Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities.

Accepted Manuscript Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities Lisa M. Wenger, PhD, Meagen Rosenthal, PhD, Jane Pearson Sharpe, B.Sc., Nancy Waite, PharmD, FCCP PII:

S1551-7411(15)00114-X

DOI:

10.1016/j.sapharm.2015.05.011

Reference:

RSAP 619

To appear in:

Research in Social & Administrative Pharmacy

Received Date: 19 February 2015 Revised Date:

22 May 2015

Accepted Date: 23 May 2015

Please cite this article as: Wenger LM, Rosenthal M, Sharpe JP, Waite N, Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities, Research in Social & Administrative Pharmacy (2015), doi: 10.1016/j.sapharm.2015.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Confronting inequities: A scoping review of the literature on pharmacist practice and health-related disparities Authors

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Lisa M. Wenger, PhD1 Meagen Rosenthal, PhD2 Jane Pearson Sharpe, B.Sc.1 Nancy Waite, PharmD FCCP1

Corresponding author 1. Lisa M. Wenger, [email protected]

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Abstract word count: 193

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1. 2. 3. 4.

Review word count (excluding references/ tables): 7010 Number of Tables: 4 Number of Figures: 1

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Acknowledgment: This scoping review resulted from an Applied Health Research Question submitted by the Ontario College of Pharmacists to the Ontario Pharmacy Research Collaboration (OPEN). OPEN is funded by a grant from the Government of Ontario.

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Ontario Pharmacy Research Collaboration (OPEN), School of Pharmacy, University of Waterloo, 10 Victoria St S, Kitchener, ON N2G1C5, Canada 2 School of Pharmacy, The University of Mississippi, P.O. Box 1848, University, MS 38677 USA

ACCEPTED MANUSCRIPT Confronting inequities Confronting inequities: A scoping review of the literature on pharmacy practice and health-related disparities Abstract

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Background: An expanding body of literature is exploring the presence and impact of health and health care disparities among marginalized populations. This research challenges policy makers, health professionals, and scholars to examine how unjust and avoidable inequities are created at the societal, institutional, and individual level, and explore strategies for mitigating challenges.

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Objectives: Recognizing the significance of this broader conversation, this scoping review provides an overview of pharmacy-specific research attentive to health-related disparities.

Methods: Following Arksey and O’Malley’s framework, a rigorous screening process yielded 93 ed and 23 grey literature articles, each analyzed for core themes.

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Results: Lending critical insight to how pharmacy practice researchers are conceptualizing and measuring health inequities, this review highlights three paths of inquiry evident across this literature, including research focused on what pharmacists know about marginalized groups, how pharmacists perceive these groups, and how they provide services. Striving to drive research and practice forward, this review details research gaps and opportunities, including a need to expand the scope of research and integrate knowledge.

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Conclusions: As pharmacists endeavor to provide equitable and impactful patient care, it is essential to understand challenges, and build strong evidence for meaningful action.

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Keywords: Pharmacy practice; Health disparities; Health care disparities; Stigma; Bias, Marginalized groups

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Introduction Within discussions of health care practice and policy, there is recognition of the

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“pathogenic consequences” of social exclusion or marginalization.1,2 Decades of research have

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evidenced how historical and cultural inequities can contribute to significant deficits in health

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experiences and outcomes among socially disadvantaged populations.3,4 This expanding body of

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literature includes scholarship attentive to the creation, facilitation, and impacts of disparities at

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societal, institutional, and individual levels.5,6 Notably, focus is not on all health differences

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across populations, but on a specific sub-set of these recognized as “unjust” and “avoidable”7

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through a human rights lens.3

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Research on the social determinants of health (SDOH) has considered how health disparities, or differences in health conditions and risks between population groups, are

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influenced by broad societal structures.8-10 For example, discussions of how geographic

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segregation and systematic racial/ethnic differences in social economic status, and medical care,

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are implicated in the reduced life expectancy of African Americans11 and Indigenous peoples in

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Canada.12 Within this broader discussion, scholarship attentive to institutional level forces has

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considered the presence of health care disparities, or inequities in the accessibility and quality of

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health services, related to how jurisdictions design and operate health support systems (e.g.,

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universal coverage vs. private or mixed private-public systems), where services are located, and

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whether health care organizations have a staffing composition reflective of the communities they

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serve, ensure access to language services, signage, and cultural training for health providers, and

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operate in a way attuned to a range of cultural patterns and preferences.13

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Similarly, research focused on individual-level dynamics has examined how health care disparities can arise through mechanisms within the practitioner-patient relationship.4, 14-16 For

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example, although clinicians might strive to treat all patients with respect and equity, they can be

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limited by language barriers17 and a lack of awareness or sensitivity to differences in health risks

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across populations and with respect to how populations learn to perceive illness, communicate

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experiences, and manage conditions.14 As well, researchers have observed that practitioners are

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not immune to biases toward groups.18,19 In fact, some have argued that even as rates of explicit

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bias have diminished over the past half-century, health training might exacerbate tendencies

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toward implicit bias.15 These unintentional and even unconscious assumptions and evaluations of

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populations (both positive and negative) can be manifest through emphasis on dominant, group-

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level health patterns in the interest of efficient diagnosis and treatment, and a prioritization of

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scientific objectivity to a degree that can encourage reliance on stereotypes and limit a clinician’s

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awareness of the influence of his or her own biases.18

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Whether examining dynamics at the societal, institutional, or individual level, health and

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health care disparities research has often focused on racial/ethnic differences.4,12,20 Researchers,

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however, also recognize patterns of disadvantage across a range of social locations and

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experiences, including socioeconomic status, immigrant status, geography, gender identity,

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sexual orientation, and disease type.10,15 Additionally, inequities can exist across a continuum of

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social advantage3 as a range of intersecting identities (i.e., race, gender, SES, disability status,

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etc.) combine to create complex social realities and inform health experiences.21

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It is critical that pharmacists engage in health and health care disparities research and take

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action on the findings. As frontline health care providers, pharmacists encounter a diversity of

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patients and are challenged to build increasingly complex clinical relationships amid their

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expanding scope of practice. As well, in small, rural, or remote communities pharmacists might

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be the only option for timely healthcare. Beyond a professional imperative to ensure patient

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access to high quality, relevant, accessible, and equitable care, pharmacists are well positioned to

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play a role in broader efforts to address health disparities. Focused and efficient action, however,

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demands that the pharmacist community have a solid understanding of how these dynamics are

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currently playing out in the context of pharmacists’ practice. To that end, this scoping review

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examined the extant pharmacy-specific literature attentive to health and health care disparities.

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Seeking to provide an overview of the research landscape, identify gaps in understanding, and

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highlight opportunities to drive research and practice forward, this review was organized around

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four core research questions:

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1. How are health and health care disparity-related conditions and processes currently

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defined/ scoped within the literature on pharmacists’ practice? 2. How are these measured within the existing literature?

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3. How do they function within pharmacist/patient relationships?

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4. How do they impact patient health outcomes?

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Methods

Scoping reviews provide a narrative description of research within an area of study. Distinct from systematic reviews, they are not designed to evaluate research quality, or provide a

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meta-analysis of findings.22 Rather, they provide an immediate map of the research landscape in

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a particular area, and help to strategically identify future research opportunities.23 Importantly,

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scoping reviews thoughtfully integrate scholarship often excluded from systematic reviews,

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including qualitative studies, research that does not follow a randomized control trial design, and

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grey literature, including important emerging research (e.g., doctoral dissertations, conference

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abstracts) and government/ policy discussions.24

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Subsequent to the identification of research questions (Stage 1), Arksey and O’Malley’s scoping review framework organized work around four additional, critical stages: (2) identifying

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and (3) selecting relevant studies, (4) charting the data, and (5) collating/summarizing/reporting

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the results. 24 To initiate this process, a deliberately broad and inclusive search of the pharmacy-

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specific scientific literature was undertaken using five health-science and pharmacy-specific

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databases, including: PubMed (MEDLINE), CINAHL, Embase, IPA, and Scopus.

Although education literature was prioritized in this review, a search of the grey literature

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(including government reports, academic theses/ dissertations, conference proceedings, research

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in progress, clinical trials, media reports, etc.) was conducted using CBCA Complete, Factiva,

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Grey literature report database, ProQuest Dissertation Database, and the Canadian Healthcare

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Network website. Additionally, the search terms were used to identify relevant discussions

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included on the websites of five North American and three Ontario-based professional

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organizations: Canadian Pharmacists Association, Canadian Society of Hospital Pharmacists

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(CSHP), American Pharmacists Association, National Community Pharmacists Association,

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American Society of Health-System Pharmacists, Ontario College of Pharmacists, Ontario

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Pharmacists Association, and Ontario Ministry of Health and Long Term Care.

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Aligned with the research questions driving this review, search terms included: Pharmacist, Patient, [bias OR disparity], [health outcome OR impact], [Implicit Bias OR

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cognitive Bias], [Inequity OR Inequality], Cultural competency, [Vulnerable OR Marginalized

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OR Underserved OR Disadvantaged], [Prejudice OR Stereotype OR Discrimination OR

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Stigmatization], Negative AND [Perceptions OR Attitudes OR Beliefs]. Boolean strings were

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trialed using the EMBASE database before being applied to each scientific database. A similar

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process was used to identify relevant articles in grey literature databases. Duplicates were

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removed leaving 357 ed and 240 grey literature articles (N=595). Inclusion and exclusion criteria were developed, piloted, and refined to guide the initial screening process (see Table 1 for details). Throughout this screening, two readers independently

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examined the abstracts of each of the scientific articles before meeting to compare and discuss

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their assessment of both the articles viewed as relevant and those marked for exclusion. Notably,

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a significant number of articles defied easy categorization. For example, research might focus on

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broad social dynamics, those within health systems, or practitioner-specific dynamics, but these

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were not always easily divided (nor should they be). As well, it was necessary to differentiate

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between groups that were challenging to treat (e.g., the elderly on multiple medications) and

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vulnerable or marginalized groups at risk for diminished health or inadequate care due to

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systematic disparities. The readers engaged with this complexity while making clear and

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consistent choices allowing them to finalize the list of relevant abstracts. At the end of this

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screening, 112 abstracts were retained (86 education and 26 grey).

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[Insert Table 1]

A second screening commenced with a review of the full text of each article, with the readers attending to misfiled or unrelated/ redundant articles and articles missed during the initial

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search. At the end of this review 43 ed and 23 grey literature articles remained. Concurrent with

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the process was a review of article bibliographies with a focus on ed articles explicitly

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referencing pharmacist attitudes, perceptions, knowledge, or services (including patient

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perspectives) in the title. Through this process, 50 new references were added to the scientific

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abstract database, bringing the total to 93 scientific articles. Notably, the high volume of

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additional research identified further highlighted the complexity of this literature. Despite these

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challenges, saturation was achieved, as fewer new references emerged by the end of this second

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screening. See Figure 1 for an overview of the screening process.

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[Insert Figure 1] Next, the two readers reviewed the content of each of the selected articles, engaging an

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inductive approach to identify key themes. Starting with a sample of 20 articles, the reviewers

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independently examined each in detail before convening to discuss and compare ideas and

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consult with additional members of the research team. Discrepancies were resolved and codes

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refined to produce a core set of broad themes relevant across the articles. Distinct from the

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research questions guiding this review, these themes highlighted patterns in how disparity-related

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dynamics are conceptualized and examined in the current literature on pharmacists’ practice.

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Once the research team had come to agreement on the core themes, each reader examined the

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full set of scientific articles (n=93), applying one or more themes, as appropriate. The first

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reviewer applied the same process to the grey literature. See Table 2 for the full Scientific

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Literature chart and Table 3 for the Grey Literature chart.

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Results

Description of the Literature

As outlined in Table 4, nearly two thirds (64.5%, n=60) of the scientific literature was

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North American based, and primarily from the United States. However, scholars around the

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world have examined patterns in the pharmacist-patient relationship that can be related to health

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disparities. Most of this research is quantitative (73.9%, n=65), with fewer qualitative (13.6%,

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n=12) or mixed methods (6.8%, n=6) studies or literature reviews (4.5%, n=4).

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The relative majority of the scientific articles focused on services for patients with either

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a diagnosis of mental illness (21.7%, n=23) or who abuse/misuse drugs (21.7%, n=23), most

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often illegal injection drug users (IDU). Less often considered were patients from racialized

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groups1 (13.2%, n=14, including African American, Asian, Indigenous, and Hispanic groups),

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those with limited English proficiency (LEP, 13.2%, n=14), or limited general or health literacy

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(8.5%, n=9), people with blood borne diseases including HIV/AIDS and Hepatitis C (6.6%,

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n=7), diverse cultural communities, as broadly defined in the research article (3.8%, n=4), those

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with low socio-economic status (SES, 4.7%, n=5) or living in a rural area (2.8%, n=3), women

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seeking contraception (1.9%, n=2), and people at risk for health care disparities, (1.9%, n=2).

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Notably, while populations of interest often transcended geographic boundaries, research specific

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to patients with HIV/AIDS (since 2000) found through this review was entirely located in

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developing countries, including Malaysia, Guyana, India, and Ghana. Overall, the grey literature

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followed similar patterns, but also included some additional patient groups: those with

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disabilities (12.3%, n=3) and one article on weight-related bias.

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Just over 40% of the articles (41.1%, n=39) included in this review considered practicing pharmacists’ perspectives, attitudes, knowledge, or practices, with more limited attention to

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patterns among pharmacy students (22.1%, n= 21) or pharmacy technicians or other staff (7.4%,

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n=7). The remaining studies considered practices within pharmacies as a unit (23.2%, n=22, e.g.,

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the availability of translation services or syringes) or dynamics in the context of pharmacist

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practice, more broadly (6.3%, n=6, e.g., gaps in cultural competency across the profession).

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Notably, nearly half (43.5%, n=10) of the research specific to pharmacy students centred on

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perceptions of patients with mental illness. Although it is important to note the diversity of

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pharmacist populations considered within this literature, subsequent discussion will refer to

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pharmacists as a general group (i.e., including students, pharmacy techs, and practicing

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pharmacists) given the broad focus of the review.

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Consistent with terminology used by the Government of Canada, articles identified as focusing on racialized populations include those featuring the experiences of community identified by their race and where race/ ethnicity is an explicit part of the analyses/ discussion.

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[Insert Table 4] Disparity-related Conditions and Processes: Definition/ Scoping Although an inclusive search approach was undertaken, seeking out literature attentive to health disparities at a population level, as well as health care disparities related to access and

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quality of services, research within the pharmacy specific literature largely focused on the latter.

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Within this focus, discussions were broadly organized around three core concepts: stigma, bias,

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or disparities. Notably, attention to these concepts was neither absolute nor exclusive, as some

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articles did not use these terms, and others worked across them. However, these research streams

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pattern the literature, focus discussions, and organize findings around slightly different research

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questions and patient populations.

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Stigma. Just under half of the research gathered attended to stigma (47.3%, n=44). Although often referenced without detailed conceptualization, Liekens, Smits, Laekeman and

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Foulon provided a more in-depth discussion, detailing three interrelated, yet distinct components

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of stigma: stereotypes, prejudice and discrimination. 25 This societal-level devaluation of a group

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of people according to particular quality or condition, the authors explained, can be experienced

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by members of a marginalized group (self stigma), and can operate through the reactions of

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others toward that population (public stigma). Self stigma can be a barrier to help-seeking and/or

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medication compliance, but public stigma is of particular relevance in understanding how

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pharmacists might participate in the perpetuation of health disparities.

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Literature focused on stigma has tended to feature discussions of pharmacists’ attitudes,

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knowledge, perceptions, or practices in three populations: those with mental illness (primarily

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depression or schizophrenia), IDUs, and those with HIV/ AIDS. Specifically, researchers have

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explored how pharmacists’ discomfort or social distance, or willingness to associate with groups,

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can further marginalize these stigmatized populations through dismissive communication,

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reluctant engagement, or even refusal to provide service.26-35 Additionally, researchers have

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explored how stigmas about particular groups can be associated with systematic deficits in

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clinicians’ knowledge about a condition and/or commitment to caring for a patient36-54 Aligned

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with this literature is a small group of articles that did not use the language of stigma, but

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attended to societal level “stereotypes” about groups or measure “negative attitudes” and related

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service gaps for those who abuse/ misuse drugs55-69 and patients with mental illness.70-72

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Bias. Similar to work on stigma, articles focused on pharmacists’ biases have rarely explicitly defined the concept. However, researchers considering bias (18.3%, n=17)

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acknowledge that a pharmacists’ own identity composition (e.g. race, ethnicity, gender, culture)

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can inform how she or he perceives, understands, and judges patients. This scholarship is closely

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related to, and often overlaps with that on, stigma through attention to patterns of prejudice,

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stereotyping, or discrimination (indeed, some authors reference both terms). Research on bias is

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distinguished, however, by a focus on the individual pharmacist’s assumptions and about certain

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groups and related preferences. Specifically, emphasis is on how pharmacists (as all people)

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learn to value or prioritize particular ways of knowing, and being, and how these biases can

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compromise their ability to effectively care for those with different perspectives and experiences.

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Literature attentive to bias has often focused on how pharmacists’ negative assumptions

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are directed toward particular populations,32,73-77 how pharmacist-patient interactions can be

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constrained by a pharmacist’s lack of knowledge, or their misguided expectations about patient

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needs/preferences,45,74,78-81 and deficits in cross-cultural acumen.82 Thus focused, research often

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attends to dynamics with patients from non-dominant cultural communities (or socially

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marginalized communities, broadly defined) as well as racialized groups, women requesting

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contraception, and people who abuse/ misuse drugs (either prescription drugs or injection street

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drugs). For example, researchers have considered a layer of racial biases over broader stigmas in

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how pharmacists engage with those seeking to purchase non-prescription syringes74 and how

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religious biases can constrain a willingness to sell legal contraceptives to women.75 In this focus

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on explicit attitudes of prejudice or judgment, scholars have less often considered pharmacists’

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implicit biases82,83 or a lack of awareness of personal biases.84 Notably, the extant literature on

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implicit bias has largely focused on pharmacy students, perhaps due to methodological

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challenges in measuring these dynamics in the field.

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Disparities. Researchers considering pharmacist practice in the context of societal level

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disparities (36.6%, n=34) tend to reference related US based reports/ programs focused on health

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care disparities related to systematic patterns of prejudice, poverty, language barriers, geography,

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and more.85,86,87 Upon this foundation, research focuses on deficits in the pharmacists’ awareness

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about societal level health inequities, inexperience with marginalized populations at risk for

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disparate health outcomes,88-91 and gaps in services for rural or low SES groups, racialized

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peoples, and/or populations with limited English proficiency or literacy. More specifically, this

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latter area of research on health care disparities has examined racial/ethnicity differences in

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immunization rates and other clinical services,74,92-95 reduced access to pharmacies, medications,

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or services, particularly within rural or poor urban areas,96-99 service gaps related to language or

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health literacy supports,100-104 or a general lack of interest/willingness of pharmacists to work in

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underserved areas.105 Again, there is a body of aligned literature not using the language of

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disparity, but which shares a focus on service gaps related to provision of accessible labels,

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services to non-English speaking populations, those with limited literacy,106-119 or the availability

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of a full range of medications and/or pharmacy supports in underserved communities.120,121

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Disparity-related Conditions and Processes: Measurement The education literature is dominated (73.9%, n=65) by research using quantitative

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methods to examine patterns related to bias, stigma, or disparities. Most often, researchers

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develop study-specific surveys designed to gather data from pharmacists using self-complete or

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telephone administered questionnaires. Less frequently, scholars have included standardized

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measures (e.g., social distance scale), or engaged alternate approaches such as geographic

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mapping of pharmacies and services96 or secondary data analyses, (including the PHARM-

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Link,92 Medical Expenditure Panel survey (MEPS93), and Texas Tech 5000 data99).

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The remaining research engaging purely qualitative, or mixed methods approaches is largely organized around interviews or focus groups, though also includes an analysis of a court

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case centred on pharmacist conscientious objection to contraceptive/sexual health care.75 In

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contrast to quantitative work, which often focus on specific dimensions (i.e., knowledge,

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attitudes), the qualitative studies take a more in-depth look at pharmacists’ experiences related to

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particular patient populations, including their knowledge, attitudes, beliefs, and perceptions

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related to working with patients (or potential patients). Notably, although some scholars have

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examined the patient perspective through surveyse.g.,42,70,72,81,95,107 and interviews or focus

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groups,32,69,77,113,119 or a combinations of methods,110,116 focused study of patient attitudes,

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understandings and experiences are less common within this literature.

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Disparity-related Conditions and Processes: Functioning

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Aligned with the focus on the clinical relationship and equity of service, discussions of

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the functioning of health care disparities oriented around three main areas: what pharmacists

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know about particular patient groups, how they perceive these groups (and their responsibility to

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provide care to them), and how they actually provide care. Although most of the articles included

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herein address more than one of these themes (see Tables 1, 2), the individual themes are

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presented separately in the interest of clarity. Pharmacists’ Knowledge. Over a third (37.6%, n=35) of the scientific articles

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considered pharmacists’ knowledge levels about marginalized or vulnerable groups as related to

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equitable care. Findings evidence some knowledge deficits, including an understanding of the

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origin of mental illness,e.g.,43,48 knowledge regarding the needs/preferences of those with mental

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illness,36,43,72 and core competencies and best practices related to service provision for those with

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mental illness.28,51,52 Pharmacists’ knowledge about the circumstances and needs of those who

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abuse/ misuse drugs, including prescription or injection street drugs,26,29,56 and of those with or at

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risk for HIV/AIDS34,37,38,46,67 or Hepatitis C is also lacking.30 As well, researchers have observed

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gaps in pharmacists’ knowledge about health disparities,88,105 heightened health risks among

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some populations,94,98 the significance and impact of limited literacy/health literacy,78 and

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culturally specific practices and preferences that can inform how a patient might perceive and

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respond to a condition.77,79 This latter discussion includes general reviews and evaluations of

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cultural competency or pharmacists’ cultural acumen. 80,81,84,108

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Knowledge gaps are not universal and are rarely described as intentional. However, some note a positive relationship between knowledge deficits and increased stigma. Scholars

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increasingly recognize that limits in what pharmacists know about a population’s preferences or

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needs can indicate a lack of prioritization of a certain groups’ experiences, and influence how

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effectively pharmacists provide services to members of these groups. As Aspden and colleagues

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explained, the provision of “comprehensive and appropriate care” requires pharmacists to be

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knowledgeable about health disparities, and properly informed about the needs and preferences

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of marginalized or vulnerable groups (p192).88 To that end, Aspden et al. have argued for

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additional training around the populations identified above via pharmacy curriculum and

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professional development for practicing pharmacists or pharmacy staff. Pharmacists’ Perceptions. More commonly, researchers have considered or referenced

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pharmacists’ perceptions of (a) marginalized or vulnerable groups (52.7%, n=49) and/or (b) their

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responsibility to provide care to these populations (51.6%, n=48). Certainly, not all studies

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examining pharmacist perceptions presented evidence of negative stereotyping, social distancing,

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or demonstrations of constrained concern or willingness to care for particular patient groups.

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Furthermore, few studies were absolute in their assessments of attitudes as articles often

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referenced a range of perspectives. However, there was evidence of concern.

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Perceiving Groups. The assembled literature indicates higher levels of social distance and/or pharmacists’ perceptions of particular patient groups as dangerous, aggressive, or

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unpredictable (mentally ill,40,43,47,54,71 IDUs63,64), morally questionable or responsible for their

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condition (women requesting contraception,32,75 IDUs,33,55 those with HIV/AIDS or Hepatitis

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C,27,34,38,46 those with low SES,89 and those with mental illness53), or simply harder to

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comfortably engage (those at risk for with HIV/AIDS,67 mentally ill45,49).

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A smaller body of literature has considered how members of marginalized groups perceive pharmacists. This includes research evidencing perceptions among some African

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American patients that their pharmacist did not respect them,77 and reports of perceived stigma

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among those with mental illness,42 IDUs,69,95and those requesting contraception.32 Notably,

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despite increasing attention to implicit or unconscious bias among practitioners in the broader

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literature, only one study addressed these dynamics among pharmacists. Focused on a student

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population (pharmacy and medicine students), the authors observed a preference for lighter skin

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tones, as measured by implicit association testing.83 Perceiving Care. Although overlapping with research on how pharmacists’ perceive

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patients, literature on pharmacists’ perception of care provision attends to a broader array of

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populations. This research indicates perceptions of those with mental illness as challenging to

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treat, a pattern contrasted with practices related to physical illness, and linked to a diminished

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sense of related competence or interest.28,36,51,52,72,97 As well, some services might be viewed by

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pharmacists as optional, problematic, or beyond the scope of practice. Examples of these services

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included non-dispensing services for those with mental illness,35,50,70,79 sale of non-prescription

334

syringes (or methadone) to IDUs,26,29,33,55,57-60,62-64,66,69,74,76 services for those with, or at risk for,

335

HIV/AIDS,37, 67 contraceptives sales,32,75 and tailored services for non-dominant cultural

336

communities (broadly), racialized, rural, low income, non-English speaking populations, and

337

other underserved groups.79,90,92,94,98,105,111,120 With respect to services for IDUs or mental illness

338

counseling, pharmacists’ sense of responsibility can be further compromised by evaluations of

339

these services as not feasible in terms of staffing or structure (i.e., no private space) or beliefs

340

that they would compromise business goals, the comfort of other clients, and staff safety.

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Pharmacists’ Provision of Care. Researchers have also attended to how pharmacists provide services, including service adequacy (44.1%, n=41) or accessibility (25.8%, n=24).

343

These discussions are closely aligned to each other, but are distinguished by both the particular

344

focus of the discussion and the range of patient populations considered.

345

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Adequacy. The majority of research focused on service adequacy measured pharmacists’

346

participation in services for three main populations: those who abuse/misuse drugs, people with

347

mental illness, and racialized groups. Scholarship centred on services for injection drug users has

15


16

largely, though not exclusively, focused on pharmacists’ response to legislative shifts allowing

349

the sale of non-prescription syringes,29,33,56,58-66,73,74,76,95 while research on mental illness has

350

focused on pharmacists’ effectiveness in providing services beyond medication dispensing,

351

including counseling.28,42,48,49,52,70,72,102 Literature on the adequacy of services for racialized

352

populations has considered disparities among racialized groups as related to pharmacy-based

353

immunization,92,93 pharmacy or medication access,74,99,121 alignment of pharmacists’ activities

354

with patient needs/preferences,77,81,91,94,102,119 and broader discriminatory practices.95 Beyond

355

these primary populations, discussion of service adequacy has considered levels of access for

356

those with HIV/ AIDS or Hep C,30,46 seeking contraception,32,75 or with limited literacy.107

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Accessibility. A small portion of the literature on accessibility of services overlaps with work on adequacy in terms of population focus, but more often considers the availability of

359

translation services for people with limited English proficiency100,102-104,106,110,111,115,117-119 or

360

clear communication (including language, visual supports) for people with limited literacy/health

361

literacy.78,101,107,109,112-114,116 Also addressed are deficits in culturally competent services for those

362

in non-dominant cultural communities81,108 and logistical service constraints, including

363

“medication deserts” (i.e., limited pharmacy hours, insufficient medication stocks) faced by low

364

income or rural communities.96,99 Notably, researchers have observed that even when

365

pharmacists are willing to provide care to marginalized populations, there can be a lack of

366

coherence between their intentions and actions. For example, research indicates that pharmacists

367

who express a positive attitude toward providing depression care might still limit their service to

368

the delivery of medication information, a dynamic possibly linked to knowledge gaps,

369

discomfort around those with depression, and related deficits in self-efficacy.47

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Focus in on Grey Literature. Overall, the grey literature confirms trends in the ed scholarship, including discussions of pharmacists’ knowledge, perceptions, and provision of

372

services for racialized, 122 rural 123 and/or underserved communities, 124,125 and among those who

373

those who have HIV/AIDs, 126 a mental illness, 127-130 or abuse/ misuse drugs. 131,132 As well, this

374

research highlights the need for enhanced cultural competency within an increasingly diverse

375

society. 133-137 Beyond the confirmation of trends in the ed scholarship, the grey literature offers

376

some complexity to the primary themes. These include the identification of (a) gaps in

377

pharmacists’ knowledge regarding the needs/ experiences of persons with disabilities138 (b)

378

evidence of stigmatizing attitudes, increased social distance, and/or reluctance to engage with

379

individuals who have higher body weight139 or have a disability/ visible difference,140,141 and (c)

380

accessibility concerns related to medication cost among low income populations138 and broader

381

disparities experienced by racialized groups less often considered in the scientific literature,

382

including immigrant142,143 or Aboriginal communities.144

383

Disparity-related Conditions and Processes: Outcomes

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384

Few articles gathered through this scoping review specifically considered or measured disparity-related health outcomes. However, the majority of scientific articles (98.9%, n=92) and

386

all of the grey literature acknowledged patient-specific health risks related to problematic

387

dynamics within the pharmacist-patient relationship, including:

388

•

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Suboptimal care. Most commonly, researchers have considered risks for suboptimal care

389

(under and over care) associated with gaps in pharmacists’ knowledge regarding care for

390

those with mental illness,28,36,42-44,48,51-53,72 HIV/AIDS,34,37,38,46 IDUs,30,31 negative perceptions

391

of these populations, and related support (i.e., mental illness;35,39,40,41,45,47,49,50,54,71,97 HIV/

392

AIDS;27,34,38,46 injection drug use 26,60,64,73). Also discussed are risks for sub-optimal patient

17


18

care due to pharmacists’ perceptions of limited time, privacy, or resources to sufficiently care

394

for those with limited English proficiency,99,102,117 mental illness,28,35,52,70 or who abuse

395

drugs,68 as well as limits in pharmacists’ cultural competencies, or interest, in serving certain

396

groups (e.g., racialized groups,77,81,83,92-95,99,102,119,121 people with low SES,81,89,90,96,120 rural

397

populations,98,99 women requesting contraception,32,75 those who abuse/misuse drugs25,65,66).

398

•

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Discordant care. Scholarship noting risks related to care practices that are misaligned with culturally informed health perceptions, preferences, and need or the language skills of a

400

population has focused on those with limited English proficiency, 100,103,104,106,109-111,115,117-119

401

non-dominant cultural communities or at-risk populations at a general level, 79-81,84,91,105,108

402

and racialized peoples. 88,102 •

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Medication risks. Discussion of medication risks, including non-adherence, errors, or adverse effects tends to focus around populations with more complicated treatment protocols

405

(those with mental illness, 28,36,48-54,72,97 and those for whom clear communication might be

406

complicated by language barriers, 99,102-104,106,109,110,115,118,119 literacy, 78,101,107,108,112,113,114,116

407

or non-dominant cultural patterns. 81 •

Disease spread. Research attentive to how problematic dynamics in the pharmacist-patient

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relationship can contribute to risk for disease spread (or the failure to mitigate) are focused

410

on populations who have a blood borne infection or are at risk for one including those with

411

HIV/AIDS or Hepatitis C 27,37,38 and IDUs. 29,33,55-63,66-69,74,76,95

412

•

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General disparities. Research attentive to dynamics in the pharmacist-patient relationship

413

contributing to the maintenance and/or reproduction of health disparities has considered

414

impacts among racialized groups,74,77,83,88,92,93,94,95,99 people with limited English proficiency,

415

100,104,106,109,117

low literacy or health literacy, 78,81,101,107 low SES, 89,90,96,120 mental illness,

18


19

416

42,44,55

and among rural populations 98 or non-dominant cultural communities/ at-risk

417

populations, more generally. 79,80,81,84,91,105

418

Discussion This scoping review provides valuable insight to patterns across a significant body of

420

research examining health and health care inequities and related dynamics in the pharmacist-

421

patient relationship. Although the assembled literature is largely based in North America and

422

dominated by studies focused on how pharmacists engage with patients who have mental illness

423

or use injection street drugs, literature from around the globe has considered pharmacists

424

engagement with patients who have limited English proficiency, literacy or health literacy, those

425

from low SES or rural areas, racialized groups, women seeking contraceptive services, people

426

with HIV/AIDS or Hepatitis C, and non-dominant cultural communities. Findings indicate that

427

although many pharmacists are engaging with a range of patient populations with respect,

428

providing concordant care, and participating in broader conversations about the value of

429

culturally competent health care, there are clear opportunities for enhanced practice.

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Specifically, literature attentive to stigma, bias, and general disparities evidences problematic patterns important to equitable care, including deficits in what pharmacists know

432

about the needs and preferences of certain marginalized populations, negative perceptions of

433

these populations and their related care, and gaps in the accessibility and adequacy of services.

434

There has been relatively limited attention to measuring the outcomes of these dynamics, but

435

researchers have discussed concerns related to potential risk for suboptimal care, discordant care,

436

medication risks, disease spread, and the perpetuation of general health disparities among

437

marginalized patient groups. These trends align with broader patterns in the literature on health

438

care disparities, as discussed in the introduction to this article. 4,14-19

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20

In addition to detailing the focus and content of research in this area, this review has found some important gaps in the literature, including the limited scope of the existing body of

441

literature and the fragmentation in focus. The following sections will focus on these limits and

442

explore opportunities for advancing research in ways that can enable a richer and more

443

comprehensive knowledge base that will be important to inform policy and practice.

444

Extending the Conversation

Although the extant literature on pharmacist practice and health disparities has

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445

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considered a range of patient populations, there are voices underrepresented and/or missing from

447

the conversation. Further, as scholars, practitioners, and policy makers pursue knowledge

448

important to enabling and sustaining equitable practice, there is value in expanding the scope of

449

research to include attention to diversities within patient and pharmacist populations, to consider

450

how disparity processes function, and explore the impact of implicit, as well as explicit bias.

451

Integrating missing voices. Relatively limited attention has been devoted to patient

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perspectives, overall, including how patients perceive pharmacists and related care. As evidenced

453

by Youmans and colleagues’ work,77 attention to patient perspectives can enhance understanding

454

of why patients might engage pharmacists’ services (or not), and how they experience elements

455

of care, information that can be important to the development of targeted and tailored services.

456

Additionally, studies leaving space for the bi-directionality of the clinical relationship, and

457

attentive to the perspectives of both pharmacists and patients, can create opportunities to

458

examine the alignment and divergence of assumptions, expectations, and experiences of care.

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452

This review also highlights the need for researchers to broaden their gaze regarding

460

marginalized patient groups. In particular, although the grey literature has considered the

461

experiences of persons with disabilities, less often considered racialized groups (including but

20


21

not limited to Aboriginal peoples and immigrant populations), and those who are discriminated

463

against because of their body weight, these groups have received more limited scholarly

464

attention. As well, few have considered how provider-patient relationships might be impacted by

465

knowledge gaps and biases related to other populations. For example, although there is evidence

466

of disparities among homeless populations,145 gendered patterns in health experiences and

467

outcomes146 and disparities related to sexual identity,147 limited attention has been devoted to

468

these dynamics within the pharmacy-specific literature.

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Attending to diversities. Aligned with the challenge to include missing voices is the value of examining diversities within a population. The broader literature on health disparities is

471

increasingly attentive to the value of examining intersections, or identity axes, including

472

intersections of one’s race and gender and income level, etc. This approach allows scholars to

473

complement studies of disparities within broad population groups (e.g., African Americans) with

474

research that is sensitized to within group differences. Specifically, research through an

475

intersectional lens attunes researchers to the complexity of human lives and helps to guard

476

against research that might homogenize groups, or produce findings based on assumptions that

477

individuals with one shared identity are uniform in their perspectives, needs, and preferences

478

(e.g., all African Americans believe/need/prefer X and, therefore, require Y services).

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The literature reviewed herein has offered limited insight to these complexities. A few of

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the articles e.g. 95,99 acknowledged multiple marginalized identities in their study population (e.g.,

481

racialized drug users), but explicit analysis and interpretation of within group variability is rare.

482

For example, although researchers have built a sizable body of literature examining pharmacist

483

encounters with those who have a mental illness, few have considered how these relationships

21


22

484

might vary according to whether that patient is racialized, presents as a man, woman, or gender

485

non-conforming, is from a high or low SES background, or identifies at lesbian, gay, or bisexual.

486

Similarly, although some researchers have considered variability according to pharmacist gender, race, etc., there are opportunities to enhance attention to within group differences in this

488

population as well, including when pharmacists, themselves, are members of marginalized

489

groups. Despite concerns about the lack of diversity among pharmacists,148 the profession

490

includes rich variability according to race/ethnicity, gender identity, body weight, immigrant

491

status, cultural and economic background, and personal experience with mental illness. There is

492

value in explicitly attending to these dynamics. Whether focused on patient or pharmacist groups

493

(or both), analysis through an intersectional lens is challenging.149 However, as researchers

494

thoughtfully consider diversities within patient and pharmacist populations they can avoid

495

superficial conclusions and are better prepared to build tailored and targeted interventions.150

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Examining disparities-related processes. Within broader discussions of health and

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health care disparities, researchers have been challenged to move beyond the production of

498

additional studies documenting the presence of disparities and devote more attention to how

499

these are created and sustained within the clinical encounter. 14,151 Consistent with this challenge,

500

the majority of research gathered in this review has emphasized whether or not bias, stereotypes,

501

knowledge deficits, or service gaps exist, with less attention to related processes. In a pharmacy

502

context, insight into these dynamics might be productively enabled through an in-depth study of

503

how patients and pharmacists make sense of needs, select a path forward, and take action over

504

time and across settings. This work could attend to how processes are informed, constrained, or

505

facilitated as related to the existing and expanding scope of practice and explicitly consider how

506

these process relate to health outcomes, an area of scholarship currently lacking.

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23

Qualitative approaches can be of particular value in this effort. As a complement to quantitative methods, qualitative methodologies designed to examine commonalities and

509

differences in how individuals perceive, interpret, and understand interactions can lend insight

510

into variability within groups and contribute to an understanding of critical patterns in

511

pharmacist or patient experiences. As well, pharmacists’ references to limited privacy, time, and

512

resources to sufficiently serve particular populations suggests that there might be value in

513

ethnographic approaches organized to examine how individuals engage within the pharmacy

514

space. This approach could enhance understanding of how pharmacies, as social spaces, inform,

515

guide and create critical processes with the pharmacist-patient relationship.

516

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Considering the presence of implicit (as well as explicit) bias. With few exceptions

517

81,83

518

related dynamics in pharmacist practice. Certainly, explicit biases have been shown to impact

519

contemporary health relationships. 14 However, attention to implicit, as well as explicit, biases

520

acknowledges that even when discriminatory or prejudicial attitudes and behaviours are actively

521

discouraged, individuals continue to carry preferences for certain groups over others. As

522

pharmacists are expected to treat all patients with respect and equity there is value in

523

opportunities to build understanding around micro processes of discrimination that are often less

524

easily identified by either pharmacists or patients, but which can powerfully disrupt feelings of

525

trust and the full engagement important to complete care. Even more, there is evidence that

526

measurements of implicit bias have greater predictive validity than those focused on explicit bias

527

in settings where individuals feel pressure to present as unbiased and can be predictors of critical

528

elements in the pharmacist-patient relationship, including the use of eye contact and non-verbal

529

cues indicating connection or discomfort.152 More broadly, as pharmacy scholars include

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implicit, or unconscious, bias has received limited attention in research examining disparity-

23


24

530

attention to implicit bias they can participate in the construction of broader understandings

531

important to health care practice, as a whole. 15

532

Contributing to a Common Dialogue As the previous recommendations have focused on strategies to extend the conversation,

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533

there are also important opportunities to harmonize or thoughtfully integrate the knowledge

535

being developed. At present, discussions of the relationship between pharmacist practice and

536

disparities are spread across several core concepts: stigma, bias, and disparities. Although these

537

share a concern for problematic and, ultimately, discriminatory patterns in the pharmacist-patient

538

relationship, much of the literature lacks explicit attention to the intersection of these dynamics

539

as well as the integration of a clear and cohesive theoretical foundation.

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Related to this conceptual divide, discussion is additionally fragmented as many scholars narrowly explore a single dynamic within a particular setting (e.g., student attitudes re: mental

542

illness) and develop study-specific tools to gather data from a small sample of respondents. This

543

approach might be justified by the research question, but can also contribute to an inventory of

544

individual cases. Both at the level of core concepts and study focus, a piecemeal approach limits

545

opportunities to identify and make sense of more systemic processes and impacts, including how

546

pharmacist-specific patterns and trends relate to broader discussions of health and health care

547

disparities. Notably, this fragmentation, and atheoretical approach to the topic is not unique to

548

pharmacy and has been observed across research on health and health care disparities, which

549

provides the profession of pharmacy a unique opportunity to lead an alternative approach. 153

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To address this challenge and propel research forward in productive and actionable

551

directions, researchers can, at a minimum, ensure that their work explicitly acknowledges the

552

broader scholarship on health and health care disparities and recognize these as grounded in

24


25

social structures and processes that privilege particular ways of being over others. For example, a

554

researcher might focus her work on a specific population (e.g., First Nations, urban low income,

555

those with low literacy, etc.), but she can also present this scholarship as connected to all those

556

(within pharmacy and in allied health professions) who seek to understand disparities, regardless

557

of their population focus. This foundation challenges researchers to become familiar with the

558

health disparities literature and to position their work within it as they consider how their

559

findings align or diverge from others’. This is critical to understanding broader trends.

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More fundamentally, pharmacy researchers are encouraged to attend to relevant theory in these efforts, an orientation that can help ensure that research questions, approaches, and

562

measures are comprehensive and appropriate, related assumptions explicit, and findings

563

meaningfully interpreted. Directly, the integration of theory into research on health and health

564

care disparities and pharmacist practice can help ensure that scholarship not only comments on

565

what is happening, but also provides deep insight to why is happening.154 To be clear, this call is

566

not about demanding common research questions and methods.155 Rather, it is about focusing on

567

and understanding particular dynamics while also explicitly contributing to the integrated

568

knowledge important to informing profession-wide responsive actions.

569

Limitations

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This review has limitations. Most notably, because the literature in this area is disparate

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571

in terms of language and focus, it was challenging to identify its boundaries and ensure a fully

572

detailed map of the research landscape. Although efforts were made to manage this diversity via

573

a broad and inclusive search strategy and careful screening process, it is possible that relevant

574

discussions and dynamics were missed because they did not align with the search terms used. As

575

well, the decision to exclude intervention-focused articles (lacking baseline data) means that

25


26

576

analyses do not benefit from parallel discussions of how to respond to disparities. Despite these

577

limitations, the patterns observed here have highlighted important trends and next steps.

579 580

Conclusion

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As pharmacists’ scope of practice expands and pharmacists strive to provide competent, respectful, and relevant care, it is critical to understand what is working well and where there are

582

opportunities for improvement. This scoping review supports that effort, detailing how a goal of

583

equitable practice can be threatened by knowledge gaps, assumptions about patient groups and

584

related care, and systematic service gaps. Researchers are challenged to deepen and expand upon

585

this knowledge as they seek to contribute to more inclusive systems and practices responsive to a

586

diversity of lived experiences. Specifically, there is value in extending the scope of this

587

scholarship by integrating missing voices, attending to within-group diversities, focusing on

588

critical processes in the pharmacist-patient relationship, and examining evidence of implicit as

589

well explicit bias. As well, there are critical opportunities to contribute to a common dialogue

590

about the source and function of problematic patterns as researchers take care to position their

591

work within the broader conversation about pharmacist practice, and consider how their work

592

connects to broader conversations transcending disciplines.

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An important next step in this analysis will be to engage with stakeholders, including

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pharmacy researchers, practicing pharmacists, pharmacy educators, policy makers, colleagues in

595

aligned disciplines, and patients about these findings, exploring their perspectives on observed

596

patterns and critical next steps. Among pharmacy’s strengths is its accessibility to patients. To

597

ensure that this accessibility is demonstrated in all aspects of practice and to all individuals who

598

can benefit from pharmacists’ care, this conversation must continue.

26


27

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35


36

Table 1. Inclusion/exclusion criteria for selecting articles included in the scoping review

M AN U

SC

Exclusion criteria

1. Discussion of practitioner bias toward a population (including negative attitudes, stereotyping, marginalizing, refusing treatment, evidencing discomfort, or lacking sufficient knowledge about a group’s needs) 2. Perspectives of marginalized/underserved people toward pharmacists as related to perceived stigma, discrimination/ judgment (i.e., not just experiences of these populations, more generally) 3. Discussion of pharmacy-specific service disparities and/or related health impacts/outcomes 1. Research centred on interventions to reduce bias/ disparities was excluded except when considering or reporting pre-intervention attitudes/ perceptions 2. Literature published before 2000 [Note: Although our initial search was unrestricted by date, our results demonstrated that the vast majority of gathered research was published since this date (95% of scientific, 90% of grey abstracts meeting inclusion criteria). This cut-off allowed for a focus on contemporary discussions.]

RI PT

Inclusion criteria

AC C

EP

TE D

1

36

ACCEPTED MANUSCRIPT

Confronting inequities

37

Table 2 Scientific literature articles included in the scoping review Author(s)/ Date Study location Pharmacy pop Patient pop

Research aims

Research methods

Pharmacy students

People with mental illness

Investigate perceived barriers to providing med counseling for people with mental health illness

Analysis of data collected via the International Pharmacy Students Health Survey (IPSHS), including social distance scale (SDS), Leeds Attitudes Toward Concordance scale (LATCon), and items on causes of disability, provision of pharmaceutical services, and mental health stigma

2010

Ahmed et al. 37

2009

Malaysia

Pharmacy students

People with HIV/AIDS

Evaluate knowledge, attitudes, and risk perceptions about HIV/ AIDS, identify areas of misconception and knowledge gaps

Cross-sectional survey including items developed by authors to assess HIV/AIDS knowledge, attitudes, and risk perceptions.

Amstislavski et al. 96

2012

United States

Pharmacies

People with low SES

Examine relationship between a NY community’s socio-economic context and access to common medications, pharmacies

Community pharmacy mapping, community demographic socio-economic indicators, pharmacy survey including items on the availability of prescription meds and provision of services

Aspden et al.88

2011

New Zealand

Pharmacists

Racialized populations

Understand the information needs of pharmacists in the context of reducing health disparities in New Zealand (NZ)

Survey informed by existing US tool assessing cultural competence & adapted for NZ, items on knowledge, awareness of resources, pharmacist role in reducing disparities.

Assemi et al.81

2004

United States

Pharmacy students

Diverse populations (general)

Implement, assess impact of a cultural competency training course designed for pharmacy students in California

Survey (pre and post), including items designed around course objectives perceptions of awareness/ knowledge/ communication skills related to cultural competence and cross cultural communication.

Bailey et al.106

2009

United States

Pharmacies

People with limited English proficiency (LEP)

Determine the availability of Spanish prescription drug label instructions in four states (GA NC CO TX)

Survey determining whether pharmacy could print prescription labels in Spanish and, if so, how instructions were translated (computer, employee, etc.).

Balfour et al.38

2010

Guyana

Pharmacists. [Note: Study also included health studies students]

People with HIV/ AIDS

Investigate HIV knowledge and its relation to HIV stigma

Cross-sectional survey including HIV Brief Knowledge Questionnaire, HIV Treatment Knowledge Scale, and AIDSrelated Stigma Scale.

Compare attitudes of 3rd year pharmacy students (no specific mental health training) and pharmacy grads (had training and work experience) toward those with schizophrenia and severe depression

Survey including the Social Distance Scale (SDS) and a 14-item questionnaire on stigmatization of persons with severe depression/ schizophrenia.

EP

TE D

M AN U

SC

RI PT

Aaltonen et al.36

Australia, Belgium, Estonia, Finland, India, Latvia

Bell et al. 39

2006

Australia

Pharmacy students, graduates

Bell et al. 40

2008


Pharmacy students


Compare and contrast the extent to which pharmacy students in study countries hold stigmatizing attitudes toward people with severe depression, schizophrenia

Analysis of data collected through the International Pharmacy Students Health Survey (IPSHS), including 12 items re: how strongly students endorsed 6 stigmatizing statements about people with schizophrenia/severe depression.

Bell et al. 41

2010


Pharmacy students


Compare students’ stigma toward people with schizophrenia, determine whether stigma is associated with stereotypical attributes of people with schizophrenia

Analysis of data collected through the International Pharmacy Students Health Survey (IPSHS), including the Social Distance Scale (SDS) and six items related to common stereotypical beliefs about people with schizophrenia.

AC C


37

ACCEPTED MANUSCRIPT


38

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

Black et al.42

2009

Canada

Pharmacies


Determine patient preferences, satisfaction, and perceived stigma related to community pharmacists in Nova Scotia

Cross-sectional survey including items on service availability, preference, satisfaction, and experiences of stigma/ discrimination.

United States

Pharmacy students

People who abuse/ misuse drugs (IDUs)

Explore pharmacy education and students knowledge, attitudes, and beliefs about HIV/ AIDS, drug use, and syringe sales to IDUs in the South East

In-depth interviews and focus groups. Sessions recorded/ transcribed/ coded.

United States

Pharmacies


Evaluate WI pharmacies’ ability to provide non-English prescription labels, info packets, and verbal communication and pharmacies’ satisfaction with communication with patients who have LEP

Cross-sectional survey, including items on language-service characteristics and open-ended questions on suggestions for improving pharmacies’ ability to meet needs of LEP.

United States

Pharmacy students

People at risk for health disparities (general)

Evaluate the effectiveness and impact of an elective service-learning course offered in cooperation with a charitable pharmacy providing services to the surrounding community in Kentucky

Pre- / post-survey including items on civic, cultural, and social issues and measuring students’ knowledge, attitudes/ perceptions about patients and community in which they serve. Post survey included additional items measuring perceived changes related to service learning experience.


Create a doctor of pharmacy curricular experience that will decrease students’ social barriers to interaction with and treatment of mentally-ill patients in Oregon

Pre-/ post-survey including items on perceived behavior of patients with schizophrenia and clinical depression, causes of these illness, usefulness of meds and/or pharmacist interaction, and social distance from patients. Also included qualitative selfreports of sense of empathy toward mentally ill patients.

People who abuse/ misuse drugs (prescription)

Brown et al.

105

2007

2008

United States

Pharmacy students

Butler, Sheridan73

2010

New Zealand

Pharmacists [Note: study also includes GPs and experts]

Cates et al. 44

2005

United States

Pharmacists

2010

United States

Pharmacy students

2003

United States

Pharmacy profession, generally

Cobaugh56

Semi-structured interviews with health care practitioners and other key experts.

Study the attitudes of Alabama pharmacists toward both mental illness and provision of pharmaceutical care to mentally ill patients

Survey including items on personal/ family history of mental illness, opinions/attitudes re: mental illness and confidence/ comfort/ interest in providing care.

People with low SES

Determine student perceptions of caring for underserved patients in relation to a mentored, experiential rotation at a community health centre (CHC) in Indiana

Analysis of a post-rotation reflection writing exercise focused on students’ perceptions of patients at a CHC, their overall experiences at the CHC, rewards/ challenges of serving the underserved, and the role of pharmacists in this type of setting.

People who abuse/ misuse drugs (general)

Opinion piece examining a lack of involvement of New York pharmacy professionals in preventing/ treating substance abuse.

NA


AC C

Chen et al.

89

Explore how pharmacists (and GPs) classify prescription drug misuers and how this influences their response to these patients, including whether they offer harm reduction

EP

Buhler, Karimi43

SC

2007

M AN U

Bradshaw et al.100

2002

TE D

Blumenthal et al. 55

RI PT

Author(s)/

38

ACCEPTED MANUSCRIPT


2000

Coffin et al.58

2002

United States

United States

Pharmacy pop

Research aims

Research methods

People who abuse/ misuse drugs (IDU)

Obtain baseline data on New York pharmacists’ attitudes and practices related to HIV prevention and IDUs.

Survey including items on pharmacy characteristics, perceived level of illegal drug activity in neighborhood, items on pharmacists’ awareness of new law, willingness to sell syringes without a prescription, factors influencing transactions, support for variety of pharmacy service related to public health, and agreement with series of statements about effects of selling syringes to IDUs.

Pharmacists (providers of OTC service)


Document changes in New York pharmacists’ opinions/ practices from the time of passage to implementation of a law permitting selling syringes without a prescription (ESAP)

Survey completed before/ after law passed and including items on pharmacy characteristics, perceived level of illegal drug activity in area, and pharmacists’ awareness of new law, willingness to sell syringes without prescription, factors influencing transactions, support for variety of pharmacy service, agreement with statements about effects of selling syringes to IDUs, and registration with the ESAP.

Pharmacists (providers of OTC service)

Patient pop

2013

United States

Pharmacies

Cooper et al.59

2007

United States

Pharmacies


People with low SES

Describe use of health literacy-based comm., expectations for use, and satisfaction with comm. as reported by patients at high risk for medication misadventures receiving care at clinic-based community pharmacy in Oklahoma.

Survey included items exploring perceptions of experiences related to verbal communication with pharmacists, expectations for communication with pharmacist, and satisfaction with current communication techniques.

Describe pharmacy part. in nonprescription syringe sales (NPSS) and related factors in 2 California counties

Survey including items exploring pharmacy policies/ practices, refusal to sell, staff attitudes regarding HIV and HCV prevention for IDUs.

Longitudinally assess pharmacy and medical students’ attitudes toward the medically underserved in the South

Used the Medical Students’ Attitudes Toward the Underserved (MSATU) survey including items on attitudes toward professional, organizational, and personal responsibilities and items assessing views on basic services individuals should receive regardless of ability to pay.

TE D

Collum et al.107

People with limited health literacy

RI PT

Coffin et al.57

Study location

SC

Date

M AN U

Author(s)/

39

2008

United States

Crawford et al.92

2011

United States

Pharmacists (at 103 pharmacies)

Racialized populations (including immigrants)

Understand individual and neighbourhood characteristics of staff support for inpharmacy vaccinations (in context of racial/ ethnic disparities) in New York

Linked data from PHARM-Link (Pharmacies as Resources Making Links to Community Services) study with US Census tract data.

Diverse populations (general), people with limited health literacy

Commentary on need to develop cultural competence in order to better serve patients from diverse backgrounds

NA


Examine Illinois pharmacists’ knowledge of low health literacy presence, scope, signs) & perceived barriers to addressing

Survey including items on knowledge, attitudes, experiences.

AC C

EP

Crandall et al.

Pharmacy students (years 1, 2, 4) Compared to med students

120

Cueller, Fitzsimmons108

2003

United States

Pharmacist Practice

Devraj, Gupchup78

2012

United States

Pharmacists

39

ACCEPTED MANUSCRIPT


40

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

Diggs, Berger (part 1 and 2)79

2004

United States

Pharmacist Practice


Explain how pharmacists can become culturally competent – using case studies specific to pharmacist practice

NA

Lit review (a) describing empirical research on communication between pharmacists and Spanish-speaking patients, (b) integrating related research on medical and nursing pops to generate a research agenda/ plan.

Systematic review of the literature (7 studies included)

Examine whether elective course reduced social distance toward people with severe mental illness in Maryland

Social Distance Scale (SDS) administered at start/ end of semester to students in course and those in a comparator group.

2009

NA

Pharmacists

Dipaula et al.45

2011

United States

Pharmacy students

People with mental illness (severe)


Self-Assessment of Perceived Level of Cultural Competence (SAPLCC), including items measuring 13 factors in six domains of cultural competence (knowledge, skills, attitudes, encounters, awareness and abilities).

Examine effectiveness of elective course in psychopharmacology on Minnesota students’ attitudes toward mental illness & treatment

Attitudes toward Psychiatry-30 (ATP-30) questionnaire. Survey validated/ used with med students and adapted for pharmacy.

Assess factors that might explain the relationship between race/ ethnicity and pharmacy use in relation to drug user population in New York.

Data from 2 IDU studies including items on experience with discrimination, drug use, use of syringe exchange programs (SEP) & purchase of syringes from a pharmacy.


Study communication and barriers to communication between pharmacists & antidepressant users in Nova Scotia and New Brunswick

Survey including items on # of prescriptions dispensed, services, rank of perceived barriers to effective communication. Patient questionnaire with items on info received at start of treatment and later.

United States

Einat, George97

2008

United States

Pharmacy students

People with mental illness, in rural areas

Pharmacies

Racialized populations, People who abuse/misuse drugs (IDU)

2004

70

United States

TE D

2013

Pharmacy students

M AN U

Measure perceived cultural competency among pharmacy students at predominantly African American University in Louisiana.

Echeverri et al.80

Fuller et al.95

SC

Dilworth et al.109


RI PT

Author(s)/

2001

Canada

Pharmacists

Gupta et al. 46

2010

India

Pharmacies


Determine the availability/ provision of ARVs and related knowledge and attitudes.

Survey including items on knowledge/ perceptions re: STIs, HIV, ART, characteristics of ARVs in pharmacy, perceptions/ attitudes toward people with HIV, prof. obligations.

Hughes et al. 110

2009

United Kingdom

Pharmacies

People with limited English proficiency

Understand views of Welsh speakers re: role of Welsh language in pharmacies in bilingual communities

Semi-structured interviews with sub-group to identify key themes followed by larger scale survey with questionnaire including statements regarding language use in the pharmacy.

Pharmacies

People who abuse/ misuse drugs (IDU), racialized groups

Summarize current research on pharmacy nonprescription syringe distribution to prevent HIV among IDUs

Literature review (47 studies included)

74

Janulis

2012

NA

AC C

EP

Gardner et al.

40

ACCEPTED MANUSCRIPT

Confronting inequities Author(s)/

Date

Study location

41 Pharmacy pop

Patient pop

Research aims

Research methods NYSDOH survey including items on whether pharmacies would participate, steps facilitating participation, what pharmacies wanted IDUs to know, current involvement in sales.

2001

United States

Pharmacists


Koester et al.61

2002

United States

Pharmacies


Determine the availability of syringes for IDUs in Colorado

Buying survey (based on existing tool) and involving active IDUs acting as RAs and seeking to buy syringes

Examine prevalence of patient-pharmacy staff communication about meds for pain/arthritis & related disparities by SES, demographic, health status in Alabama

Survey including a series of yes/ no answers to items re: communication with pharmacists.

Examine the issue of conscientious objection re: reproductive/ sexual health care & women’s access to health care

Analysis of a court case: Pichon and Sajous v. France (2001)

Identify factors that influence pharmacists’ decisions to sell syringes to IDUs in Colorado

Semi-structured interviews (modeled on study in Atlanta), questions on attitudes/ policies toward IDUs syringe sale to suspected IDUs, impact of HIV & Hep C and thoughts on increasing availability of syringes

Measure stigma among community pharmacists toward patients who have been hospitalized with depression.

Survey including items on social distance (based on SDS scale), cognitive attitudes (modified version of DAQ), stereotypical beliefs, and behavioral tendencies toward pharmaceutical care for patients with depression.

Assess attitudes toward/ current practices of pharmaceutical care for people with depression vs. those with other illnesses

Survey including items on social distance (based on SDS scale), cognitive attitudes (modified version of DAQ), stereotypical beliefs, and behavioral tendencies toward pharmaceutical care for patients with depression.


Measure impact of a depression training session for pharmacists

Pre- / post- survey on depression care practices with control group, including items on stigma, current practice, and attitudes toward pharmaceutical care.

United States

Pharmacy staff

Lamackova75

2008

Europe

Pharmacy practice

Women requesting contraception

Pharmacists


Lewis et al.

62

2002

United States

SC

2009

M AN U

LaCivita et al.

Racialized populations, limited health literacy, low SES

81

RI PT

Klein et al.60

Assess attitudes about syringe sales to IDUS to aid development of NY’s Expanded Syringe Access Demonstration Program (ESAP).

Liekens et al.

2012a

Belgium

Pharmacists


Liekens et al.48

2012b

Belgium

Pharmacists


Liekens et al.49

2013

Belgium

Pharmacists

Linas et al.63

2000

United States

Pharmacists

People who abuse/misuse drugs (IDU)

Obtain baseline data on pharmacist attitudes toward sale of syringes to IDUs prior to NY change in law

Survey including items on willingness to provide various preventive health and health education services and factors influence sale of nonprescription syringes.

Mackie et al.64

2004

Scotland

Pharmacists

People who abuse/misuse drugs (heroin)

Determine the extent & nature of pharmacists’ (in Dublin and Glasgow) participation in methadone services, views on service and suggestions for future

Survey including items on service provision (including why provided or not, as applicable).

Mackridge, Scott26

2009

Great Britain

Pharmacy support staff

People who abuse/misuse drugs

Explore experiences, attitudes, and training needs of pharmacy support staff providing services to drug users

Analysis of open-ended comments included on a questionnaire.

AC C

EP

TE D

47

41

ACCEPTED MANUSCRIPT

Confronting inequities Study location

Pharmacy pop

Patient pop

Research aims

Research methods

65

2002

Scotland

Pharmacists


Assess provision levels of needle exchange, methadone, health promotion and assess training levels relative to 5 years prior

Survey including items on attitudes, training levels, & past/ present/ future involvement with drug users.

Morrison et al.121

2000

United States

Pharmacies

Racialized populations

Investigate the availability of commonly prescribed opioids in New York pharmacies

Survey including items on stock (complete, nearly complete, incomplete, or absent). If stock was incomplete or absent reps of the pharmacy were asked open-ended questions about why.

Murphy et al.35

2014

Canada

Pharmacy students


Understand student experiences in providing service to people with mental illness in community pharmacy settings in Nova Scotia

Focus groups organized around a semi-structured interview guide.

Document/ measure available languageassistance services, how pharmacists perceive the effectiveness of these, and attitudes/ cultural sensitivity of pharmacists in relation to counseling Spanish-speaking patients in Georgia

Survey including items on practice site and services, +/statements about counseling, cultural sensitivity.

Summarize literature on med nonadherence, health literacy, and the use of written info in pharmacy practice

Literature review

SC

Matheson et al.

RI PT

Date

M AN U

Author(s)/

42

2004

United States

Pharmacists

Ngoh112

2009

United States

Pharmacy practice


O’Connor et al.98

2012

United States

Pharmacy students

Rural populations

Determine whether prospective pharmacy students had interest in a Rural Pharm Curriculum to address service shortage in North Carolina

Survey included items examining whether students were from a rural area, their perceptions of rural health, and interest in rural health curriculum.

Okoro et al.84

2012

United States

Pharmacy students

People at risk for health disparities (general)

Evaluate level of cultural competency and health disparity knowledge among students at two universities in Florida

Cross-sectional survey, including a modified version of Clinical Cultural Competency Questionnaire (CCCQ) with items on knowledge, skills, comfort, attitudes, self-awareness, training.

O’Neal et al.113

2012

United States

Pharmacies, Pharmacy staff

People with limited health literacy (n=60)

Pilot/evaluate/adapt Agency for Healthcare Research and Quality tool, describe health literacy practices & identify opportunity to improve in Oklahoma

Post-test, control group design including a workshop for staff at the intervention pharmacies (n=3 for each). Two additional pharmacies were selected as a site for pilot of the tool.

O’Reilly et al.50

2010a

Australia

People with mental Pharmacy students illness (depression & schizophrenia)

Evaluate consumer led- teaching intervention to reduce stigma toward people with mental illness, improve care attitudes

Survey including items previously used & validated scales on stigma, service delivery. Post-testing included focus groups.

AC C

EP

TE D

Muzyk et al.111


42

ACCEPTED MANUSCRIPT


43

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

O’Reilly et al.51

2010b

Australia

Pharmacists

People with mental illness (depression & schizophrenia)

Assess beliefs about the helpfulness depression & schizophrenia interventions

Survey including a mental health literacy (MHL) measure, vignettes about individuals with mental illness, and open-ended questions about the people in the vignettes, likely prognosis, discrimination, outcomes.

Owusu et al.27

2010

Ghana

Pharmacists


Determine pharmacists’ perceptions of persons living with HIV/ AIDS (stigma)

Survey including items to measure attitudes.

Phokeo et al.28

2004

Canada

Pharmacists


Determine attitudes toward/ professional interactions of Ontario pharmacists with patients who take psychotropic meds (vs. those on meds for cardiovascular disease)

Survey including items on attitudes, comfort in counseling, service barriers, counselor role orientation, attitude toward communication with patients, etc.

Praska et al.114

2005

United States

Pharmacies

People with low literacy

Determine frequency with which pharmacies in Georgia identify patients with low literacy, provide assistance.

Survey including items on whether pharmacy does anything to identify low literacy patients, measures taken when identified, and any special services to improve med adherence, in general.

Reich et al.76

2002

United States

Pharmacists


Determine opinions of pharmacists in four states (CO CN KY MO) re: role of pharmacists in preventing spread of HIV.

Focus groups with urban & rural pharmacists, focused on legal aspects of syringe sale, how IDUs are distinguished from diabetics, attitudes toward sale to IDUs, and views about participation in SEP.

Rich et al.29

2002

United States

Pharmacists


Examine pharmacists’ attitudes/ obstacles to selling syringes to IDUs without a prescription in Rhode Island

Survey including items about willingness to provide health education, referral services, syringe disposal units, and accept used syringes and factors influencing sale.

Richmond et al.30

2007

Australia

Pharmacists

People with Hepatitis C

Examine the inter-relationship between Hep C-related knowledge, attitudes, and care among nurses, MDs, dentists, complementary therapists

Cross-sectional survey including items on knowledge, attitudes, self-reported behavior, and personal/ professional contact with people who have Hep C.

Compare how community pharmacists in the Northeast U.S. assess own and other health professionals’ perceptions of individuals with depression/ schizophrenia and factors re: willingness to provide service.

Survey including a modified scale measuring attitudes toward mental illness, specially developed sections on willingness to provide services for asthma/ mental illness and a rating of importance of provision of services to people with mental illness, and a previously validated measure of perceived value in counseling patients.

Examine the role of the Dutch Community Pharmacist in schizophrenia care

Triangulated study including a survey of patients & relatives of those with schizophrenia/ psychosis including items on information service, adverse effects, use of antipsychotics, and expectation/evaluation of pharmacies. Pharmacists were interviewed using a semi-structured guide exploring how pharmacists assisted/ provided info for these patients.

Rijcken et al. 72

2008

United States

Nether-lands

Pharmacists

Pharmacists

SC

M AN U

TE D

EP

2010

People with mental illness (depression & schizophrenia)

AC C

Rickles et al. 71

RI PT

Author(s)/

People with mental illness (and relatives)

43

ACCEPTED MANUSCRIPT


44

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

Roberts et al.66

2007

Scotland

Pharmacists


Identify barriers to methadone/ needle exchange service, program improvements/ changes and pharmacists’ opinions

Survey including items on practices, views on methadone/ needle exchange, etc.

Scheerder et al.52

2008

Belgium

Pharmacists


Examine pharmacists’ attitudes, practices, and barriers re: depression care

Survey including items on pharmacists’ role in depression care, preferred partners in care and assessment of current levels of/ barriers to cooperation.

Scheerder et al.53

2009

Belgium

Pharmacists


Pilot designed to explore attitudes toward depression, including components of attitudes and related factors.

Survey based on a modified Depression Attitude Questionnaire (DAQ), including professional and personal experiences.

Sharif et al.115

2006

United States

Pharmacies


Determine the availability of Spanish prescription labels in an area with 43% Spanish speaking pop in New York

Sheridan, Cronin31

2001

England

Pharmacy support staff


Shiyanbola et al.116

2014

United States

Pharmacies

Low SES, limited health literacy

Shoveller et al.32

2007

Canada

Pharmacists

Women requesting contraception

Investigate barriers to the effective use of emergency contraception use among women aged 15-29 in British Columbia

In-depth interviews and focus groups with purposive sample of women (seeking ethnic diversity) and focused on experiences. Also consulted key informants (including a pharmacist)

Sleath117

2002

United States

Pharmacists


Examine pharmacists’ experiences/ perceptions related to provide care for Spanish-speaking patients in North Carolina

Survey including items on percentage of Spanish speaking patient pop, services, language of counseling, need/interest in learning Spanish.

Taussig et al.33

2002

United States

Pharmacists


Understand individual and structural factors that influence decisions to sell syringes to IDUs in Atlanta, GA

Semi-structured, in-depth interviews with convenience sample. Questions focused on attitudes/ beliefs re: syringe sale to IDUs, related practices, structural factors influencing these practices

Thomason et al.90

2013

United States

Pharmacy students

People with low SES

Determine impact of an advance experiential ed. program designed to impact students’ attitudes toward underserved

Prospective study with 4th year students as intervention and 3rd year as the control. Questionnaire included items re: underserved pops and related care.

Tkacz et al.101

2008

United States

Pharmacy practice


Commentary on the need to address health literacy in pharmacy

NA

M AN U

SC

RI PT

Author(s)/

Obtain views of staff on providing services for drug users and whether pharmacies should provide these services

Survey including items on pharmacy’s involvement in services, staff’s roles and responsibilities, views on service provision, views on drug users in the pharmacy, and related training.

Understand how underserved pops attend to/experience prescription warning labels (PWL)

Cross-sectional design using convenience sampling and semistructured interviews, including a health literacy assessment & items on PWL (how read/used, how a pharmacist might help).

TE D

EP

AC C

Cross-sectional survey of pharmacies, including items asking whether pharmacist provided Spanish language labels and, if so, what method used to provide translations.

44

ACCEPTED MANUSCRIPT


45

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

Ubaka et al.34

2014

Ghana

Pharmacy students and pharmacists


Evaluate the level and predictors of discriminatory attitudes toward people with HIV/AIDS

Cross sectional survey including items taken from previous surveys focused on pharmacy students and discrimination. Items assessed discriminatory attitudes, knowledge items.


Assess attitudes of students toward people with schizophrenia and determine whether stigma predicts less positive attitudes re: concordant med counseling

Data collected through IPSHS, items on attitudes toward people with mental illness, the SDS, and the LATCon scale.

RI PT

Author(s)/

2008

Estonia

Wang et al.93

2014

United States

Pharmacies

Racialized population

Examine racial/ ethnic disparities in receipt of flu vaccine among community and noncommunity pharmacy respondents

Retrospective cross-sectional secondary data analysis using Medical Expenditure Panel Survey (MEPS) data.

Warrick et al.94

2012

United States

Pharmacists

Racialized men

Assess DC based pharmacists’ ability and willingness to counsel on prostate cancer

Pharmacist practice survey with items on knowledge about PC, barriers to/ benefits in counseling, interest in training.

2003

Scotland

Pharmacies

Weiss et al.118

2007

United States

Pharmacies


2012

Examine pharmacist access to, provision of, and perceptions regarding multilingual written/ verbal prescription med info for LEP patients in New York City

Cross sectional, random sample survey (part of a broader study including interviews/ focus groups) asking about the availability of multilingual medication info, process/ frequency of identifying patients and accessing translations.

Pharmacies


Measure availability of foreign lang. services in pharmacies near clinic with high # of immigrant patients (Minneapolis-St. Paul area), determine if drug therapy problems varied between English/ nonEnglish patients

Survey of pharmacies asking about presence/ type of LEP services and researcher encounter with patients, including documentation of meds and evaluation of pharmaceutical care.

Australia

Pharmacists

Racialized population, People with limited English proficiency

Examine relationships of elderly Chinese and Vietnamese migrants with pharmacists, how relationships influence attitudes/ awareness re: home medicine review

Focus groups in the community languages with attention to presence of medicine problems, strategies for managing, knowledge/ perceptions of HMR program.


Measure, compare, contrast objective and subjective cognitive promises among students in health training in the Southern Delta region and discern implications for potential health disparities

Part of a multiyear study to access cultural competency, implicit bias among pre-professionals. Measures include cultural competency tool by Assemi & Cullander (2003) and the implicit association test (IAT) from Project Implicit.

Rural, racialized, limited English proficiency

Examine rural/ urban and ethnic differences in perceived access to ancillary pharmacy services among older adults in Texas

Analysis of data collected via Texas Tech 5000 survey by Dept. of Health Services Research and Management, a longitudinal study including items on pharmaceutical care, etc. %

United States

TE D

Cross-sectional survey including items informed by expert interviews, examining knowledge/ practice/ attitudes to advising public & high risk groups about blood borne disease.

EP

White, Klinner119

2005

Assess current activity, knowledge and attitudes in community pharmacies in Grampian

AC C

Westberg, Sorensen103

M AN U

Watson et al.

People at high-risk for HIV/ AIDs & Hep. B/ C (incl. IDU)

67

SC

Volmer et al.

Pharmacy students

54

White-Means et al. 83

2009

United States

Pharmacy students (note: study also including nursing & med students)

Xu & RojasFernandex99

2003

United States

Pharmacies

45

ACCEPTED MANUSCRIPT


46

Date

Study location

Pharmacy pop

Patient pop

Research aims

Research methods

Youmans et al.77

2007

United States

Pharmacists


Describe how older African Americans communicate with pharmacists and their opinions, beliefs, perceptions and attitudes about community pharmacists in California

Focus groups to assess knowledge of pharmacist role, perceived effectiveness of pharmacist communication, trust in pharmacist, perceived discrimination, and views on medication costs

United States

Pharmacists

People with mental illness, Racialized population, limited English proficiency

Assess provision of antidepressant info & effect of patient ethnicity/ language on info/ ed provided in community pharmacy in Wisconsin

Cross-sectional survey based on previous literature and expert suggestions and including a vignette describing a scenario and inviting responses.


Assess level of contact pharmacy staff have with IDUs and their attitudes/ experiences related to this contact, drug use, and HIV prevention in Rhode Island

Survey including items asking about attitudes/ beliefs re: syringe laws, experiences selling, perceive role in sale, current HIV-related services, willingness to provide additional HIVrelated services.

Zaller et al.

2010

United States

Pharmacists, pharmacy staff

Zaller et al.69

2012

United States

Pharmacists, pharmacy technicians


Zargarzadeh, Law104

2011

United States

Pharmacies


Zweber91

2002

United States

Pharmacy practice


Understand the interpersonal experiences of syringe sale/ purchase in Rhode Island, implications of related policies & staff and IDU perceptions of each other

In-depth, semi-structured interviews with IDU and with pharmacy staff facilitated by topic guides asking about drug use/ sale experiences

Examine self-reported capability and actual provision of non-English labels or verbal medical info & describe those pharmacies that provide these in California

Cross-sectional, observational, telephone interview design inquiring about provision of non-English materials, approximate % of patients requiring materials, beliefs re: provision, etc.

Discussion paper on developing cultural competence within pharmacy practice

Review of literature

AC C

EP

TE D

68

SC

2011

M AN U

Young et al.102

RI PT

Author(s)/

46

ACCEPTED MANUSCRIPT


47

Table 3: Grey literature articles included in the scoping review Author(s) Date Article location Pharmacy pop

Patient pop

Article type

Article focus

Canada

Pharmacy practice

People with disabilities/ visible difference, low SES

News article

Discussing government plan to eliminate pharmacist fee to reduce costs of generic drugs and risks related to Pharmacist services for those on Ontario Drug Benefit Program (Seniors, people with disabilities)

140

2011

Qatar

Pharmacists, pharmacy students

People with disabilities/ visible difference

Conference abstract

Examining pharmacist engagement with people with disabilities (attitudes toward care, professionalism, social distance) and variability related to years of practice

American Pharmacists Association122

2012

United States

Pharmacy practice


Association site

Examining racial/ ethnic disparities in flu vaccinations, particularly among African American, Hispanic, American Indian and Alaska Native communities

Audu126

2013

Nigeria

Pharmacists


PhD dissertation

Blazejewski 124

2012

United States

Pharmacists

Racialized population, low SES, uninsured

PhD Dissertation

Examining current practices as well as willingness and capability to provide services for underserved populations. Considered work, personal barriers

Canadian Pharmacist Association130

2011

North America

Pharmacy practice


Translator (issue on mental illness)

Discussion of provision of care to those with mental illness, including articles profiled in scientific abstract file. Topics featured include how to improve outcomes, patient perspectives, collaborative programs, and co-morbidities

Chang, Yochim123

2012

Canada

Pharmacy practice

Rural population

Article for Canadian Healthcare Network

Consideration of rural/ urban disparities, including (a) primary factors influencing pharmacy practice, (b) ideas/ initiatives to attract pharmacists to rural areas, (c) supports for rural pharmacists, (d) ways of enhancing viability of rural practices

Chaudhary133

2006

North America

Pharmacists


Conference abstract

Workshop to help pharmacists understand/ counteract bias that negatively impacts clients, colleagues, and coworkers and to understand how equity/ cultural competence can positively impact health workshop environments

Cueller134

2005

United States

Pharmacist practice


Conference abstract

Argument for enhanced cultural competence in pharmacy. Impacts: outcomes, processes, quality, ability to obtain medical history, patient satisfaction, adherence

DaCosta, Rickles127

2013

United States

Pharmacists

People with mental illness (severe)

Conference abstract

Measure pharmacist attitudes toward people with severe and persistent mental illness following a consumer led educational intervention

Dhinsa144

2014

Canada

Pharmacist practice


Article for Canadian Healthcare Network

Discussion of disparities between Aboriginal and non-Aboriginal Canadians, including lack of pharmacy engagement with healthcare programs (often led by physicians and nurses) to address disparities.

Duckett135

2011

England

Pharmacists


Doctoral dissertation

Exploration of how pharmacists need to remain relevant amid shifting professional realities and community landscapes, including gap related to pharmacist cultural competency and diversities within the pharmacist population itself.

Pharmacists


News article (CBC)

Discussion of how some pharmacists treat addicts differently than other patients with notes concerning a lack of training, bias, etc. and how that impacts patients (including case study wherein a pharmacist would not fill a prescription for Suboxone due to association of drug with methadone and the impacts of having to go to a much less accessible pharmacy to have the prescription filled).

Dyer

131

2014

Canada

SC

Detailing barriers to service for people with HIV/AIDs, including pharmacists per patient population, availability of antiretroviral, time with patients

M AN U

TE D

EP

AC C

Al-Dahir et al.

RI PT

2010

Toronto Star Staff138

47

ACCEPTED MANUSCRIPT


Fitzsimmons

Date

136

2005

Article location

Pharmacy pop

Patient pop

Article type

Article focus

United States

Pharmacy practice


Conference abstract

Discussion of need for enhanced cultural competency in pharmacy, including diverse staff, linguistically appropriate signage, culturally appropriate facilities, translation, awareness of health literacy concerns, understanding of prevalence of disease types/risks among different populations, etc. Risk: non-adherence, discrimination, reduced access, etc.

Article for Pharmacy news

Discussion of research indicating that users unable to pay for methadone programs are at risk for relapsing and how current system can marginalize addicts as different clients (“Current-day lepers”). Argument that pharmacists need to recognize the importance of building trusting relationships with patients and reduced cost of Opiate Replacement Therapy (ORT) could enable this

Conference abstract

RI PT

Author(s)

48

Australia

Pharmacists

128

2011

Austria

Pharmacists


Heisler129

2011

United States

Pharmacy practice


LaRoche142

2006

Canada

Pharmacists


Levy143

2006

United States

Pharmacies


Article for Drug Topics

Argument that Pharmacists need to tailor marketing/ services to meet needs of diverse populations in the US. Profiles several pharmacies in US doing well.

137

2007

United States

Pharmacy practice


White Paper

Overview of cultural competency and disparities (definitions), issues in pharmacy ed. and research (incl. examples of challenges for pharmacists/ patient), and recommendations for the practice

Siyame141

2012

Tanzania

Pharmacists

People with Albinism

Article for All Africa

Report of a pharmacist who refused to treat patients with albinism and how it was treated by health authorities

Stefanac139

2011

Canada

Pharmacists

People who are overweight

Article for Pharmacy Practice

Discussion of weight bias, including stereotypes held by health providers, lack of respect for and interest in supporting these patients, and health implications (bias can prompt unhealthy behaviours)

Syed et al. 125

2012

United States

Pharmacies

People at risk for disparities (general)

Conference Abstract

Examination of distribution of pharmacies, particularly in medically underserved area indicates that patients here have (a) less access to medicine and (b) less opportunity for counseling/ support from pharmacists.

M AN U

Examination of Pharmacists training on psychotropic vs. cardiovascular drugs, including argument that Pharmacists need more information on psychotropic meds and need to improve ability to counsel patients.

Article for Drug Topics

Argument that depression screening could be integrated with the medication therapy management (MTM) process, noting challenges including skepticism among pharmacists about their role, lack of training, and limited cooperation from primary care physicians

Conference abstract

Discussion of challenges of cultural differences and value of cultural competency in Canadian society demonstrated through anecdotes from pharmacist experiences and illustrating how people from different backgrounds might react differently

TE D

O’Connell et al.

EP

Hagmair et al.

AC C

Fleming

SC

2008


132

48


49

Table 4: Summary characteristics of articles included in the scoping review Scientific

Grey % (n)

AC C

EP

TE D

64.5 (60) 61.1 (55) 5.6 (5) 20.0 (18) 7.8 (7) 2.2 (2) 1.1 (1) 1.1 (1) 1.1 (1) 0.0 (0)

73.9 (17) 39.1 (9) 26.1 (6) 8.7 (2) 8.7 (2) 8.7 (2) 0.0 (0) 0.0 (0) 0.0 (0) 4.2 (1)

73.9 (65) 13.6 (12) 6.8 (6) 4.5 (4) 1.1 (1)

42.9 (3) 28.6 (2) 28.6 (2) 0.0 (0) 0.0 (0)

21.7 (23) 21.7 (23) 13.2 (14) 13.2 (14) 8.5 (9) 6.6 (7) 4.7 (5) 3.8 (4) 2.9 (3) 1.9 (2) 1.9 (2) 0.0 (0) 0.0 (0) 0.0 (0)

8.3 (2) 16.7 (4) 0.0 (0) 12.5 (3) 0.0 (0) 4.2 (1) 4.2 (1) 29.2 (7) 4.2 (1) 0.0 (0) 8.0 (2) 12.5 (3) 4.0 (1) 4.0 (1)

41.1 (39) 23.2 (22) 22.1 (21) 7.4 (7) 6.3 (6)

50.0 (12) 8.3 (2) 4.2 (1) 0.0 (0) 37.5 (9)

100 (93) 37.6 (35) 71.0 (66) 52.7 (49) 51.6 (48) 65.6 (60) 44.1 (41)

100 (23) 39.1(9) 37.5 (9) 26.1 (6) 13.0 (3) 91.3 (21) 78.3 (18)

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Region2 North America United States Canada Europe Australia/NZ Africa South Asia Southeast Asia Caribbean Middle East Methods3 Quantitative Qualitative Mixed Literature Review Other Patient population4 People who misuse/ abuse drugs People with mental illness People with limited English proficiency Racialized population (race/ ethnicity) People with limited literacy/ health literacy People with blood borne disease (HIV/ AIDS, HEP C) People with low SES Non-dominant cultural communities (general) People in rural areas Women requesting contraception People at risk for health disparities (general) People with disabilities/ visible differences People who have a higher body weight Other Pharmacist population Practicing pharmacists Pharmacies Pharmacy students Pharmacy staff/ tech Pharmacist practice (generally) Themes5 Processes that can contribute to disparities Knowing enough Perceiving A marginalized group The role of pharmacists in their care Providing Adequate services

If relevant If applicable A study can include more than one patient population (e.g., low income groups with limited health literacy) 5 The percentage/ number indicates how many articles included this code (totals will not add up to 100 because each article included multiple codes) 2 3 4

49


50 25.8 (24) 98.9(92) 60.2 (56) 19.4 (18) 33.3 (31) 22.6 (21) 32.3 (30)

17.4 (4) 100 (23) 69.6 (16) 30.4 (7) 4.3 (1) 4.3 (1) 4.3 (1)

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Accessible services Related outcomes (or risks) Suboptimal care Discordant care Medication non adherence/ errors/ adverse effects Disease spread Disparate health outcomes (general)

50


51

Figure 1 Overview of screening process for selecting articles for inclusion in the scoping review

First screening: title review

112 abstracts (86 peer-reviewed and 26 grey)

Second search through bibliographies

50 peer-reviewed

Final literature for review

46 rejected

SC

66 articles (43 peer-reviewed and 23 grey)

483 rejected

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Second screening: full review

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595 (357 peerreviewed and 240 grey)

First search

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116 (93 peerrevieed, 23 grey)

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ACCEPTED MANUSCRIPT

Highlights

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We conducted a scoping review of literature on pharmacy and health-related disparities. A significant body of research was identified lending insight to current patterns. However, this literature is fragmented across a range of concepts/populations. There are critical opportunities to advance scholarship.

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• • • •

Comorbidity and dementia: a scoping review of the literature.

Scoping Review of the Zika Virus Literature.

Executive functioning: a scoping review of the occupational therapy literature.

A scoping review of the proximal humerus fracture literature.

Understanding the Burden on Caregivers of People with Parkinson's: A Scoping Review of the Literature.

Millennium development goal four and child health inequities in indonesia: a systematic review of the literature.

Critical thinking in nursing: Scoping review of the literature.

How to report professional practice in nursing? A scoping review.

Reflective practice in speech-language pathology: a scoping review.

Berberis vulgaris for cardiovascular disorders: a scoping literature review.

The drinking water disparities framework: on the origins and persistence of inequities in exposure.

A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim.

Description of a practice model for pharmacist medication review in a general practice setting.

A scoping review of 10 years of published literature on community-based rehabilitation.

Economic evaluations of clinical pharmacist interventions on hospital inpatients: a systematic review of recent literature.

Ethnic Minority Status and Body Image Dissatisfaction: A Scoping Review of the Child and Adolescent Literature.

Health outcome disparities among subgroups of people with disabilities: a scoping review.

A scoping review of the association between rural medical education and rural practice location.

Empirical relationships between health literacy and treatment decision making: a scoping review of the literature.

Scoping literature review on the Learning Organisation concept as applied to the health system.

Risk Policies in the United States: Definition and Characteristics Based on a Scoping Review of the Literature.

Measuring the burden of treatment for chronic disease: implications of a scoping review of the literature.

What is the patient experience in advanced liver disease? A scoping review of the literature.

Factors Affecting Length of Stay in Adult Outpatient Physical Rehabilitation: A Scoping Review of the Literature.