reclaiming best practices is a challenge given the genocidal policies that outlawed Native culture. Despite this challenge Native people have proven resilient in restoring culture. The Native American Health Center in Oakland, California, has made cultural interventions an option for an urban, intertribal and sometimes multiracial Native American population to create and maintain their health on a spiritual, emotional, mental and physical level. Nevertheless, sustaining these cultural options to maintain health continues to be a challenge. While the passage of the Mental Health Services Act (MHSA) in 2004 in California to transform treatment of mental and behavioral health "as we know it" would seem to create a gateway for cultural options, mainstream mental health has a hard time perceiving cultural interventions as a viable means to treat mental illness and maintain wellness. Frequently, the author has attended meetings of decisionmaking bodies that oversee how MHSA money is spent and someone will blurt out after someone has described an innovative cultural intervention "What does that have to do with mental illness?" The following article discusses how the clash of the two cultures, Native and mainstream, continues to be a challenge for sustained funding to implement culturally competent programs.     

Patient registries in primary care: essential element for quality improvement

Primary care in the United States has been in the midst of a transformation from a system based solely on individual office interactions to one that includes managing health at a population level. The chronic care model provides a robust framework for health systems to transform and restructure their delivery of care to one that is committed to delivering multidisciplinary quality care with a proactive approach. Patient and disease registries are the essential tools necessary to inform all elements of the chronic care model and guide practices though this transformation. Nationally as well as internationally, when used as part of a robust continuous quality-improvement program, registries have demonstrated to improve patient outcomes and reduce healthcare costs. Despite challenges practices may confront when initially developing a patient registry, it is evident that population management is now an important and integral component of a successful primary-care practice whose aim is to improve quality of patient care.     

Dental care and oral disease in alcohol-dependent persons

Dental/Oral health of alcohol-dependent persons and substance abusers is often neglected. It is not clear that alcohol dependence has effects on oral health beyond those expected in nonalcoholic persons of similar socioeconomic status (SES). Study objectives were to examine the personal dental care habits, ability to access professional dental care, and the types of services received and to examine their effect on the oral health of alcohol-dependent persons and substance abusers. Forty Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised-diagnosed alcohol-dependent persons and a comparison group of 25 non-alcohol-dependent subjects matched for race, age, gender, and SES were recruited. Subjects were medically healthy. Each subject received a comprehensive oral/dental examination, and an interview was conducted to record personal dental hygiene habits, ability to access professional dental care, and types of dental services provided. No statistical differences were found between the oral care habits of the groups. Forty-four percent of all subjects had access to charity professional dental care. Tooth extraction was the main dental service they received. Seventy-five percent of subjects brushed their teeth once or more per day. In the non-alcohol-dependent group, brushing frequency was inversely associated with plaque levels (p < .05); in the alcohol-dependent group, brushing frequency showed no statistical effect on plaque levels. Access to professional dental care was inversely associated with periodontitis in the alcohol-dependent group (p < .05). Alcohol dependence may increase plaque levels above that seen in race, gender, age, and SES-matched controls, but professional dental care can limit the subsequent development of periodontal disease in these people.     

Culture, moral experience and medicine

No one can doubt any longer that culture is crucial to medicine. The evidence for health disparities across ethnic and racial groups as well as for cultural influences on health care practices is too impressive to overlook. Yet the concept of culture and how it is employed in medicine today is quite different from the way culture is now regarded in anthropology, the discipline that originated and popularized the concept. Rather than understand culture as a "timeless" ethnic stereotype applied to patients-which is a common but dangerous practice-physicians need to understand how culture influences doctors as much as patients. And physicians need to understand that culture is not only about differences in dress, etiquette and diet, but also and most profoundly, about what really matters to people. That is, culture is about the changing moral experiences of patients, families, and practitioners, and how those moral experiences powerfully affect the doctor-patient relationship. This article suggests that there is a moral crisis in today's medicine that reflects global cultural transitions. This crisis must be addressed if practitioners are to provide care at the highest moral and human level.     

Engaging Pharmacy Students with Diverse Patient Populations to Improve Cultural Competence

Objective

To develop and implement learning activities within an advanced pharmacy practice experience (APPE) to improve students'' cultural competence.

Design

During their AAPE at Community Access Pharmacy, students participated in topic discussions with faculty members, used interpreters to interview Hispanic patients, visited a Mexican grocery store, evaluated nontraditional medicine practices in the Hispanic community, and served as part of a patient care team at a homeless shelter and an HIV/AIDS clinic. The students reflected on these activities in daily logs and completed a final evaluation of their experiences.

Assessment

Forty-three students completed the rotation from 2004-2007. Almost all learned something new about counseling patients with cultural/language differences (98%) and became more aware of financial barriers to health care and potential solutions to overcome them (93%). Students'' reflections were positive and showed progression toward cultural competence.

Conclusion

A culturally diverse patient population provided opportunities for APPE students to develop the skills necessary to become culturally competent pharmacists. Future work should focus on potential evaluation tools to assess curricular cultural competency outcomes in APPE''s.     

小学生口腔保健知识与卫生习惯与龋齿发生的关系

目的：探讨家长口腔保健意识、掌握正确刷牙的方法及口腔卫生习惯与儿童龋齿发生的相关性。方法：对社区门诊和窝沟封闭的165名小学二年级学生及家长进行口腔卫生问卷调查,内容包括口腔卫生知识、卫生习惯及家长对口腔保健的态度。结果：165名小学生口腔保健知识合格率为46．10％,患龋率为52．12％,龋均为3．12只。具有良好口腔卫生知识和习惯的学生患龋率低,家长的文化程度与日常督促与患龋率有关。结论：培养儿童良好的口腔卫生习惯,加大对家长口腔健康教育的力度,是预防儿童龋齿的重要措施。     

Walking the tightrope: balancing health and drug use

This article stems from a study on San Francisco drug users and their health care experiences. Two hundred thirty-eight study participants were administered depth interviews and questionnaires to reveal a variety of health concerns and health behaviors. For these analyses, which focused on health practices and risky behaviors, the sample was divided into two groups: marijuana users, and other drug users (including methamphetamine, cocaine, heroin, and crack). The findings indicate that drug users behave similarly to the general population regarding health practices, such as eating regularly, sleeping regularly, taking vitamins, and exercising. One finding of interest was the high-risk sexual behaviors of the young, educated marijuana users. A majority of participants demonstrated strong concerns for their health and well-being, and further encouragement on this front is advised. Future research and directions for interventions are recommended.     

Disability in cultural competency pharmacy education

Improving health care providers' knowledge and ability to provide culturally competent care can limit the health disparities experienced by disadvantaged populations. As racial and ethnic cultures dominate cultural competency topics in education, alternative cultures such as disability have consistently been underrepresented. This article will make the case that persons with disabilities have a unique cultural identity, and should be addressed as an important component of cultural competency education in pharmacy schools. Examples of efforts in pharmacy education to incorporate cultural competency components are highlighted, many of which contain little or no mention of disability issues. Based on initiatives from other health professions, suggestions and considerations for the development of disability education within pharmacy curricula also are proposed.     

培养药师良好药学习惯的实践与体会

目的:培养药师良好的药学习惯,提高药学服务水平。方法:在具体的药学服务实践中,培养药师的工作习惯、卫生习惯、学习习惯和交流习惯。结果:通过培养良好的药学习惯,可使药学人员的服务更加规范,服务质量和水平得到提高。结论:在药学服务中,药学人员只有养成良好的药学习惯,才能更好地发挥作用。