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The United States is becoming more and more culturally diverse. In percentage terms, Asians are the most rapidly growing minority group, whereas, in absolute numbers, Hispanics are the most rapidly growing group. According to the US Census, by 2020, Asians will comprise 6.5% and Hispanics 16% of the US population.1 Pharmacists increasingly will need to provide care to individuals from different cultural backgrounds. To provide care successfully to all patients, pharmacists should attempt to understand each person?s cultural frame of reference. The word culture means "patterns of human behavior including thoughts, actions, customs, values, and beliefs that can bind a racial, ethnic, religious, or social group within society." Pharmacists should assess their own cultural frame of reference by asking themselves these questions:
? Where was I born?
? Where were my parents born?
? What is my sense of belonging in terms of culture?
? What positive and negative experiences have I had with different cultural groups?
Next, pharmacists should think about the different cultural backgrounds of the people who visit their pharmacy. How well do they understand these different backgrounds? Pharmacists should take the following steps to learn about the cultural backgrounds of their patients:
? Ask patients to discuss their cultural background
? Go to the library and read about the cultural groups in the area
? Visit an ethnic community center near your pharmacy Cultural competence is a complex integration of knowledge, attitudes, and skills that enhances cross-cultural communication and appropriate interactions with others. Cultural competence includes at least 2 perspectives:
? Knowledge of the effects of culture on others? beliefs and behaviors
? Awareness of one?s own cultural attributes and biases and their impact on others
Culture and Patient Health Beliefs
Patients from different ethnic groups may have different beliefs about their medical conditions and the medications used to treat these conditions. In addition, all ethnic groups themselves are extremely diverse. Therefore, it is important to take a patient-centered approach when providing care to patients. Pharmacists need to gain an understanding of patients? health beliefs when communicating with them about their health and medications. It is also important to realize that patients may not discuss their health beliefs until a safe environment has been created and a trusting relationship has been established. For example, there is evidence that 1 of 3 Americans uses alternative therapies, yet very few patients tell their health care providers. Therefore, pharmacists should be open to different ways of thinking about health, illness, and treatment (Table 1).
Cultural competence is an ongoing acceptance of and respect for differences among and within cultures. Culturally competent pharmacists are continually expanding their cultural knowledge and resources and are adopting service models to meet the needs of different racial and ethnic groups (Table 2).
Questions That Show Understanding of Patients? Health Beliefs
To better understand patients? health beliefs, Arthur Kleinman, a physician, suggests asking the following types of questions: Etiology: What or who caused this illness and why?
Symptoms: What are your symptoms? When did they begin? Why do you think they began? Pathophysiology: How has your body (or mind) been affected by this illness?
Diagnosis: What do you know about the illness? What have people told you? What do you believe about this diagnosis? Treatment: What should be done about this illness? What have you tried already? Did it work? How do you feel about taking medications?
Prognosis: How long do you think you will be ill? Will anything you do help to control or cure this illness? Coping: What or whom do you need to help cope with this illness?
Meaning: What does this illness mean to you?
Adapted from: Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med. 1978;88:251-258.
It is becoming especially important, for example, to better understand the Hispanic culture. The US Hispanic population is itself diverse: individuals may come from Spanish, Mexican American, Puerto Rican, Cuban, or other backgrounds. Important cultural values of the Hispanic culture include the following2:
? Familialism: strong identification with and attachment to nuclear and extended families
? Simpatia: behaviors that promote smooth and pleasant relationships
? Respeto: self-respect and respecting others
? Personal space: Hispanics are often considered a "contact culture," preferring shorter distances when interacting with others
? Time: Hispanics are a "present-oriented" culture; patients may be late for appointments, which needs to be respected
Pharmacists need to understand these values when interacting with Hispanic patients. Some ways to ensure the respect of Hispanic patients are as follows3:
? If you are a younger pharmacist, be more formal in interactions with older Hispanic patients.
? Even if you do not know Spanish, greet a patient with Buenos dias or Buenos tardes to show respect for the
? Encourage Hispanic patients to ask questions.
American society is becoming increasingly culturally diverse. Cultural health beliefs can affect patient use of medications. Pharmacists need to be aware of cultural considerations when providing patient counseling and care.
For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Campagnola, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: firstname.lastname@example.org.
Improving Cultural Competence
Here are some ways to improve cultural competence in the workplace:
? Hire support staff from different cultural backgrounds (especially those who are from cultural backgrounds similar to those of your patients)
? Train existing staff in cultural diversity
? Encourage high school students and support staff (especially those from different cultural backgrounds) to go into the pharmacy profession
? Provide prescription labels and educational leaflets in languages other than English
? Work with local community and/or professional societies to find out about the availability of interpreters in the area
Adapted from: Health Communication for Culturally Diverse Patients. Partners in Health Care: A Continuing Education Monograph Series for Pharmacists. Washington, DC: American Pharmaceutical Association; 2002.