Int J Clin Pharm (2014) 36:922–932 DOI 10.1007/s11096-014-0009-8
RESEARCH ARTICLE
A culturally competent education program to increase understanding about medicines among ethnic minorities Lourdes Cantarero-Are´valo • Dumoue Kassem Janine Marie Traulsen
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Received: 21 February 2014 / Accepted: 21 August 2014 / Published online: 7 September 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background It has been previously suggested that the risk of medicine-related problems—i.e., negative clinical outcomes, adverse drug reactions or adverse drug events resulting from the use (or lack of use) of medicines, and human error including that caused by healthcare personnel—is higher among specific ethnic minority groups compared to the majority population. Objective The focus of this study was on reducing medicine-related problems among Arabic-speaking ethnic minorities living in Denmark. The aim was twofold: (1) to explore the perceptions, barriers and needs of Arabic-speaking ethnic minorities regarding medicine use, and (2) to use an education program to enhance the knowledge and competencies of the ethnic minorities about the appropriate use of medicines. Settings Healthcare in Denmark is a tax-financed public service that provides free access to hospitals and general practitioners. In contrast to the USA or the UK, serving ethnically diverse populations is still a relatively new phenomenon for the Danish healthcare system. Ethnic minorities with a nonWestern background comprised a total of 6.9 % of the Danish population. Methods Data were collected through qualitative research. Four focus group interviews were conducted before and four after the education program. Thirty Arabic-speaking participants were recruited from language and job centers in Copenhagen. Participants
Electronic supplementary material The online version of this article (doi:10.1007/s11096-014-0009-8) contains supplementary material, which is available to authorized users. L. Cantarero-Are´valo (&) D. Kassem J. M. Traulsen Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark e-mail: [email protected]
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received teaching sessions in Arabic on appropriate medicine use. The education program was evaluated by two methods: a written quiz for knowledge evaluation and focus group interviews for process evaluation. It took place during the first semenester of 2012. Results The majority of the participants were dissatisfied with the knowledge about medicines inherited from their parents. They also expressed their frustrations due to communication problems with Danish doctors. According to the impressions and quiz results of participants, the program was relevant, rich in information and effective. The program helped bridge the gap between participants and doctors. The commonality of the culture, language and gender shared by the researcher pharmacist and participants enhanced the success of the program. Conclusion The education program may potentially reduce medicine-related problems by providing participants with knowledge and competencies about appropriate medicine use. We recommend implementing education programs for ethnic minorities using the cultural competence approach to the appropriate use of medicines. Ideally, programs should be implemented in places that are frequented by ethnic minorities, and taught by health professionals with the same ethnic background as participants. Keywords Cultural competence Ethnicity Language concordance Medicine use Medicine-related problems Patient education Qualitative research Impacts on Practice •
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Implementing cultural competent education programs for ethnic minorities to encourage appropriate use of medicines may reduce medicine-related problems. Programs should be implemented in places that are frequented by ethnic minorities.
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We recommend health professionals with the same ethnic background as participants to engage in these time of education programs
Introduction It has been previously suggested that the risk of medicinerelated problems (MRPs)—i.e., negative clinical outcomes, adverse drug reactions or adverse drug events resulting from the use (or lack of use) of medicines, and human error including that caused by healthcare personnel—is higher among specific ethnic minority groups compared to the majority population, and that their medicine-related needs may be poorly met [1]. Patients with different ethnic backgrounds may have their own perceptions and beliefs about health and healthcare that can affect their use of medicines. In addition, ethnic minority groups may face non-structural barriers, such as communication and language difficulties, which may also influence their ability to manage their medicines effectively [2–4]. By reviewing MRPs experienced by ethnic minority patients in the United Kingdom (UK), Alhomoud et al. [1] identified the following causes of MRPs: (1) limited knowledge of illness as well as its consequences and therapies [5–11]; (2) not taking medicines as advised [5–14]; (3) missing clinical appointments [9]; (4) high risk of adverse drug reactions (ADRs) [15, 16]; (5) drug interactions and adverse effects (AEs) [17]; (6) concern or fear about drug dependency or side effects [7, 18]; (7) cognitive, physical and sensory problems affecting use of medicines [11]; (8) language and communication barriers [12]; (9) lack of regular monitoring and review of medicines [5, 11]; (10) problems with non-prescription medicines [12]; (11) and problems with the use of and access to healthcare services [7, 11, 12]. Similar MRPs exist in Denmark. Ethnic minorities residing in this country experience an average of 3.4 MRPs per person annually. The most frequently identified MRPs are related to compliance problems and not following physicians’ recommendations for intake of medication [19, 20]. Furthermore, Folmann and Jørgensen [21] showed on the basis on data from national registers of medication that although the use of healthcare services is generally higher among ethnic minorities, consumption of medicine for a number of chronic diseases is less than expected among ethnic minorities compared to ethnic Danes. The authors further suggest that non-compliance problems may explain this discrepancy. Moreover, approximately 38 % of ethnic minorities living in Denmark take medication that is not prescribed for them, with over half taking medications purchased in their respective countries of origin [19, 22]. In addition to non-compliance and self-medication,
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inappropriate use of antibiotics is widespread among Arabicspeaking ethnic minorities [23–25]. MRPs are expensive for society. Inappropriate use of medication is a health risk factor that costs human lives and healthcare resources and is thus a serious problem for patient safety and society in general [23]. Therefore, there is an urgent need for research and intervention studies to enhance the appropriate use of medicines and reduce MRPs among ethnic minorities. A culturally competent education program was developed in Copenhagen, Denmark, which followed the recommendations of Povlsen et al. [24] after the implementation of their program aiming to educate families from ethnic minorities about type 1 diabetes. The recommendations taken into consideration were: involving people from ethnic communities in the earliest planning stages, emphasizing the importance of recognizing the role and influence of the immigrants’ culture and traditions, and including trainers and facilitators who share ethnic and cultural backgrounds with participants.
Theoretical inspiration: the cultural competence approach Culture has powerful influence on health, diagnosis, treatment, healing and the perception of illness and disease [25]. It also influences how patients seek healthcare and how they deal with healthcare providers. Therefore, healthcare systems and professionals frequently employ the cultural competence approach in order to work effectively in cross-cultural environments [26, 27]. Cultural competence is an approach based on a number of supportive social theories, such as socialization, theories of power, and theories about diversity and values, such as equity and social justice [28]. Implementing specific standards, policies and practices that comply with patients’ social, cultural and linguistic needs has been shown to increase the quality of healthcare services and produce better outcomes [29]. The approach is also said to enhance mutual understanding and improve communication between healthcare providers and patients, [30] reducing cultural and social barriers by recognizing and valuing the worth of individuals [31]. Moreover, awareness of one’s own cultural identity is said to help reduce stereotyping and increase the acceptance of diversity within other groups [32]. Based on the above, we used the cultural competence approach—defined as the ability to interact effectively and successfully with people from different cultural and ethnic backgrounds [32]—as a theoretical inspiration for developing an education program to prevent MRPs.
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Aim of the study This article argues for the need to implement a culturally competent education program for the appropriate use of medicines. The focus is on reducing MRPs among Arabicspeaking ethnic minorities living in Denmark. The aim is twofold: (1) to explore the perceptions, barriers and needs of Arabic-speaking ethnic minorities regarding medicine use, and (2) to use an education program to enhance the knowledge and competencies of ethnic minorities in the appropriate use of medicines and prevention of MRPs. Ethical approval The focus groups were conducted in a way that made individual identification impossible. This project did not require ethical approval by the Regional Committee on Biomedical Research Ethics. All personal identifiers have been removed or disguised so the persons described are not identifiable and cannot be identified through the details of the stories.
Methods Setting Healthcare in Denmark is a tax-financed public service that provides free access to hospitals and general practitioners [33]. Every person who resides legally in Denmark for more than 3 months is provided with a unique personal identification number that is used for administrative purposes and provides access to healthcare services on an equal basis with the majority population. Denmark operates with a system of progressive reimbursement for prescribed medication; the more expenses one incurs for reimbursable medicine within a 1-year period, the greater the reimbursement. The amount of reimbursement also depends on whether the recipient is under the age of 18 at the start of the reimbursement period, in which case the amount of reimbursement increases. The role of pharmacists in the Danish health care system Community pharmacies are privately owned, but the health authorities regulate drug prices and the number of pharmacies. All pharmacies provide prescription and over-thecounter products, advice about medicine use, dose dispensing, generic substitutions, and administration of individual reimbursement registers. Except for very simple
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processes, compounding is centralized at 3 pharmacies. Many pharmacies offer measurement of blood glucose, blood pressure, and cholesterol, and 60 % offer inhalation counseling, a reimbursed service. Research in pharmacy practice is well established and conducted primarily at universities and at Pharmakon A/S, which is owned by the Danish Pharmaceutical Association [34]. In contrast to the United States of America (USA) or the UK, serving ethnically diverse populations is still a relatively new phenomenon for the Danish healthcare system. Denmark has only had immigration in relatively large numbers and from non-Western countries within the past 50 years. As of 1 January 2013, ethnic minorities with a non-Western background comprised 6.9 % of the Danish population, a doubling since 1980. The largest groups are of Turkish, Iraqi, Lebanese, Bosnian Herzegovinian, and Pakistani descent [35]. Study design Figure 1 presents the overall structure of the study. Participants were recruited from the City of Copenhagen, Denmark and surrounding areas, where 14 % of the population has a non-Danish background (Statistics Denmark bank accessed in June 2014). The settings for initiating the education program were language, integration and job centers, places that Arabic-speaking ethnic minorities frequent. Inclusion criteria for participants were: belonging to an Arabic-speaking ethnic minority (Arabic being the most widely spoken non-Western language in the country), being at least 18 years old, and being willing to complete the entire education program, including participating in the final evaluation. Purposive sampling was used to recruit participants [36]. Pre-intervention Various centers were contacted, primarily by telephone. Initial contact was followed up by a detailed email about the objective and process of the intervention study. In total 18 centers were contacted and six of them agreed to implement the program. The number of participants recruited was 30. The recruitment process was handled through a series of presentations before the start of the program proper. Focus group interviews (30 participants in four different focus groups) were conducted to explore the topics that the participants wanted to learn about. Education content was prepared on the basis of these interviews. In keeping with the cultural competence approach, teaching content met the participants’ needs and expectations, as they were involved in selecting the topics. Four focus group pre-program
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Fig. 1 Overview of the program
In which ways could a culturally competent education program concerning appropriate medicine use help to reduce medicine-related problems among Arabic-speaking ethnic minorities in Denmark?
Pre-intervention Focus group interviews 30 participants
Intervention Education program 30 participants
Post-intervention Evaluation 23 particiants
Process evaluation Focus group interviews
Knowledge evaluation Quiz 8 participants
23 participants
interviews were conducted in three different centers. A semi-structured interview guide was prepared to provide structure and order while the interviews were being conducted. Interviews began with a brief description of the background of the researcher (Arabic-speaking pharmacist born in Lebanon and residing in Denmark for 10 years) as well as a description of the education program. The interviews were audio recorded with the permission of the group. Although all participants spoke Arabic, they came from different countries and thus spoke different dialects. Therefore, a simple and clear version of Arabic was used to avoid colloquial expressions and references to modern Standard Arabic (Standard or Literary Arabic is the standardized and literary form of Arabic used in writing and in most formal speech). The researcher avoided scientific and medical terms, as well as long comments and explanations. Participants were encouraged to talk, discuss and debate among themselves in order to generate rich data.
increased action competence through practical advice and guidance, and (3) raising their awareness about the consequences and complications of inappropriate medicine use. In acknowledgement of the limitations of previous education programs held in Denmark [24], and as a way of developing trust with participants, the education program was conducted in Arabic to ensure that participants with limited Danish language proficiency were effectively informed. Two 90-min teaching sessions (two different lessons) were held. The 30 participants were encouraged to ask questions and discuss issues in depth, which allowed the researcher to modify the content of the talk to meet the specific needs and interests of the group. Short exercises such as calculating daily calcium intake and filling out a questionnaire on depression were introduced to stimulate interaction and the exchange of experiences between participants.
Intervention
The evaluation of the intervention was intended to assess the extent to which the education program achieved its objectives. The evaluation consisted of two parts, process evaluation (23 participants) and knowledge evaluation (eight participants), and considered the program as a whole. The aim of the process evaluation was to evaluate whether the program was worthwhile, relevant and
The objective of the education program was to enhance the knowledge and competencies of Arabic-speaking ethnic minorities concerning appropriate medicine use by: (1) providing them with information and facts about medicinerelated topics and medicine groups, (2) giving them
Post-intervention
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beneficial from the point of view of participants. It was conducted in the form of focus group interviews because two participants were illiterate. The aim of the knowledge evaluation was to examine whether the education program enhanced the knowledge and competencies of participants concerning appropriate medicine use. Knowledge was assessed before and after the program. A written (or oral for the two illiterate participants) evaluation was conducted in the form of a quiz consisting of true/false and multiple-choice questions. Quiz
Fig. 2 Nationality of participants (N = 30)
Written evaluation was conducted in the form of a combined quiz consisting of true/false and multiple-choice questions. The quiz was based on the original teaching materials and quiz developed by Pharmakon. This evaluation addressed the following supplementary research question: ‘‘How does the teaching program influence the knowledge of participants about optimal medicine use?’’ All five classes took the quiz at the completion of the education program, but only three of them were tested before the program. The first two classes were conducted early in the process before the evaluation method had been fully developed, which is why they did not get the chance to take the quiz before the education program commenced. Participants were only tested on the topics that were explained to them; questions addressing other topics were eliminated. Only those participants who took part in the pre-intervention focus groups, all teachings and postintervention focus group were eligible to take the quiz. The quiz was conducted between two to 3 weeks after the intervention, right before the process evaluation. The degree of difficulty of the quiz was designed as moderate to accommodate the variation in education level of participants from illiterate to highly educated. Participants who were illiterate or could not read Arabic met in a group and the pharmacist read each question aloud, after which participants were asked to select their preferred option. Although there were only four participants in the group, the process was time consuming. The quizzes were graded and a percentage was calculated based on the number of correct responses. Wrong responses did not penalize. The total mark varied from one lesson to another depending on the number of topics covered and thus the number of questions. Percentages were calculated to facilitate the comparison of the results.
These statements were sorted into the simplest themes/categories possible. Additional themes were identified, such as ‘‘mistrust in Danish doctors’’. The schema also included a descriptive statement column where the meaning of the various statements was summarized and clarified. This technique allowed greater comparability of the meaning condensation schemas across the different interviews.
Data analysis A meaning condensation schema [36] was made for each interview in order to create an overview. The entire transcript was read carefully and meaningful statements identified.
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Results The 30 participants (27 females, 3 males) ranged in age from 21 to 60 years (mean age: 38). All participants spoke Arabic. Figure 2 presents participants by nationality. Eleven participants had lived in Denmark for more than 10 years. Only three participants were newcomers, that is, had lived in Denmark for less than a year. Based on the focus group discussions, the education program selected the topic of major interests for the participants. Among the most commons ones are children medication, Generics and reimbursements, antidepressants and side effects as well as communication with Danish doctors. Results from the pre-intervention focus group interviews On beliefs, perceptions and barriers Many participants asserted that they had inherited their beliefs and perceptions concerning optimal medicine use from their parents. They were, however, dissatisfied with these beliefs. The majority reported having incorrect information about medicines. We have wrong beliefs from our parents that all medicines must be stored in the fridge and that children should be given medicines as soon as they feel the symptoms of infection. (FG 5) Several participants complained about the lack of guidance from Danish doctors concerning appropriate
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We are coming from a different country, culture and system, and we have to adjust to a new society. Everything is different. (FG 8)
Mistrust
Figure 3 presents an overview of the three most frequently mentioned barriers participants face concerning appropriate use of medicines. Needs concerning appropriate medicine use
Language
Alienation
Fig. 3 Barriers participants face concerning appropriate use of medicines
Many participants expressed the need for information about medicines and appropriate medicine use. In their opinion, the lack of effective regulatory systems and awareness campaigns in their countries of origin has contributed to their need for this information. There are no regulatory systems in our countries, so we need information about medicines. (FG 7)
medicine use, and voiced doubts about their medical skills and experience. Moreover, some participants were frustrated by the inability of these doctors to deal with them and their needs as foreigners.
Some participants expected to get this information primarily from doctors. As newcomers, they expected doctors to give them the necessary information and instructions on medicine-related topics.
We have a huge problem. Danish doctors ignore our needs. They never prescribe medicine for us, even when we are very sick. (FG 1)
Doctors should take the initiative and inform us about these [medicine-related] topics, at least for those of us who are newcomers and can’t speak Danish. (FG 7)
In contrast, some of the participants refused to take medication prescribed by Danish doctors, preferring to consult doctors in their home countries. When I go home, I don’t take the prescribed medication, because I think that he [the Danish doctor] just wants to get rid of me. So when I visit Morocco, I consult a doctor. (FG 6) Citing their limited proficiency in Danish, all participants reported having difficulties in communicating with healthcare providers concerning appropriate medicine use. They believed that the language barrier applies to all foreigners, but is more significant for newcomers than for those who have been living in Denmark for a long period of time. We don’t speak Danish properly, which hinders us from communicating with the doctor about medicines and their side effects. (FG 6) The majority of participants found it impossible to understand the instructions and recommendations of their doctor in Danish. This lack of understanding is why some participants believed that it is useless to consult a doctor. Some participants expressed general feelings of isolation and alienation after moving to a new country with new rules, values and principles, and this spilled over into their contacts with the healthcare system.
The majority of the participants thought that foreigners should be informed about the appropriate use of medicine as soon as they arrive in Denmark in order to raise awareness and avoid MRPs. Selected medicine-related topics Figure 4 provides an overview of the medicine-related topics selected by participants The majority of the participants expressed interest in children and medicines. Most of them complained about the strict policy Danish doctors follow concerning medicating children. This topic [children’s medication] is important. Especially if you could tell us why Danish doctors do not prescribe medicines for children. (FG 4) In addition to children’s medication, the majority, especially newcomers, expressed an interest in generic medicines and the reimbursement system. I have never heard about it [the reimbursement system]. (FG 2) All participants seemed quite confused and insecure regarding the difference between generic and branded medicines. Some of them believed that the price difference was due to variation in quality.
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Selected topics by lesson Number of lessons
Fig. 4 Selected medicinerelated topics by lesson taught
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Selected topics
I feel insecure about choosing the cheapest. I do not have enough money to choose the good quality product. (FG 1) The majority of participants considered ‘side effects of medicines’ a relevant and important topic. They were curious to know about side effects and their causes. They were also interested in learning how they could avoid side effects. I take my pills and I am afraid that they are damaging my body. (FG 1) All participants complained about the difficulty of getting access to antibiotics because, in most cases, doctors refuse to prescribe them. The only advice that Danish doctors have whenever I am sick is drink water! Water is not a cure. We need antibiotics to treat infections, so it is not for fun we ask for them! (FG 1) Results from the education program Participants’ acquired knowledge after the education program Based on the statements from participants, the education program provided them with new knowledge and information about various medicine-related topics. According to participants, approximately 70–80 % of the teaching content was new information (FG 7). The majority believe that this information made them aware of the consequences and dangers of using medicines inappropriately. It also made them able to distinguish between correct and incorrect practices such as the importance of continuing a course of antibiotics and the consequences of suddenly discontinuing. One of the most important things we learned was following the doctor’s recommendations about
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finishing the course of antibiotics and not quitting the medicine the moment we feel better. (FG 8) In addition to acquiring new information about medicine-related topics, some participants stated that the teaching program helped them improve their communication with doctors. Moreover, their beliefs and perception of Danish doctors changed after the program. Mistrust in the competencies of Danish doctors to become more accepting, understanding and appreciating their decisions. Now we know that they [Danish doctors] want to help us find the appropriate treatment. (FG 6) When the doctor refuses to prescribe medicine for my son, now I know it is for my son’s sake. (FG 8) After the program, the majority of participants agreed that it was wrong to share their prescribed medicines with relatives or friends or buy medicines from home countries. I shouldn’t share medicines with relatives or friends without a doctor’s prescription. (FG 8) Quiz results Many participants found it daunting to answer the questions in the quiz prior to the education program. They were uncertain about their answers and hesitated a long time over each question. After the program, they spent less time answering the quiz questions and seemed more confident about their answers. When we answered the questions in the quiz at the beginning [prior to the program], there were many things we didn’t understand, but now it’s different. I felt that I know more and can answer more confidently. (FG 8) To simplify analyzing and comparing the results of the quiz, only eight participants who answered the quiz before
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Fig. 5 The quiz results of participants in percentage of correct answers (N = 8)
Marks
Quiz results
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Participants Pre-Intervention
and after the education program are presented below (Fig. 5). Participants’ knowledge increased after the education program (Fig. 5). Overall, marks increased after the education program. The highest and lowest mark pre-program is 74 and 46 %, respectively. In contrast, the highest and lowest mark post-program is 91 and 62 %, respectively. The difference between mean pre-program (62 %) and mean post-program (84 %) is 22 %. Influence of researcher’s ethnic background on education program The majority of participants believe that culture and language play an important role in the success of a project like this one. You [the researcher] have lived in an Arabic country and share the same background as ours, so that’s why you understand our conditions and circumstances. (FG 6) All participants appreciated that the education program was conducted in Arabic due to their limited proficiency in Danish. They did not believe they would not have benefited had the program been conducted in Danish. The best thing you did is decide to teach us in Arabic. (FG 6) Impressions and feedback about the education program All participants considered the program quite beneficial and useful because it provided them with relevant information, made them aware of consequences and changed their beliefs and habits. Furthermore, many of them reported that they gained valuable information about Danish healthcare providers, which made them increase their understanding. If you did not come here and teach us about medicines, we would have been sleeping [Arabic expression meaning unaware of the consequences]. (FG 5)
Post-Intervention
Discussion The results show that a culturally competent education program to prevent MRPs among ethnic minorities is relevant and effective. Moreover, it reveals that participants were not only aware of but also dissatisfied with their own knowledge about medicines. This is in accordance with the results of the Al-Saeedi study, which showed a high rate of treatment-related misconceptions [37]. These misconceptions have obviously influenced medicine-related behavior and habits, and in most cases led to inappropriate use of medicines. In addition to misconceptions, participants identified various barriers to their acceptance of the Danish healthcare system that indirectly affected their use of medicines. Several studies have shed light on these barriers and their significance on ethnic minorities’ access to the healthcare system [24, 38, 39]. The main findings of this study reveal mistrust in Danish doctors as one of the major barriers between participants and appropriate medicine use. Lack of confidence in the competencies and skills of doctors can lead to doubts about diagnosis and thus prescribed treatment. Consequently, participants’ compliance and adherence to doctors’ recommendations is low. This finding is in accordance with studies showing high non-compliance rates among ethnic minorities [19, 20]. Lack of effective communication due to linguistic barriers between healthcare providers and participants appeared to lead to inappropriate use of medicines. This finding supports earlier Danish and international studies that focus on linguistic barriers among ethnic minorities. These studies elucidate the association between linguistic barriers, MRPs and constrained communication [19, 38, 40]. Furthermore, the participants reported feelings of alienation and isolation that may affect their psychological wellbeing, health and medicine use. Povlsen has also described how alienation and lack of social network affects minorities’ psychological state and limits their access to healthcare services [24].
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The evaluation reveals that having an Arabic-speaking pharmacist who shares the same culture and background as the majority of participants had a great impact on the success of the program. Knowledge of and acquaintance with the traditions, norms, beliefs, perceptions and communication styles of participants appeared to reduce the gap between them and the pharmacist. Moreover, it reduced former barriers including mistrust in the healthcare provider and feelings of alienation and isolation. In addition, having confidence in the pharmacist created an open and relaxing atmosphere that facilitated dissemination of the message about appropriate use of medicines. Consequently, participants were more open to new knowledge. This is similar to the results of the evaluation reported by Nielsen, in which participants saw health intermediaries as peers because they shared the same ethnic background [41]. Language is another major factor that influenced the success of the program. This finding is in agreement with the results of Nielsen that stress the importance of conducting teaching sessions in participants’ native language to avoid language barriers [41]. Arab culture is relatively conservative, with the relationship between men and women set by norms and traditions defined by society. Therefore, the majority of female participants stressed the importance of being taught by a pharmacist of the same gender to avoid discomfort, embarrassment and shyness. The same results were found in Nielsen’s 2008 report in which participants expressed the importance of gender on communication, confidence and trust in the health intermediary [41]. The education program had impact on the participants’ beliefs and perceptions. Introducing them to scientific knowledge and the potential consequences of medicines raised awareness among those who used medicines inappropriately. This in turn resulted in motivating them to change their inherit beliefs, perceptions and behavior about medicines. After the education program, participants perceived sharing, misusing or buying medicines from home countries as wrong. Participants understood the danger of this behavior after being informed about interactions, side effects and other MRPs. One major impact of the program was reducing mistrust towards Danish doctors. Explaining the strict policy followed by Danish doctors in prescribing medicines, especially antibiotics and children’s medication, helped participants understand doctors and appreciate their decisions. We believe that bridging the gap between participants and doctors can lead to better communication resulting in appropriate use of medicines. Strengths and limitations The cultural and linguistic sensitivity of the program proved to be effective. The combination of the professional
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and cultural background and gender of the pharmacist instructor made it possible for her to motivate and communicate easily with participants. Nonetheless, there are some limitations to this education program. Although all the participants could speak Arabic, those from North Africa had difficulty understanding some specific terms from Standard Arabic, as they spoke a dialect. We therefore assume that their level of understanding and acquisition of knowledge was negatively affected. Future education programs could focus on grouping ethnic minorities by country and dialect. Ideally and if the resources are available, the researcher would also come from the same country or at least be fluent in the participants’ dialect.
Conclusion The results of the study reported in this article showed the relevance and effectiveness of conducting a culturally competent education program on appropriate use of medicines. The evaluation showed that providing knowledge and competencies about the appropriate use of medicine raises awareness about MRPs. Consequently, participants were motivated to change and adapt their attitudes according to the information provided. Moreover, the program also contributed indirectly to the appropriate use of medicines by potentially bridging the gap between participants and Danish doctors. We recommend future research to examine the effect of this education program on actual changes in medicine behavior as well as to tailor this kind of program for ethnic minority groups sharing the same country of origin. Acknowledgments We are grateful to the people who participated in the program. We would also like to thank Pharmakon for allowing us to use original teaching materials for translation and adaptation. Funding This project was funded by the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. Conflicts of interest The authors have no conflicts of interest to declare.
References 1. Alhomoud F, Dhillon S, Aslanpour Z, Smith F. Medicine use and medicine-related problems experienced by ethnic minority patients in the United Kingdom: a review. Int J Pharm Pract. 2013;21(5):277–87. 2. Gordon KJ, Smith FJ, Dhillon S. The development and validation of a screening tool for the identification of patients experiencing medication-related problems. Int J Pharm Pract. 2005;13(3): 187–93.
Int J Clin Pharm (2014) 36:922–932 3. Szczepura A. Access to health care for ethnic minority populations. Postgrad Med J. 2005;81(953):141–7. 4. Kontopantelis E, Roland M, Reeves D. Patient experience of access to primary care: identification of predictors in a national patient survey. BMC Fam Pract. 2010;11(1):61. 5. Lip GYH, Kamath S, Jafri M, Mohammed A, Bareford D. Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project. Strok. 2002;33(1):238–42. 6. Lip GYH, Khan H, Bhatnagar A, Brahmabhatt N, Crook P, Davies MK. Ethnic differences in patient perceptions of heart failure and treatment: the West Birmingham heart failure project. Heart. 2004;90(9):1016–9. 7. Morgan M, Figueroa-Mun˜oz JI. Barriers to uptake and adherence with malaria prophylaxis by the African Community in London, England: focus Group Study. Ethn Health. 2005;10(4):355–72. 8. Horne R, Graupner L, Frost S, Weinman J, Wright SM, Hankins M. Medicine in a multi-cultural society: the effect of cultural background on beliefs about medications. Soc Sci Med. 2004;59(6):1307–13. 9. Pardhan S, Mahomed I. Knowledge, self-help and socioeconomic factors in South Asian and Caucasian diabetic patients. Eye. 2004;18(5):509–13. 10. Lawton J, Ahmad N, Hallowell N, Hanna L, Douglas M. Perceptions and experiences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: qualitative study. BMJ. 2005;330(7502):1247. 11. Gordon K, Smith F, Dhillon S. Effective chronic disease management: patients’ perspectives on medication-related problems. Patient Educ Couns. 2007;65(3):407–15. 12. Chan C. A study of health services for the Chinese minority in Manchester. Br J Community Nurs. 2000;5(3):140–7. 13. Kumar K, Gordon C, Toescu V, Buckley CD, Horne R, Nightingale PG, et al. Beliefs about medicines in patients with rheumatoid arthritis and systemic lupus erythematosus: a comparison between patients of South Asian and White British origin. Rheumatology. 2008;47(5):690–7. 14. Wheatly RS, Shelly MP. Drug treatment during Ramadan. Stopping bronchodilator treatment is dangerous. BMJ. 1993; 307(6907):801. 15. McDowell SE, Coleman JJ, Ferner RE. Systematic review and metaanalysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine. BMJ. 2006;332(7551):1177–81. 16. Ormerod S, McDowell SE, Coleman JJ, Ferner PRE. Ethnic differences in the risks of adverse reactions to drugs used in the treatment of psychoses and depression. Drug Saf. 2008;31(7): 597–607. 17. Tsang C, Majeed A, Banarsee R, Gnani S, Aylin P. Recording of adverse events in English general practice: analysis of data from electronic patient records. Inform Prim Care. 2010;18(2):117–24. 18. Harris Y, Gorelick PB, Samuels P, Bempong I. Why African Americans may not be participating in clinical trials. J Natl Med Assoc. 1996;88(10):630–4. 19. Sønderga˚rd B, Haugbølle LS, Traulsen JM, El-souri M, Mygind A. Optimal drug use among non-ethnic Danes (part 2) Implementation of medication review. (Optimal lægemiddelanvendelse blandt ikke-etniske danskere (del 2); Gennemførelse af medicingennemgang). Copenhagen: Faculty of Pharmacy, University of Copenhagen; 2009. 20. Lauridsen L, Gudex C, Hansen M. Evaluation of medication review given to non-ethnic Danish patients. (Evaluering af medicingennemgang givet til ikke-etniske danske patienter). Odense: University of Sounthern Denmark; 2009. 21. Folmann N, Jørgensen T. Ethnic minorities—illness and the use of healthcare services (Etniske minoriteter – sygdom og brug af
931
22.
23.
24.
25.
26.
27.
28. 29.
30.
31.
32.
33. 34.
35. 36.
37.
38.
39.
sundhedsvæsenet). Copenhagen: The National Board of Health; 2006. Volodina A, Bertsche T, Kostev K, Winkler V, Haefeli WE, Becher H. Drug utilization patterns and reported health status in ethnic German migrants (Aussiedler) in Germany: a cross-sectional study. BMC Public Health. 2011;11:509. Knudsen P, Sønderga˚rd B, Rossing C, Herborg H. Evidence report: survey of medicine-related problems (Evidensrapport: Kortlægning af lægemiddelrelaterede problemer). Copenhagen: Pharmakon; 2006. Povlsen L, Olsen B, Ladelund S. Educating families from ethnic minorities in type 1 diabetes—experiences from a Danish intervention study. Patient Educ Couns. 2005;59(2):164–70. Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry. Berkeley: University of California Press; 1981. Cross TL, Others A. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Marts 1989 [Last cited 6. December 2013]; Hentet fra: http://eric.ed.gov/?id=ED330171. Isaacs MR, Benjamin MP. Towards a culturally competent system of care. Volume II: programs which utilize culturally competent principles. December 1991 [Last cited 6. December 2013]; Hentet fra: http://eric.ed.gov/?id=ED345393. Farley JE. Minority-majority relations. USA: Prentice Hall; 2005. Exploring the Intersection Between Cultural Competency and Managed Behavioral Health Care Policy: Implications for State and County Mental Health Agencies. [Internet]. National Health Care for the Homeless Council. [Last cited 6. December 2013]. Hentet fra: http://www.nhchc.org/bibliograpy/exploring-the-inter section-between-cultural-competency-and-managed-behavioralhealth-care-policy-implications-for-state-and-county-mentalhealth-agencies/. How health systems can address health inequities linked to migration and ethnicity [Internet]. [Last cited 6. December 2013]. Hentet fra: http://www.euro.who.int/en/health-topics/health-deter minants/social-determinants/publications/2010/how-health-systemscan-address-health-inequities-linked-to-migration-and-ethnicity. Gallegos JS, Tindall C, Gallegos SA. The need for advancement in the conceptualization of cultural competence. Adv Soc Work. 2008;9(1):51–62. National Association of Social Workers (NASW). NASW standars for cultural competence in social work practice. Washington: NASW; 2001. Krasnik A, Christiansen T, Høyer K, Vallga˚rda S. Health Services and Health policy. Denmark: Gyldendal/Munksgaard; 2008. Herborg H, Sørensen EW, Frøkjaer B. Pharmaceutical care in community pharmacies: practice and research in Denmark. Ann Pharmacother. 2007;41(4):681–9. Statistical Yearbook 2012. Statistics Denmark. Copenhagen, 13 June 2012. Ebrahim S, Bowling A. Handbook of health research methods: investigation, measurement and analysis. New York: McGrawHill International; 2005. p. 639. Al-Saeedi M, Elzubier AG, Bahnassy AA, Al-Dawood KM. Treatment-related misconceptions among diabetic patients in Western Saudi Arabia. Saudi Med J. 2002;23(10):1243–6. Michaelsen J, Krasnik A, Nielsen A, Norredam M, Torres AM. Health professionals’ knowledge, attitudes, and experiences in relation to immigrant patients: a questionnaire study at a Danish hospital. Scand J Public Health. 2004;32(4):287–95. Mygind A, Espersen S, Nørgaard LS, Traulsen JM. Encounters with immigrant customers: perspectives of Danish community pharmacy staff on challenges and solutions. Int J Pharm Pract. 2013;21(3):139–50.
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932 40. Clark T, Sleath B, Rubin RH. Influence of ethnicity and language concordance on physician–patient agreement about recommended changes in patient health behavior. Patient Educ Couns. 2004;53(1): 87–93.
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Int J Clin Pharm (2014) 36:922–932 41. Nielsen AS, København DF. Sundhed pa˚ dit sprog: evalueringsrapport. Københavns Kommune, Sundheds- og Omsorgsforvaltningen, Folkesundhed København; 2006. 40 p.
RESEARCH ARTICLE
A culturally competent education program to increase understanding about medicines among ethnic minorities Lourdes Cantarero-Are´valo • Dumoue Kassem Janine Marie Traulsen
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Received: 21 February 2014 / Accepted: 21 August 2014 / Published online: 7 September 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background It has been previously suggested that the risk of medicine-related problems—i.e., negative clinical outcomes, adverse drug reactions or adverse drug events resulting from the use (or lack of use) of medicines, and human error including that caused by healthcare personnel—is higher among specific ethnic minority groups compared to the majority population. Objective The focus of this study was on reducing medicine-related problems among Arabic-speaking ethnic minorities living in Denmark. The aim was twofold: (1) to explore the perceptions, barriers and needs of Arabic-speaking ethnic minorities regarding medicine use, and (2) to use an education program to enhance the knowledge and competencies of the ethnic minorities about the appropriate use of medicines. Settings Healthcare in Denmark is a tax-financed public service that provides free access to hospitals and general practitioners. In contrast to the USA or the UK, serving ethnically diverse populations is still a relatively new phenomenon for the Danish healthcare system. Ethnic minorities with a nonWestern background comprised a total of 6.9 % of the Danish population. Methods Data were collected through qualitative research. Four focus group interviews were conducted before and four after the education program. Thirty Arabic-speaking participants were recruited from language and job centers in Copenhagen. Participants
Electronic supplementary material The online version of this article (doi:10.1007/s11096-014-0009-8) contains supplementary material, which is available to authorized users. L. Cantarero-Are´valo (&) D. Kassem J. M. Traulsen Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, Universitetsparken 2, 2100 Copenhagen, Denmark e-mail: [email protected]
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received teaching sessions in Arabic on appropriate medicine use. The education program was evaluated by two methods: a written quiz for knowledge evaluation and focus group interviews for process evaluation. It took place during the first semenester of 2012. Results The majority of the participants were dissatisfied with the knowledge about medicines inherited from their parents. They also expressed their frustrations due to communication problems with Danish doctors. According to the impressions and quiz results of participants, the program was relevant, rich in information and effective. The program helped bridge the gap between participants and doctors. The commonality of the culture, language and gender shared by the researcher pharmacist and participants enhanced the success of the program. Conclusion The education program may potentially reduce medicine-related problems by providing participants with knowledge and competencies about appropriate medicine use. We recommend implementing education programs for ethnic minorities using the cultural competence approach to the appropriate use of medicines. Ideally, programs should be implemented in places that are frequented by ethnic minorities, and taught by health professionals with the same ethnic background as participants. Keywords Cultural competence Ethnicity Language concordance Medicine use Medicine-related problems Patient education Qualitative research Impacts on Practice •
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Implementing cultural competent education programs for ethnic minorities to encourage appropriate use of medicines may reduce medicine-related problems. Programs should be implemented in places that are frequented by ethnic minorities.
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We recommend health professionals with the same ethnic background as participants to engage in these time of education programs
Introduction It has been previously suggested that the risk of medicinerelated problems (MRPs)—i.e., negative clinical outcomes, adverse drug reactions or adverse drug events resulting from the use (or lack of use) of medicines, and human error including that caused by healthcare personnel—is higher among specific ethnic minority groups compared to the majority population, and that their medicine-related needs may be poorly met [1]. Patients with different ethnic backgrounds may have their own perceptions and beliefs about health and healthcare that can affect their use of medicines. In addition, ethnic minority groups may face non-structural barriers, such as communication and language difficulties, which may also influence their ability to manage their medicines effectively [2–4]. By reviewing MRPs experienced by ethnic minority patients in the United Kingdom (UK), Alhomoud et al. [1] identified the following causes of MRPs: (1) limited knowledge of illness as well as its consequences and therapies [5–11]; (2) not taking medicines as advised [5–14]; (3) missing clinical appointments [9]; (4) high risk of adverse drug reactions (ADRs) [15, 16]; (5) drug interactions and adverse effects (AEs) [17]; (6) concern or fear about drug dependency or side effects [7, 18]; (7) cognitive, physical and sensory problems affecting use of medicines [11]; (8) language and communication barriers [12]; (9) lack of regular monitoring and review of medicines [5, 11]; (10) problems with non-prescription medicines [12]; (11) and problems with the use of and access to healthcare services [7, 11, 12]. Similar MRPs exist in Denmark. Ethnic minorities residing in this country experience an average of 3.4 MRPs per person annually. The most frequently identified MRPs are related to compliance problems and not following physicians’ recommendations for intake of medication [19, 20]. Furthermore, Folmann and Jørgensen [21] showed on the basis on data from national registers of medication that although the use of healthcare services is generally higher among ethnic minorities, consumption of medicine for a number of chronic diseases is less than expected among ethnic minorities compared to ethnic Danes. The authors further suggest that non-compliance problems may explain this discrepancy. Moreover, approximately 38 % of ethnic minorities living in Denmark take medication that is not prescribed for them, with over half taking medications purchased in their respective countries of origin [19, 22]. In addition to non-compliance and self-medication,
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inappropriate use of antibiotics is widespread among Arabicspeaking ethnic minorities [23–25]. MRPs are expensive for society. Inappropriate use of medication is a health risk factor that costs human lives and healthcare resources and is thus a serious problem for patient safety and society in general [23]. Therefore, there is an urgent need for research and intervention studies to enhance the appropriate use of medicines and reduce MRPs among ethnic minorities. A culturally competent education program was developed in Copenhagen, Denmark, which followed the recommendations of Povlsen et al. [24] after the implementation of their program aiming to educate families from ethnic minorities about type 1 diabetes. The recommendations taken into consideration were: involving people from ethnic communities in the earliest planning stages, emphasizing the importance of recognizing the role and influence of the immigrants’ culture and traditions, and including trainers and facilitators who share ethnic and cultural backgrounds with participants.
Theoretical inspiration: the cultural competence approach Culture has powerful influence on health, diagnosis, treatment, healing and the perception of illness and disease [25]. It also influences how patients seek healthcare and how they deal with healthcare providers. Therefore, healthcare systems and professionals frequently employ the cultural competence approach in order to work effectively in cross-cultural environments [26, 27]. Cultural competence is an approach based on a number of supportive social theories, such as socialization, theories of power, and theories about diversity and values, such as equity and social justice [28]. Implementing specific standards, policies and practices that comply with patients’ social, cultural and linguistic needs has been shown to increase the quality of healthcare services and produce better outcomes [29]. The approach is also said to enhance mutual understanding and improve communication between healthcare providers and patients, [30] reducing cultural and social barriers by recognizing and valuing the worth of individuals [31]. Moreover, awareness of one’s own cultural identity is said to help reduce stereotyping and increase the acceptance of diversity within other groups [32]. Based on the above, we used the cultural competence approach—defined as the ability to interact effectively and successfully with people from different cultural and ethnic backgrounds [32]—as a theoretical inspiration for developing an education program to prevent MRPs.
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Aim of the study This article argues for the need to implement a culturally competent education program for the appropriate use of medicines. The focus is on reducing MRPs among Arabicspeaking ethnic minorities living in Denmark. The aim is twofold: (1) to explore the perceptions, barriers and needs of Arabic-speaking ethnic minorities regarding medicine use, and (2) to use an education program to enhance the knowledge and competencies of ethnic minorities in the appropriate use of medicines and prevention of MRPs. Ethical approval The focus groups were conducted in a way that made individual identification impossible. This project did not require ethical approval by the Regional Committee on Biomedical Research Ethics. All personal identifiers have been removed or disguised so the persons described are not identifiable and cannot be identified through the details of the stories.
Methods Setting Healthcare in Denmark is a tax-financed public service that provides free access to hospitals and general practitioners [33]. Every person who resides legally in Denmark for more than 3 months is provided with a unique personal identification number that is used for administrative purposes and provides access to healthcare services on an equal basis with the majority population. Denmark operates with a system of progressive reimbursement for prescribed medication; the more expenses one incurs for reimbursable medicine within a 1-year period, the greater the reimbursement. The amount of reimbursement also depends on whether the recipient is under the age of 18 at the start of the reimbursement period, in which case the amount of reimbursement increases. The role of pharmacists in the Danish health care system Community pharmacies are privately owned, but the health authorities regulate drug prices and the number of pharmacies. All pharmacies provide prescription and over-thecounter products, advice about medicine use, dose dispensing, generic substitutions, and administration of individual reimbursement registers. Except for very simple
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processes, compounding is centralized at 3 pharmacies. Many pharmacies offer measurement of blood glucose, blood pressure, and cholesterol, and 60 % offer inhalation counseling, a reimbursed service. Research in pharmacy practice is well established and conducted primarily at universities and at Pharmakon A/S, which is owned by the Danish Pharmaceutical Association [34]. In contrast to the United States of America (USA) or the UK, serving ethnically diverse populations is still a relatively new phenomenon for the Danish healthcare system. Denmark has only had immigration in relatively large numbers and from non-Western countries within the past 50 years. As of 1 January 2013, ethnic minorities with a non-Western background comprised 6.9 % of the Danish population, a doubling since 1980. The largest groups are of Turkish, Iraqi, Lebanese, Bosnian Herzegovinian, and Pakistani descent [35]. Study design Figure 1 presents the overall structure of the study. Participants were recruited from the City of Copenhagen, Denmark and surrounding areas, where 14 % of the population has a non-Danish background (Statistics Denmark bank accessed in June 2014). The settings for initiating the education program were language, integration and job centers, places that Arabic-speaking ethnic minorities frequent. Inclusion criteria for participants were: belonging to an Arabic-speaking ethnic minority (Arabic being the most widely spoken non-Western language in the country), being at least 18 years old, and being willing to complete the entire education program, including participating in the final evaluation. Purposive sampling was used to recruit participants [36]. Pre-intervention Various centers were contacted, primarily by telephone. Initial contact was followed up by a detailed email about the objective and process of the intervention study. In total 18 centers were contacted and six of them agreed to implement the program. The number of participants recruited was 30. The recruitment process was handled through a series of presentations before the start of the program proper. Focus group interviews (30 participants in four different focus groups) were conducted to explore the topics that the participants wanted to learn about. Education content was prepared on the basis of these interviews. In keeping with the cultural competence approach, teaching content met the participants’ needs and expectations, as they were involved in selecting the topics. Four focus group pre-program
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Fig. 1 Overview of the program
In which ways could a culturally competent education program concerning appropriate medicine use help to reduce medicine-related problems among Arabic-speaking ethnic minorities in Denmark?
Pre-intervention Focus group interviews 30 participants
Intervention Education program 30 participants
Post-intervention Evaluation 23 particiants
Process evaluation Focus group interviews
Knowledge evaluation Quiz 8 participants
23 participants
interviews were conducted in three different centers. A semi-structured interview guide was prepared to provide structure and order while the interviews were being conducted. Interviews began with a brief description of the background of the researcher (Arabic-speaking pharmacist born in Lebanon and residing in Denmark for 10 years) as well as a description of the education program. The interviews were audio recorded with the permission of the group. Although all participants spoke Arabic, they came from different countries and thus spoke different dialects. Therefore, a simple and clear version of Arabic was used to avoid colloquial expressions and references to modern Standard Arabic (Standard or Literary Arabic is the standardized and literary form of Arabic used in writing and in most formal speech). The researcher avoided scientific and medical terms, as well as long comments and explanations. Participants were encouraged to talk, discuss and debate among themselves in order to generate rich data.
increased action competence through practical advice and guidance, and (3) raising their awareness about the consequences and complications of inappropriate medicine use. In acknowledgement of the limitations of previous education programs held in Denmark [24], and as a way of developing trust with participants, the education program was conducted in Arabic to ensure that participants with limited Danish language proficiency were effectively informed. Two 90-min teaching sessions (two different lessons) were held. The 30 participants were encouraged to ask questions and discuss issues in depth, which allowed the researcher to modify the content of the talk to meet the specific needs and interests of the group. Short exercises such as calculating daily calcium intake and filling out a questionnaire on depression were introduced to stimulate interaction and the exchange of experiences between participants.
Intervention
The evaluation of the intervention was intended to assess the extent to which the education program achieved its objectives. The evaluation consisted of two parts, process evaluation (23 participants) and knowledge evaluation (eight participants), and considered the program as a whole. The aim of the process evaluation was to evaluate whether the program was worthwhile, relevant and
The objective of the education program was to enhance the knowledge and competencies of Arabic-speaking ethnic minorities concerning appropriate medicine use by: (1) providing them with information and facts about medicinerelated topics and medicine groups, (2) giving them
Post-intervention
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beneficial from the point of view of participants. It was conducted in the form of focus group interviews because two participants were illiterate. The aim of the knowledge evaluation was to examine whether the education program enhanced the knowledge and competencies of participants concerning appropriate medicine use. Knowledge was assessed before and after the program. A written (or oral for the two illiterate participants) evaluation was conducted in the form of a quiz consisting of true/false and multiple-choice questions. Quiz
Fig. 2 Nationality of participants (N = 30)
Written evaluation was conducted in the form of a combined quiz consisting of true/false and multiple-choice questions. The quiz was based on the original teaching materials and quiz developed by Pharmakon. This evaluation addressed the following supplementary research question: ‘‘How does the teaching program influence the knowledge of participants about optimal medicine use?’’ All five classes took the quiz at the completion of the education program, but only three of them were tested before the program. The first two classes were conducted early in the process before the evaluation method had been fully developed, which is why they did not get the chance to take the quiz before the education program commenced. Participants were only tested on the topics that were explained to them; questions addressing other topics were eliminated. Only those participants who took part in the pre-intervention focus groups, all teachings and postintervention focus group were eligible to take the quiz. The quiz was conducted between two to 3 weeks after the intervention, right before the process evaluation. The degree of difficulty of the quiz was designed as moderate to accommodate the variation in education level of participants from illiterate to highly educated. Participants who were illiterate or could not read Arabic met in a group and the pharmacist read each question aloud, after which participants were asked to select their preferred option. Although there were only four participants in the group, the process was time consuming. The quizzes were graded and a percentage was calculated based on the number of correct responses. Wrong responses did not penalize. The total mark varied from one lesson to another depending on the number of topics covered and thus the number of questions. Percentages were calculated to facilitate the comparison of the results.
These statements were sorted into the simplest themes/categories possible. Additional themes were identified, such as ‘‘mistrust in Danish doctors’’. The schema also included a descriptive statement column where the meaning of the various statements was summarized and clarified. This technique allowed greater comparability of the meaning condensation schemas across the different interviews.
Data analysis A meaning condensation schema [36] was made for each interview in order to create an overview. The entire transcript was read carefully and meaningful statements identified.
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Results The 30 participants (27 females, 3 males) ranged in age from 21 to 60 years (mean age: 38). All participants spoke Arabic. Figure 2 presents participants by nationality. Eleven participants had lived in Denmark for more than 10 years. Only three participants were newcomers, that is, had lived in Denmark for less than a year. Based on the focus group discussions, the education program selected the topic of major interests for the participants. Among the most commons ones are children medication, Generics and reimbursements, antidepressants and side effects as well as communication with Danish doctors. Results from the pre-intervention focus group interviews On beliefs, perceptions and barriers Many participants asserted that they had inherited their beliefs and perceptions concerning optimal medicine use from their parents. They were, however, dissatisfied with these beliefs. The majority reported having incorrect information about medicines. We have wrong beliefs from our parents that all medicines must be stored in the fridge and that children should be given medicines as soon as they feel the symptoms of infection. (FG 5) Several participants complained about the lack of guidance from Danish doctors concerning appropriate
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We are coming from a different country, culture and system, and we have to adjust to a new society. Everything is different. (FG 8)
Mistrust
Figure 3 presents an overview of the three most frequently mentioned barriers participants face concerning appropriate use of medicines. Needs concerning appropriate medicine use
Language
Alienation
Fig. 3 Barriers participants face concerning appropriate use of medicines
Many participants expressed the need for information about medicines and appropriate medicine use. In their opinion, the lack of effective regulatory systems and awareness campaigns in their countries of origin has contributed to their need for this information. There are no regulatory systems in our countries, so we need information about medicines. (FG 7)
medicine use, and voiced doubts about their medical skills and experience. Moreover, some participants were frustrated by the inability of these doctors to deal with them and their needs as foreigners.
Some participants expected to get this information primarily from doctors. As newcomers, they expected doctors to give them the necessary information and instructions on medicine-related topics.
We have a huge problem. Danish doctors ignore our needs. They never prescribe medicine for us, even when we are very sick. (FG 1)
Doctors should take the initiative and inform us about these [medicine-related] topics, at least for those of us who are newcomers and can’t speak Danish. (FG 7)
In contrast, some of the participants refused to take medication prescribed by Danish doctors, preferring to consult doctors in their home countries. When I go home, I don’t take the prescribed medication, because I think that he [the Danish doctor] just wants to get rid of me. So when I visit Morocco, I consult a doctor. (FG 6) Citing their limited proficiency in Danish, all participants reported having difficulties in communicating with healthcare providers concerning appropriate medicine use. They believed that the language barrier applies to all foreigners, but is more significant for newcomers than for those who have been living in Denmark for a long period of time. We don’t speak Danish properly, which hinders us from communicating with the doctor about medicines and their side effects. (FG 6) The majority of participants found it impossible to understand the instructions and recommendations of their doctor in Danish. This lack of understanding is why some participants believed that it is useless to consult a doctor. Some participants expressed general feelings of isolation and alienation after moving to a new country with new rules, values and principles, and this spilled over into their contacts with the healthcare system.
The majority of the participants thought that foreigners should be informed about the appropriate use of medicine as soon as they arrive in Denmark in order to raise awareness and avoid MRPs. Selected medicine-related topics Figure 4 provides an overview of the medicine-related topics selected by participants The majority of the participants expressed interest in children and medicines. Most of them complained about the strict policy Danish doctors follow concerning medicating children. This topic [children’s medication] is important. Especially if you could tell us why Danish doctors do not prescribe medicines for children. (FG 4) In addition to children’s medication, the majority, especially newcomers, expressed an interest in generic medicines and the reimbursement system. I have never heard about it [the reimbursement system]. (FG 2) All participants seemed quite confused and insecure regarding the difference between generic and branded medicines. Some of them believed that the price difference was due to variation in quality.
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Selected topics by lesson Number of lessons
Fig. 4 Selected medicinerelated topics by lesson taught
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Selected topics
I feel insecure about choosing the cheapest. I do not have enough money to choose the good quality product. (FG 1) The majority of participants considered ‘side effects of medicines’ a relevant and important topic. They were curious to know about side effects and their causes. They were also interested in learning how they could avoid side effects. I take my pills and I am afraid that they are damaging my body. (FG 1) All participants complained about the difficulty of getting access to antibiotics because, in most cases, doctors refuse to prescribe them. The only advice that Danish doctors have whenever I am sick is drink water! Water is not a cure. We need antibiotics to treat infections, so it is not for fun we ask for them! (FG 1) Results from the education program Participants’ acquired knowledge after the education program Based on the statements from participants, the education program provided them with new knowledge and information about various medicine-related topics. According to participants, approximately 70–80 % of the teaching content was new information (FG 7). The majority believe that this information made them aware of the consequences and dangers of using medicines inappropriately. It also made them able to distinguish between correct and incorrect practices such as the importance of continuing a course of antibiotics and the consequences of suddenly discontinuing. One of the most important things we learned was following the doctor’s recommendations about
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finishing the course of antibiotics and not quitting the medicine the moment we feel better. (FG 8) In addition to acquiring new information about medicine-related topics, some participants stated that the teaching program helped them improve their communication with doctors. Moreover, their beliefs and perception of Danish doctors changed after the program. Mistrust in the competencies of Danish doctors to become more accepting, understanding and appreciating their decisions. Now we know that they [Danish doctors] want to help us find the appropriate treatment. (FG 6) When the doctor refuses to prescribe medicine for my son, now I know it is for my son’s sake. (FG 8) After the program, the majority of participants agreed that it was wrong to share their prescribed medicines with relatives or friends or buy medicines from home countries. I shouldn’t share medicines with relatives or friends without a doctor’s prescription. (FG 8) Quiz results Many participants found it daunting to answer the questions in the quiz prior to the education program. They were uncertain about their answers and hesitated a long time over each question. After the program, they spent less time answering the quiz questions and seemed more confident about their answers. When we answered the questions in the quiz at the beginning [prior to the program], there were many things we didn’t understand, but now it’s different. I felt that I know more and can answer more confidently. (FG 8) To simplify analyzing and comparing the results of the quiz, only eight participants who answered the quiz before
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Fig. 5 The quiz results of participants in percentage of correct answers (N = 8)
Marks
Quiz results
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3
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Participants Pre-Intervention
and after the education program are presented below (Fig. 5). Participants’ knowledge increased after the education program (Fig. 5). Overall, marks increased after the education program. The highest and lowest mark pre-program is 74 and 46 %, respectively. In contrast, the highest and lowest mark post-program is 91 and 62 %, respectively. The difference between mean pre-program (62 %) and mean post-program (84 %) is 22 %. Influence of researcher’s ethnic background on education program The majority of participants believe that culture and language play an important role in the success of a project like this one. You [the researcher] have lived in an Arabic country and share the same background as ours, so that’s why you understand our conditions and circumstances. (FG 6) All participants appreciated that the education program was conducted in Arabic due to their limited proficiency in Danish. They did not believe they would not have benefited had the program been conducted in Danish. The best thing you did is decide to teach us in Arabic. (FG 6) Impressions and feedback about the education program All participants considered the program quite beneficial and useful because it provided them with relevant information, made them aware of consequences and changed their beliefs and habits. Furthermore, many of them reported that they gained valuable information about Danish healthcare providers, which made them increase their understanding. If you did not come here and teach us about medicines, we would have been sleeping [Arabic expression meaning unaware of the consequences]. (FG 5)
Post-Intervention
Discussion The results show that a culturally competent education program to prevent MRPs among ethnic minorities is relevant and effective. Moreover, it reveals that participants were not only aware of but also dissatisfied with their own knowledge about medicines. This is in accordance with the results of the Al-Saeedi study, which showed a high rate of treatment-related misconceptions [37]. These misconceptions have obviously influenced medicine-related behavior and habits, and in most cases led to inappropriate use of medicines. In addition to misconceptions, participants identified various barriers to their acceptance of the Danish healthcare system that indirectly affected their use of medicines. Several studies have shed light on these barriers and their significance on ethnic minorities’ access to the healthcare system [24, 38, 39]. The main findings of this study reveal mistrust in Danish doctors as one of the major barriers between participants and appropriate medicine use. Lack of confidence in the competencies and skills of doctors can lead to doubts about diagnosis and thus prescribed treatment. Consequently, participants’ compliance and adherence to doctors’ recommendations is low. This finding is in accordance with studies showing high non-compliance rates among ethnic minorities [19, 20]. Lack of effective communication due to linguistic barriers between healthcare providers and participants appeared to lead to inappropriate use of medicines. This finding supports earlier Danish and international studies that focus on linguistic barriers among ethnic minorities. These studies elucidate the association between linguistic barriers, MRPs and constrained communication [19, 38, 40]. Furthermore, the participants reported feelings of alienation and isolation that may affect their psychological wellbeing, health and medicine use. Povlsen has also described how alienation and lack of social network affects minorities’ psychological state and limits their access to healthcare services [24].
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The evaluation reveals that having an Arabic-speaking pharmacist who shares the same culture and background as the majority of participants had a great impact on the success of the program. Knowledge of and acquaintance with the traditions, norms, beliefs, perceptions and communication styles of participants appeared to reduce the gap between them and the pharmacist. Moreover, it reduced former barriers including mistrust in the healthcare provider and feelings of alienation and isolation. In addition, having confidence in the pharmacist created an open and relaxing atmosphere that facilitated dissemination of the message about appropriate use of medicines. Consequently, participants were more open to new knowledge. This is similar to the results of the evaluation reported by Nielsen, in which participants saw health intermediaries as peers because they shared the same ethnic background [41]. Language is another major factor that influenced the success of the program. This finding is in agreement with the results of Nielsen that stress the importance of conducting teaching sessions in participants’ native language to avoid language barriers [41]. Arab culture is relatively conservative, with the relationship between men and women set by norms and traditions defined by society. Therefore, the majority of female participants stressed the importance of being taught by a pharmacist of the same gender to avoid discomfort, embarrassment and shyness. The same results were found in Nielsen’s 2008 report in which participants expressed the importance of gender on communication, confidence and trust in the health intermediary [41]. The education program had impact on the participants’ beliefs and perceptions. Introducing them to scientific knowledge and the potential consequences of medicines raised awareness among those who used medicines inappropriately. This in turn resulted in motivating them to change their inherit beliefs, perceptions and behavior about medicines. After the education program, participants perceived sharing, misusing or buying medicines from home countries as wrong. Participants understood the danger of this behavior after being informed about interactions, side effects and other MRPs. One major impact of the program was reducing mistrust towards Danish doctors. Explaining the strict policy followed by Danish doctors in prescribing medicines, especially antibiotics and children’s medication, helped participants understand doctors and appreciate their decisions. We believe that bridging the gap between participants and doctors can lead to better communication resulting in appropriate use of medicines. Strengths and limitations The cultural and linguistic sensitivity of the program proved to be effective. The combination of the professional
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and cultural background and gender of the pharmacist instructor made it possible for her to motivate and communicate easily with participants. Nonetheless, there are some limitations to this education program. Although all the participants could speak Arabic, those from North Africa had difficulty understanding some specific terms from Standard Arabic, as they spoke a dialect. We therefore assume that their level of understanding and acquisition of knowledge was negatively affected. Future education programs could focus on grouping ethnic minorities by country and dialect. Ideally and if the resources are available, the researcher would also come from the same country or at least be fluent in the participants’ dialect.
Conclusion The results of the study reported in this article showed the relevance and effectiveness of conducting a culturally competent education program on appropriate use of medicines. The evaluation showed that providing knowledge and competencies about the appropriate use of medicine raises awareness about MRPs. Consequently, participants were motivated to change and adapt their attitudes according to the information provided. Moreover, the program also contributed indirectly to the appropriate use of medicines by potentially bridging the gap between participants and Danish doctors. We recommend future research to examine the effect of this education program on actual changes in medicine behavior as well as to tailor this kind of program for ethnic minority groups sharing the same country of origin. Acknowledgments We are grateful to the people who participated in the program. We would also like to thank Pharmakon for allowing us to use original teaching materials for translation and adaptation. Funding This project was funded by the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. Conflicts of interest The authors have no conflicts of interest to declare.
References 1. Alhomoud F, Dhillon S, Aslanpour Z, Smith F. Medicine use and medicine-related problems experienced by ethnic minority patients in the United Kingdom: a review. Int J Pharm Pract. 2013;21(5):277–87. 2. Gordon KJ, Smith FJ, Dhillon S. The development and validation of a screening tool for the identification of patients experiencing medication-related problems. Int J Pharm Pract. 2005;13(3): 187–93.
Int J Clin Pharm (2014) 36:922–932 3. Szczepura A. Access to health care for ethnic minority populations. Postgrad Med J. 2005;81(953):141–7. 4. Kontopantelis E, Roland M, Reeves D. Patient experience of access to primary care: identification of predictors in a national patient survey. BMC Fam Pract. 2010;11(1):61. 5. Lip GYH, Kamath S, Jafri M, Mohammed A, Bareford D. Ethnic differences in patient perceptions of atrial fibrillation and anticoagulation therapy: the West Birmingham Atrial Fibrillation Project. Strok. 2002;33(1):238–42. 6. Lip GYH, Khan H, Bhatnagar A, Brahmabhatt N, Crook P, Davies MK. Ethnic differences in patient perceptions of heart failure and treatment: the West Birmingham heart failure project. Heart. 2004;90(9):1016–9. 7. Morgan M, Figueroa-Mun˜oz JI. Barriers to uptake and adherence with malaria prophylaxis by the African Community in London, England: focus Group Study. Ethn Health. 2005;10(4):355–72. 8. Horne R, Graupner L, Frost S, Weinman J, Wright SM, Hankins M. Medicine in a multi-cultural society: the effect of cultural background on beliefs about medications. Soc Sci Med. 2004;59(6):1307–13. 9. Pardhan S, Mahomed I. Knowledge, self-help and socioeconomic factors in South Asian and Caucasian diabetic patients. Eye. 2004;18(5):509–13. 10. Lawton J, Ahmad N, Hallowell N, Hanna L, Douglas M. Perceptions and experiences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: qualitative study. BMJ. 2005;330(7502):1247. 11. Gordon K, Smith F, Dhillon S. Effective chronic disease management: patients’ perspectives on medication-related problems. Patient Educ Couns. 2007;65(3):407–15. 12. Chan C. A study of health services for the Chinese minority in Manchester. Br J Community Nurs. 2000;5(3):140–7. 13. Kumar K, Gordon C, Toescu V, Buckley CD, Horne R, Nightingale PG, et al. Beliefs about medicines in patients with rheumatoid arthritis and systemic lupus erythematosus: a comparison between patients of South Asian and White British origin. Rheumatology. 2008;47(5):690–7. 14. Wheatly RS, Shelly MP. Drug treatment during Ramadan. Stopping bronchodilator treatment is dangerous. BMJ. 1993; 307(6907):801. 15. McDowell SE, Coleman JJ, Ferner RE. Systematic review and metaanalysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine. BMJ. 2006;332(7551):1177–81. 16. Ormerod S, McDowell SE, Coleman JJ, Ferner PRE. Ethnic differences in the risks of adverse reactions to drugs used in the treatment of psychoses and depression. Drug Saf. 2008;31(7): 597–607. 17. Tsang C, Majeed A, Banarsee R, Gnani S, Aylin P. Recording of adverse events in English general practice: analysis of data from electronic patient records. Inform Prim Care. 2010;18(2):117–24. 18. Harris Y, Gorelick PB, Samuels P, Bempong I. Why African Americans may not be participating in clinical trials. J Natl Med Assoc. 1996;88(10):630–4. 19. Sønderga˚rd B, Haugbølle LS, Traulsen JM, El-souri M, Mygind A. Optimal drug use among non-ethnic Danes (part 2) Implementation of medication review. (Optimal lægemiddelanvendelse blandt ikke-etniske danskere (del 2); Gennemførelse af medicingennemgang). Copenhagen: Faculty of Pharmacy, University of Copenhagen; 2009. 20. Lauridsen L, Gudex C, Hansen M. Evaluation of medication review given to non-ethnic Danish patients. (Evaluering af medicingennemgang givet til ikke-etniske danske patienter). Odense: University of Sounthern Denmark; 2009. 21. Folmann N, Jørgensen T. Ethnic minorities—illness and the use of healthcare services (Etniske minoriteter – sygdom og brug af
931
22.
23.
24.
25.
26.
27.
28. 29.
30.
31.
32.
33. 34.
35. 36.
37.
38.
39.
sundhedsvæsenet). Copenhagen: The National Board of Health; 2006. Volodina A, Bertsche T, Kostev K, Winkler V, Haefeli WE, Becher H. Drug utilization patterns and reported health status in ethnic German migrants (Aussiedler) in Germany: a cross-sectional study. BMC Public Health. 2011;11:509. Knudsen P, Sønderga˚rd B, Rossing C, Herborg H. Evidence report: survey of medicine-related problems (Evidensrapport: Kortlægning af lægemiddelrelaterede problemer). Copenhagen: Pharmakon; 2006. Povlsen L, Olsen B, Ladelund S. Educating families from ethnic minorities in type 1 diabetes—experiences from a Danish intervention study. Patient Educ Couns. 2005;59(2):164–70. Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry. Berkeley: University of California Press; 1981. Cross TL, Others A. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Marts 1989 [Last cited 6. December 2013]; Hentet fra: http://eric.ed.gov/?id=ED330171. Isaacs MR, Benjamin MP. Towards a culturally competent system of care. Volume II: programs which utilize culturally competent principles. December 1991 [Last cited 6. December 2013]; Hentet fra: http://eric.ed.gov/?id=ED345393. Farley JE. Minority-majority relations. USA: Prentice Hall; 2005. Exploring the Intersection Between Cultural Competency and Managed Behavioral Health Care Policy: Implications for State and County Mental Health Agencies. [Internet]. National Health Care for the Homeless Council. [Last cited 6. December 2013]. Hentet fra: http://www.nhchc.org/bibliograpy/exploring-the-inter section-between-cultural-competency-and-managed-behavioralhealth-care-policy-implications-for-state-and-county-mentalhealth-agencies/. How health systems can address health inequities linked to migration and ethnicity [Internet]. [Last cited 6. December 2013]. Hentet fra: http://www.euro.who.int/en/health-topics/health-deter minants/social-determinants/publications/2010/how-health-systemscan-address-health-inequities-linked-to-migration-and-ethnicity. Gallegos JS, Tindall C, Gallegos SA. The need for advancement in the conceptualization of cultural competence. Adv Soc Work. 2008;9(1):51–62. National Association of Social Workers (NASW). NASW standars for cultural competence in social work practice. Washington: NASW; 2001. Krasnik A, Christiansen T, Høyer K, Vallga˚rda S. Health Services and Health policy. Denmark: Gyldendal/Munksgaard; 2008. Herborg H, Sørensen EW, Frøkjaer B. Pharmaceutical care in community pharmacies: practice and research in Denmark. Ann Pharmacother. 2007;41(4):681–9. Statistical Yearbook 2012. Statistics Denmark. Copenhagen, 13 June 2012. Ebrahim S, Bowling A. Handbook of health research methods: investigation, measurement and analysis. New York: McGrawHill International; 2005. p. 639. Al-Saeedi M, Elzubier AG, Bahnassy AA, Al-Dawood KM. Treatment-related misconceptions among diabetic patients in Western Saudi Arabia. Saudi Med J. 2002;23(10):1243–6. Michaelsen J, Krasnik A, Nielsen A, Norredam M, Torres AM. Health professionals’ knowledge, attitudes, and experiences in relation to immigrant patients: a questionnaire study at a Danish hospital. Scand J Public Health. 2004;32(4):287–95. Mygind A, Espersen S, Nørgaard LS, Traulsen JM. Encounters with immigrant customers: perspectives of Danish community pharmacy staff on challenges and solutions. Int J Pharm Pract. 2013;21(3):139–50.
123
932 40. Clark T, Sleath B, Rubin RH. Influence of ethnicity and language concordance on physician–patient agreement about recommended changes in patient health behavior. Patient Educ Couns. 2004;53(1): 87–93.
123
Int J Clin Pharm (2014) 36:922–932 41. Nielsen AS, København DF. Sundhed pa˚ dit sprog: evalueringsrapport. Københavns Kommune, Sundheds- og Omsorgsforvaltningen, Folkesundhed København; 2006. 40 p.
