A medical mission to Guatemala as an advanced pharmacy practice experience

How cultural competence is conceptualised, developed and delivered in pharmacy education: a systematic review

BACKGROUND

It is important to have a pharmacy workforce that is culturally competent to recognise a patient's health beliefs to improve medication adherence and reduce poor treatment outcomes.

AIM

This systematic review aimed to identify, critically appraise and summarise how cultural competency is conceptualised, developed and embedded in pre-qualification pharmacy education.

METHOD

Medline, Scopus, PsychInfo, Web of Knowledge, CINAHL, and Embase databases were searched for relevant papers published in English between January 2012 and December 2021, following PRISMA guidelines. Data from included papers were thematically analysed. Educational quality of papers was appraised using the GREET criteria. This systematic review was registered on PROSPERO, CRD42021295875.

RESULTS

The review included 47 papers (46 studies) with 18 papers meeting ≥ 9 points on the GREET criteria thus considered of good educational quality. Forty papers focused on educational interventions implemented to pharmacy students only, the remaining included students from different health disciplines. Half of the educational interventions focused on cultural competence in general. Most educational interventions lasted over a week and 21 were compulsory. Cultural competence conceptualisation varied; a focus on knowledge about different cultures or on culturally competent behaviours or a continuum with knowledge at one end and behaviour at the other.

CONCLUSION

There is variation in how cultural competence is embedded in pharmacy programmes, which could be a reflection of the differences in how educators conceptualised cultural competence. Further research is needed to develop a unified understanding of the meaning of cultural competence and how it can be embedded in pharmacy education.

A Systematic Review of Assessment Tools Measuring Cultural Competence Outcomes Relevant to Pharmacy Education

Objective. To identify and describe validated assessment tools that measure cultural competence and are relevant to pharmacy education.Methods. A systematic approach was used to identify quantitative cultural competence assessment tools relevant to pharmacy education. A systematic search of the literature was conducted using the OVID and EBSCO databases and a manual search of journals deemed likely to include tools relevant to pharmacy education. To be eligible for the review, the tools had to be developed using a study sample from the United States, have at least one peer-reviewed validated publication, be applicable to the pharmacy profession, and be published since 2010.Results. The systematic literature and manual search identified 27 tools. Twelve assessment tools met the criteria to be included in the summary and their relevancy to pharmacy education is discussed.Conclusion. A review of literature demonstrates that assessment tools vary widely and there is no one tool that can effectively assess all aspects of cultural competence in pharmacy students or the Doctor of Pharmacy curriculum. As cultural competence is a priority within the accreditation standards for pharmacy education, PharmD programs are encouraged to develop additional tools that measure observed performance.

Improvement in the Cognitive Aspects of Cultural Competence after Short-Term Overseas Study Programs

Universities are providing short-term overseas study programs for healthcare students to increase their cultural competence (i.e., capacity to work effectively in cross-cultural situations). However, there is limited empirical research evaluating the effects of these programs using well-controlled research designs. In the present research study, undergraduate healthcare students in an Australian university were selected as participants. Group 1 (n = 32) participated in a short-term overseas study program in Asia (i.e., China, Vietnam, Singapore, and Taiwan), whereas Group 2 (n = 46) stayed in Australia to continue their university education as usual. All participants completed a self-developed demographic questionnaire, Cultural Intelligence Scale, and Multicultural Personality Questionnaire. Cultural competence was surveyed pre- and post-short-term overseas programs. After controlling for prior overseas experiences and the open-mindedness trait, an ANCOVA indicated that Group 1 had a significantly higher scores than Group 2 in cultural knowledge (p < 0.05), but not in cultural awareness, attitude, or skills. It is suggested that short-term overseas study programs may increase healthcare students' cultural knowledge, a component of competence, and that more needs to be accomplished to improve other areas of cultural competence.

An interactive teaching module for increasing undergraduate physiotherapy students' cultural competence: A quantitative survey

OBJECTIVES

To provide safe and effective healthcare, physiotherapists must be aware of, and able to appropriately respond to, the individual needs of their clients. Cultural competence is an essential part of the curriculum to prepare physiotherapy students for their graduate practice. The primary aim of this study was to investigate the effectiveness of a 4-week educational intervention to increase the perceived cultural competence of undergraduate physiotherapy students and whether effectiveness changed as students progressed in their education. Secondary aims were to understand if a clinical placement prior to the course intervention, or the student's cultural background, influenced the effectiveness of the intervention.

METHODS

A prospective cohort study was conducted with 73 students in their second year of an Australian Bachelor of Physiotherapy programme who participated in a 4-week tutorial module to develop their cultural competence. Perception of cultural competence was measured at three time points (pre, post, post 18 months) using the Cultural Intelligence Scale questionnaire which assesses metacognitive, cognitive, motivational and behavioural domains. Participant and their parents' country of birth data were collected.

RESULTS

Cultural intelligence scores for the cohort significantly increased from pre- to post-intervention (mean change 0.4, p < 0.001). A 3-week clinical placement prior to the teaching intervention had no effect on the change in scores. Students who were not born in Australia, or who had a parent not born in Australia, demonstrated less change in overall cultural intelligence score than Australian-born participants.

CONCLUSION

Undergraduate physiotherapy students at an Australian university can increase their perceived level of cultural competence by participating in a 4-week classroom-based tutorial module, and this effect can be sustained over an 18-month period. Exposure to cultural diversity is not sufficient by itself for a change in perceived cultural competence. However, classroom-based teaching needs to be responsive to the cultural characteristics of the students.

Development and implementation of a remotely precepted, interprofessional advanced pharmacy practice experience in rural Guatemala

BACKGROUND AND PURPOSE

It is well-established that interprofessional experiences in the international setting provide students with additional skills in cultural humility and adapting to specific patient circumstances. Though these experiences are integral to the development of students, they are difficult to establish due to a lack of in-country preceptorship. This manuscript describes the development and implementation of an interprofessional advanced pharmacy practice experience (APPE) and outlines the interventions students have made to advance patient care, build trust, and improve the education of patients and providers in rural Guatemala.

EDUCATIONAL ACTIVITY AND SETTING

The APPE in rural Guatemala was developed to include pharmacy distribution activities, education (patient, technician, provider, community), and clinical pharmacy services in an interprofessional environment. Pharmacy faculty served remotely as the primary preceptors using FaceTime, WhatsApp, and email.

FINDINGS

A total of 12 APPE pharmacy students have completed the six-week Guatemala rotation since implementation. Students reported that they spent the majority of their time (60% to 70%) seeing patients and training the technician. The remaining time was split between assisting United States and Guatemalan providers during clinic visits and conducting home visits with community nurses. Students made 1191 patient care recommendations, of which 969 were accepted (81.4%). Students completed 17 patient education and quality improvement projects.

SUMMARY

This APPE in Guatemala meets the needs of underserved populations, establishes effectiveness of distance precepting by pharmacy faculty, and provides international, interprofessional opportunities for fourth year pharmacy students.

Short-term Experiences in Global Health: What is the Cost of Cultural Competence?

Students in a wide variety of health professions are increasingly interested in volunteering on a short-term experience in global health (STEGH). The literature suggests that STEGHs pose a variety of potential risks and benefits, and may carry a significant cost to plan and provide. One potential mitigating factor for any risks and costs is that student participation on a STEGH may enhance their cultural competence. Since monies spent on STEGHs are fungible, and there may be other opportunities to improve students' cultural competence, the objectives of this study were to determine if participation on a STEGH increased students' cultural competence and if so, what the cost for any such increase was. In this study, 20 students who participated on a 1-week STEGH to the Dominican Republic completed the Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals - Student Version (IAPCC-SV) before and after the STEGH. The costs for all students and 7 supervising health professionals to volunteer for the STEGH were calculated, and the size of any increase in cultural competence was determined. The cost was divided by the change in cultural competence to ascertain the cost of the change. Students showed a measureable increase on the IAPCC-SV overall and on the subscales of knowledge and skill. The cost of a 1% overall increase in students' cultural competence ranged from $287 to $401. These results may allow schools offering STEGHs to determine if their offerings are cost-effective or not.

Comparing Photovoice to Traditional Reflection to Identify Student Learning on a Medical Mission Trip

Objective. To compare the effectiveness of photovoice with traditional reflection as a methodology to identify student learning during an international advanced pharmacy practice experience (APPE). Methods. Over seven years, seven cohorts of two to three pharmacy students completed an APPE in which they participated in a medical mission trip to Guatemala. Cohorts were assigned to use either photovoice or traditional reflection techniques to identify and document their learning. After returning from the mission trip, a focus group was conducted with each cohort of students. Students' comments were audio-recorded and the audio recording was transcribed and the text was qualitatively analyzed. In addition, all students completed the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals (IAPCC-SV) before and after travel. Results. All 18 students who participated in the mission trips, (nine in each group) agreed to participate in the study. Several themes were identified when the transcripts of the focus group sessions were reviewed. Students in both groups emphasized learning about the enhancement of pharmacy skills, cultural appreciation, and self-examination in their reflections. However, students in the photovoice group emphasized three additional areas that were not emphasized by students in the traditional reflection group: emotional impact, critical reflection on privilege, and ethical distribution of health resources. Students' post-intervention mean scores on the IAPCC-SV increased more for the photovoice group (8.5 points) than the reflection group (6.8); however, this difference was not significant. Conclusion. Students who used photovoice focused more on the connection between their learning and emotional or moral experiences than did students who used traditional reflection techniques. Photovoice may represent a promising methodology for deeper reflection into affective learning domains because of students' connection between visual images and their lived experiences.

Student-reported value of a short-term service-learning trip to Nicaragua

BACKGROUND

The purpose of this qualitative study was to assess the student-reported professional and personal value of a one-week service-learning trip to a Nicaraguan community.

METHODS

Five pharmacy students who participated in a one-week service-learning trip to Jinotepe, Nicaragua were invited to participate in this study. Individual, semi-structured interviews were conducted following the trip.

RESULTS

A variety of themes and subthemes surfaced, demonstrating the student-reported professional and personal value of the short-term service-learning experience. While each pharmacy student was impacted differently, common themes demonstrated transformative pharmacy student learning. These themes included recognition that every individual has a unique story that is essential to understanding how to care properly for that individual; the benefit of establishing a relationship with a community to more effectively and compassionately serve them; the importance of determining community-specific needs to ensure that service provided is beneficial; and recognition that those who are served have wisdom to offer healthcare providers.

CONCLUSIONS

Short-term service-learning opportunities can provide impactful learning for pharmacy students. Established service-learning visits with a consistent host site allow for deeper and more trusting relationships, resulting in the ability to respond to the needs and requests of the partner organization in developing communities and not impose agendas. Organizers of service-learning trips must cater to the needs of the developing community to ensure that the trip is effective in providing value to the host site rather than creating unnecessary burdens and unanticipated hardship.

Study Abroad Course for Pre-pharmacy and Pharmacy Students to Learn About Global Health

Objective. To design, implement, and assess a study abroad course in Ireland for pre-professional and Doctor of Pharmacy (PharmD) students. Methods. An elective study abroad course was created for pre-professional and PharmD students at North Dakota State University. The course included comparison of the US and Ireland's health care delivery systems and participation in history and cultural experiences in Ireland. Prior to the trip, students and preceptors attended seminars related to the culture of Ireland. The three-week trip to Ireland took place between the spring and summer semesters in 2016. Student assignments while abroad included completion of a self-reflection journal with daily entries describing what the student learned and how the experience impacted them, and completion and presentation of a term paper comparing Ireland's pharmacy system with that in the United States. Pre- and post-travel surveys were conducted to assess students' perceptions of and learning from the experience, and to identify areas for course improvement. Results. Students' evaluations of the course and travel experiences were positive. However, students' perceptions of their cultural awareness were largely unchanged. Conclusion. The course was well received by students. Other PharmD programs may benefit from implementing similar study abroad experiences.

Determining the Associations between Dietetic-Related Activities and Undergraduate Dietetic Students’ General Cultural Knowledge, Attitudes, and Beliefs

Background: As required by the Accreditation Council for Education in Nutrition and Dietetics, undergraduate dietetic programs need to include classroom learning activities to support cultural competence among dietetic students. Though these activities vary in terms of type, length, and engagement, it is not known the impact these activities have on students’ general knowledge, attitudes, and beliefs (KAB) towards cultural aspects. Therefore, the study’s purpose was two-fold: (1) validate a general cultural KAB instrument for dietetic students, and (2) determine associations among dietetic-related cultural activities and students’ KAB. Methods: A general KAB instrument was developed based on a literature review and dietetic curriculum. The original instrument (34 items) consisted of two dimensions (i.e., knowledge and attitudes/beliefs) that was reviewed by content matter experts (n = 4) and a focus group with dietetic graduate students (n = 6), resulting in a 41-item tool. This instrument was further piloted in a diverse population of undergraduate dietetic students across the United States. Exploratory Factor Analysis (EFA) and Cronbach alpha (α) for internal consistency were conducted. Multiple linear regressions and Spearman correlation analyses determined associations between demographics, activities, and KAB scores. Statistical significance was determined at p < 0.05. Results: Students (n = 187) completed the questionnaire. From the EFA, the Knowledge dimension included 12 items and the Attitudes/Beliefs dimension included 10 items. Internal consistency for the overall instrument (α = 0.86), Knowledge (α = 0.93), and Attitudes/Beliefs (α = 0.74) was high. Students’ cultural knowledge was associated (r = 0.30; p < 0.05) with cultural-related activities. Similarly, students who had lived or studied abroad had better attitudes and beliefs towards cultural aspects. Conclusions: The KAB had good validity. Cultural learning activities enhanced cultural knowledge, however to a lesser extent influenced the attitudes and beliefs of dietetic students.

Describing pharmacy student participation in an international, interprofessional medical mission trip as part of an advanced pharmacy practice experience (APPE)

BACKGROUND AND PURPOSE

Several schools of pharmacy across the United States have taken steps to incorporate international medical mission trips into the doctor of pharmacy (PharmD) curriculum. This study aims to describe the impact of advanced pharmacy practice experience (APPE)-level student pharmacists on an interprofessional team during an international medical mission trip to Jamaica.

EDUCATIONAL ACTIVITY AND SETTING

The Jamaica Medical Mission (JMM) trip is an annual event involving healthcare professionals from several disciplines across multiple universities and healthcare systems. At this institution, the JMM trip is included as part of a rural health elective APPE rotation. Students electing to participate in this rotation are provided with the opportunity to serve as active participants on an interprofessional healthcare team in underserved and under-resourced communities throughout Jamaica. The JMM trip that took place during June 2016 included healthcare professionals and students in the fields of medicine, dentistry, optometry, nursing, and pharmacy. A total of five pharmacist preceptors and 10 pharmacy students attended the JMM trip in June 2016. Approximately three to five clinic sites per day were conducted simultaneously on each of the seven clinic days at various locations throughout Jamaica. The interprofessional healthcare teams provided free medical care, including physical exams and access to prescription and non-prescription medications.

FINDINGS

The interprofessional healthcare team saw a total of 1014 patients and dispensed 1879 prescriptions during the seven clinic days. A total of 811 clinical recommendations were made by student pharmacists and/or pharmacy preceptors. Of these recommendations, 561 (69%) were made by student pharmacists without pharmacy preceptor prompting, 103 (13%) were made by the student pharmacist with preceptor prompting, and 147 (18%) were made by pharmacy preceptors. Over 70% of recommendations made by student pharmacists without pharmacy preceptor prompting were accepted by prescribers.

DISCUSSION AND SUMMARY

This study sought to describe the impact of APPE-level student pharmacists on an interprofessional team during an international medical mission trip. Our findings demonstrate that APPE-level student pharmacists were capable of making a substantial number of clinical recommendations without preceptor prompting. The number of recommendations made by students without preceptor prompting were consistently greater than the number of recommendations made with preceptor prompting throughout the trip. Future studies should address student competence in achieving learning objectives associated with international, interprofessional APPE rotations.

A Systematic Meta-ethnographic Review of the Beneficial Outcomes of International Internships to Student Pharmacists

Objective. To describe the benefits that pharmacy students gain by completing international internships as a part of their pharmacy education. Methods. A systematic literature search was conducted from database inception to November 2016. Articles that reported on any measure of outcome or impact on student learning were included in the study. A meta-ethnographic approach was used to translate and synthesize findings. Results. Analysis of the reported outcomes produced nine distinct themes: cultural awareness, collaboration, communication, clinical skills, knowledge, adaptability, compassion, confidence, and personal growth. Conclusion. Pharmacy students experienced many benefits that align with program competencies. The most frequently described benefits were development of clinical skills and compassion.

Recommendations for Planning and Managing International Short-term Pharmacy Service Trips

International pharmacy service trips by schools and colleges of pharmacy allow students to provide health care to medically underserved areas. A literature review (2000-2016) in databases and Internet searches with specific keywords or terms was performed to assess current practices to establish and maintain successful pharmacy service trips. Educational documents such as syllabi were obtained from pharmacy programs and examined. A preliminary draft was developed and authors worked on sections of interest and expertise. Considerations and current recommendations are provided for the key aspects of the home institution and the host country requirements for pharmacy service trips based on findings from a literature search and the authors' collective, extensive experience. Evaluation of the trip and ethical considerations are also discussed. This article serves as a resource for schools and colleges of pharmacy that are interested in the development of new pharmacy service trips and provides key considerations for continuous quality improvement of current or future activities.

Global Health Education in Doctor of Pharmacy Programs in the United States

Objective. To determine the extent and manner in which global health education is taught at US PharmD programs. Methods. A pre-tested 40-question electronic survey instrument was developed and sent to each of the 127 accredited or candidate-status US doctor of pharmacy (PharmD) programs. Results. Twenty-eight public and 27 private PharmD programs responded to the survey (43.3%). Twenty-five (45.5%) programs had integrated global health topics into their required didactic curriculum, and 30 of 52 programs (57.7%) offered at least one standalone global health elective course. Of the 52 programs that provided details regarding experiential education, 41 (78.8%) offered introductory and/or advanced pharmacy practice experiences (IPPEs and/or APPEs) in global health, and 34 (65.4%) programs offered medical mission trips. Conclusion. Doctor of pharmacy programs participating in global health education most commonly educate students on global health through experiential learning, while inclusion of required and elective coursework in global health was less common. To adequately prepare students for an increasingly global society, US PharmD programs should consider expanding global health education.

Exploration of Learning during an International Health Elective Using Photovoice Methodology

Based on surveys and structured interviews, International Health Experiences (IHEs) improve cultural sensitivity, communication, and self-confidence among health professions students. However, open-ended methods to explore student learning during an IHE are not widely utilized. We sought to explore pharmacy student-identified learning during an IHE in an open-ended fashion using Photovoice methodology. Pharmacy students on an IHE in Guatemala were given disposable cameras and asked to photograph images that reflected their learning. Through the application of Photovoice methodology students captured, reflected upon, and presented photos to describe the learning they experienced. Themes were drawn from the reflective and focus group data collected. During three IHEs, six students captured seventy-seven photos. Four main learning themes emerged: culture/cultural competence, professional growth, shifting of attitudes, and meaningful/emotional experiences. Pharmacy students documented learning in expected (cultural competence, professional growth) and unexpected (emotional experiences) domains during an IHE. Photovoice may be an effective methodology for the exploration of learning, allowing students to capture their own learning including and beyond what is expected by their instructors.

Current Practices in Global/International Advanced Pharmacy Practice Experiences: Preceptor and Student Considerations

The objective of this article is to describe the key areas of consideration for global/international advanced pharmacy practice experience (G/I APPE) preceptors, students and learning objectives. At the 2013 Annual Meeting of the American Association of Colleges of Pharmacy (AACP), the GPE SIG prepared and presented an initial report on the G/IAPPE initiatives. Round table discussions were conducted at the 2014 AACP Annual Meeting to document GPE SIG member input on key areas in the report. Literature search of PubMed, Google Scholar and EMBASE with keywords was conducted to expand this report. In this paper, considerations related to preceptors and students and learning outcomes are described. Preceptors for G/I APPEs may vary based on the learning outcomes of the experience. Student learning outcomes for G/I APPEs may vary based on the type of experiential site. Recommendations and future directions for development of G/IAPPEs are presented. Development of a successful G/I APPE requires significant planning and consideration of appropriate qualifications for preceptors and students.

The Sustained, Positive Impact of a Native American Cultures and Health Course on Students' Education and Practice-Related Choices

OBJECTIVE

To encourage pharmacy students to elect education and practice opportunities in Native American communities, including careers with the Indian Health Service (IHS).

METHODS

Students in 2 elective courses were educated on various aspects of contemporary Native American life in urban and reservation environments, including cultural traditions, social and health-related challenges, health access disparities, and cultural approaches to health and wellness. The teachers were Native American leaders and healers primarily from Plains tribes, as well as non-Native American practitioners affiliated with IHS hospitals and tribal health facilities. Students kept reflective journals, and a subset spent 5 days immersed in a rural Navajo community where they lived and worked alongside IHS practitioners and Community Health Representatives.

RESULTS

Student engagement with IHS opportunities was tracked for 11 years. Of the 69 pharmacy students who completed the electives, 11 applied for a Junior Commissioned Officer Student Training and Externship Program (Jr. COSTEP) (8 accepted, 6 completed), 43 requested one or more IHS APPEs (43 accepted, 32 completed, 8 in progress), 17 applied for an IHS residency (1 pending, 8 accepted, 5 completed), and 5 became IHS Commissioned Corps officers. Five additional students accepted an IHS or tribal position, with 3 pursuing a USPHS commission.

CONCLUSION

Since the first report on the impact of this elective experience was published, the course continues to meet its primary objective of promoting interest in IHS/tribal education experiences and pharmacy practice careers.

Ethics in global health outreach: three key considerations for pharmacists

OBJECTIVE

The objective of this article is to explore three key ethical tenets that pharmacists should consider prior to participating in global health outreach.

KEY FINDINGS

There are increasing opportunities for pharmacists to be involved in global health outreach; however, little attention has been given to the ethical issues that participation may raise for pharmacists. Pharmacists' widely accepted and basic ethical obligations at home lay the foundation for effective management of these ethical challenges abroad. At home, pharmacists have an ethical obligation to provide the best possible quality of care to the patients for whom they serve. During global health outreach, this involves identifying and mitigating the potential for harm, as well as understanding and respecting cultural differences. Furthermore, pharmacists have an ethical obligation to not only meet individual patient needs, but also community and societal needs, when applicable. In global health outreach, this involves tailoring interventions to the needs of the population served.

CONCLUSIONS

Because of their unique skillset, pharmacists have the potential to make significant contributions to global health. Applying ethical principles, such as providing the best possible care, respecting cultural differences and meeting societal needs, provides the foundation for successful global health outreach by pharmacists.

A comparison of educational interventions to enhance cultural competency in pharmacy students

OBJECTIVE

To determine the degree to which 3 different educational interventions enhance cultural competency in pharmacy students.

METHODS

Students were equally divided among a simulated-patient activity group, a written case-scenarios group, and a formal lecture group. Mean scores for pre- and post-intervention cultural self-assessment surveys were compared.

RESULTS

In the simulation group, there were significant positive changes in the cultural skills and cultural desire components; in the case-scenario group, there was a significant positive change in the cultural awareness component; and in the lecture group, there were significant positive changes in the cultural skills and cultural empathy components. With respect to the cultural skills component, there was greater post-intervention improvement in the simulation and lecture groups than in the case-scenario group.

CONCLUSIONS

There were significant positive changes within each group, indicating that ideologies and behaviors may be altered based on the educational intervention received. However, a 1-hour practicum may not be sufficient to enhance cultural competency.