The authors of a new systematic review on unconscious bias towards ethnic minority groups in healthcare reveal what pharmacists can learn from overseas to improve their practice.

Co-authors Ramesh Walpola MPS, pharmacist and senior lecturer at the University of New South Wales, and physiotherapist and PhD student Ashfaq Chauhan found that patients from ethnic minority groups are significantly more at risk of medicine safety events than the majority population.

They experienced higher rates of hospital-acquired infections, adverse drug events and dosing errors due to factors including language barriers, use of interpreters, and lack of engagement and communication with healthcare professionals.

There were three papers identified in the review that clearly demonstrated the impact of unconscious bias on patient wellbeing and safety, Mr Chauhan said.

One UK-based review in various healthcare settings, including community pharmacy, looked at medicine-related problems that can occur among ethnic minority patients.

‘That [paper] highlighted that there was often an underestimation by healthcare providers of what level patients wanted to be engaged in their care,’ Mr Chauhan said. ‘This limits interactions or affects [providers] behaviour towards [patients]’. 

The second paper, a qualitative study conducted in Dutch hospitals, included healthcare practitioners’ assumptions of people from ethnic minorities’ experience of pain. Presumptions that patients from certain cultural backgrounds express pain more intensely led to underestimation of their complaint of pain.

In a US-based study looking at discharge information in a paediatric hospital around the dosing of paracetamol, the authors observed that the instructions provided to English-speaking versus Spanish-speaking parents were different.

For Mr Walpola, a former community pharmacist, the study revealed a significant lack of information given to patients during the counselling process.

‘There was a huge disparity in the amount of information given, not only verbal, but also written,’ he said. ‘Sometimes verbal information was given rather than written, but in some cases, [there was] neither.’

As a result, Spanish-speaking parents who did not request an interpreter had a two-fold increased risk of adverse events compared to those who did.

Addressing unconscious bias

The review identified three levels where unconscious bias needs to be addressed to ensure patients from ethnic minority groups receive safe and appropriate care. 

At an individual level, Mr Chauhan said being aware of the issue can enhance understanding. 

Having a desire to learn about different cultures can also enhance one’s ability to understand patients and provide patient-centred care. 

At an organisational level, having support structures in place, such as interpreters, can address language barriers. 

‘Providing training to staff, encouraging cross-cultural communication and mentoring can [improve both] individual and organisational capacity to address the issue,’ Mr Chauhan told Australian Pharmacist. 

Lastly, at a systemic level, engaging patients in their care is a priority, which can improve the quality and safety of care delivery. 

‘Engaging [patients] in designing education programs and standards can help in terms of [identifying] the issues we need to look for, and what consumers really want,’ Mr Chauhan said. 

Lessons for pharmacists

In healthcare, there has been a movement away from the concept of cultural competence towards cultural safety, Mr Walpola said. 

‘Cultural competence is focused around learning about others,’ he said. ‘But cultural safety really encompasses the concept of reflexivity.’ 

Reflecting on one’s practice, for example about patient interactions at the end of the day, is important.

‘Reflection is a huge part of our training as pharmacists, and our Continued Professional Development,’ he said. 

Patients from ethnically diverse backgrounds often have poorer experiences in healthcare settings, such as community pharmacies, because it may take a bit longer to assist them, Mr Walpola said. 

However, once pharmacists have figured out how to best manage a particular patient, Mr Walpola said it’s much easier the next time.

When working on the review, Mr Walpola reflected on his own practice and what worked best when providing services for culturally diverse patients.

‘There were times where I’d have to say, “We’re flat out, but I really want to spend this time with you and go through your medicines”,’ he said. 

‘90% of the time, they were very happy to wait when the competing demands were clearly explained.’

It’s not only the patients who return, Mr Walpola said, but also their families. 

‘I’ve had experiences where [patients] referred their families for care, so you’re building a lot of trust,’ he said. ‘And you or your pharmacy owner are actually benefiting from your time through additional revenue.’

Staff training

While there are adjustments pharmacists can make to their own practice, Mr Walpola said it’s also critical to consider other pharmacy staff, who may be the first line of contact for patients. 

This includes the person who greets patients at the door, through to pharmacy assistants who take their scripts, pharmacists who dispense medicines and counsel patients, to the person who rings them up at the register.

Having conversations in staff meetings around how a patient or situation was handled can be beneficial to ensuring all staff are on board, Mr Walpola said.

‘You can use hypothetical scenarios in staff meetings and say, “If a particular patient came in, how could we best as a team support [them]?” he suggested. 

Open discussions with staff are more effective than the requisite online training, Mr Walpola said.

‘This has been shown in the literature to have the biggest impact in terms of creating [a more culturally safe] environment, rather than just forcing people to do online modules to learn about something.’

Using interpreters effectively

Healthcare practitioners sometimes rely on family members or other staff to act as interpreters, Mr Chauhan said. But this could lead to medicine-related events.

‘There are concerns that if family members are provided with certain information, they may withhold some from the patient, or may not be able to translate complex medical terminology correctly,’ he said.

Using bilingual staff can also present issues.

‘If a staff member speaks Mandarin, [for example] and they’re translating information to a patient, those interactions have not been assessed in the context of patient safety,’ Mr Chauhan said. ‘So, it’s always advised to use trained professional interpreters for translation purposes.’

There are free telephone interpreter services community pharmacists can access, but they are not always immediately available.

Identifying interpreter services and having a list of important telephone numbers in the pharmacy can help. Pharmacists could also look at using approved apps such as CALD Assist, which helps to overcome language barriers in healthcare.

‘There is some [information] on CALD ASSIST around COVID-19 and vaccinations, so you can use that as part of vaccine education,’ Mr Walpola said. 

Community engagement

Pharmacists can learn a lot about different cultures by getting to know their community, Mr Walpola said.

Nick Logan MPS, who owns a pharmacy in the north Sydney suburb of Artarmon, is a prime example of the impact community engagement can have. 

Artarmon sits at a cross-section of various multicultural communities. Surrounding suburbs like Chatswood have been home to the Chinese community for over 20 years, while nearby St Leonards has a large Japanese population.

There are also growing numbers of Indian and Nepalese residents moving in, Mr Logan told AP.

To develop and maintain strong relationships, he engages with the community on numerous levels, including sport, business and education.

Mr Logan sponsors a local cricket club, the ‘Artarmon Maestros’, which is run by a group of ‘cricket obsessed’ Indian dads.

‘It’s a healthy outdoor community pastime, and it’s fantastic watching it grow and the enthusiasm of people who live in the blocks around,’ he said. ‘You go down to the park and share something together.’ 

Team members often come into the pharmacy or approach Mr Logan on the street to express their enthusiasm.

‘[They’ll] say, “We’ve lived in lots of places, and this is the greatest community atmosphere we’ve come across”,’ he said.

Mr Logan is also President of the Chamber of Commerce in Artarmon, which allows for healthy relationships with the Progress Association and the local school. 

‘I’ve given health talks at the school, and drug and alcohol presentations to teenagers for the Progress Association, which have been really good,’ he said.

Maintaining a grassroots connection to the community is something Mr Logan considers vital. These activities strengthen relationships with patients, allowing for better healthcare interactions. 

However, at times, Mr Logan has pondered the benefits of his level of community engagement.

He recalls one incident when he was putting up signs for the school fete at 6:30 am on a Saturday morning, thinking ‘What am I doing here?’ 

‘But by the end of the day, so many people came up and said thank you, which reassured me I wasn’t wasting my time,’ he said. 

Mr Logan has also reaped the financial benefits of his community engagement efforts.

‘When a [large pharmacy chain] opened 60 metres up the road, I was absolutely terrified, but our script numbers went up,’ he said. 

‘I realised that all of those community engagement [activities] absolutely paid off, and the community really appreciates it.’