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

Background It is important to have a pharmacy workforce that is culturally competent to recognise a patient’s health beliefs to improve medication adherence and reduce poor treatment outcomes. Aim This systematic review aimed to identify, critically appraise and summarise how cultural competency is conceptualised, developed and embedded in pre-qualification pharmacy education. Method Medline, Scopus, PsychInfo, Web of Knowledge, CINAHL, and Embase databases were searched for relevant papers published in English between January 2012 and December 2021, following PRISMA guidelines. Data from included papers were thematically analysed. Educational quality of papers was appraised using the GREET criteria. This systematic review was registered on PROSPERO, CRD42021295875. Results The review included 47 papers (46 studies) with 18 papers meeting ≥ 9 points on the GREET criteria thus considered of good educational quality. Forty papers focused on educational interventions implemented to pharmacy students only, the remaining included students from different health disciplines. Half of the educational interventions focused on cultural competence in general. Most educational interventions lasted over a week and 21 were compulsory. Cultural competence conceptualisation varied; a focus on knowledge about different cultures or on culturally competent behaviours or a continuum with knowledge at one end and behaviour at the other. Conclusion There is variation in how cultural competence is embedded in pharmacy programmes, which could be a reflection of the differences in how educators conceptualised cultural competence. Further research is needed to develop a unified understanding of the meaning of cultural competence and how it can be embedded in pharmacy education. Supplementary Information The online version contains supplementary material available at 10.1007/s11096-023-01644-3.


Introduction
Culture refers to the values, beliefs and norms that are adopted by a specific group which guide thinking and behaviour.Culture can relate to ethnicity, age, gender, groups with special needs, religion, socioeconomic status, sexual orientation, and health beliefs [1,2].Culture is unconscious and affects all aspects of life, including experiences of health and illness.The influence and impact of culture on health is complex and not 1 3 always understood, but there is a need to consider culture when providing care [1][2][3][4].With increasing diversity of populations due to globalisation, the need for culturally competent health professionals has increased [4,5].Failure to address crosscultural issues in the delivery of healthcare services can reduce patient satisfaction and compromise health outcomes [4,5].
Cultural competence (CC) has been defined in several ways.One of the earlier definitions by Cross [6] states CC is: 'a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations'.Campinha-Bacote [7] defined it as: 'an ongoing process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of a client' [1,8].The literature indicates there may be different ways CC can be understood, which presents a challenge for the teaching and training of healthcare professionals.
As integral members of the healthcare team, pharmacists are medicines experts tasked with the delivery of pharmaceutical care [8].Pharmaceutical care relates to medication supply but also how the medication is used and can be influenced by non-clinical patient-related factors, such as culture, socioeconomic status and language [8].Failure to accommodate a patient's health beliefs, could lead to poor treatment adherence and reduced health outcomes [1].In line with the General Pharmaceutical Council's Standards for pharmacy professionals in the UK and the Accreditation Standards and Guidelines for the Professional Program in Pharmacy in the US, when considering a patient's culture, pharmacists should not stereotype by applying cultural characteristics from a specific culture to all patients, as this can lead to inappropriate healthcare decision making [1,9].Rather, pharmacists should "recognise and value diversity, and respect cultural differences-making sure that every person is treated fairly whatever their values and beliefs" [10].The Pharmacy Council of New Zealand (PCNZ) and the Truth and Reconciliation Commission of Canada also call for pharmacists to demonstrate CC skills and knowledge [11,12].However, there is no specific guidance on how to implement training that would help develop a culturally competent pharmacy workforce.
The development of a culturally competent health workforce requires the integration of cultural competency training in educational programmes.However, before doing so, a clear definition of the concept needs to be established.A recent systematic review identified tools used to assess cultural competency within pharmacy programmes and acknowledged considerable variation in the tools used to assess CC as the intended learning outcomes, design and target audience of the educational interventions differed [13].To our knowledge, there are no systematic reviews exploring what CC means in pharmacy education, how it is conceptualised and as a consequence how it is embedded within pharmacy education.

Aim
To identify, critically appraise and summarise how CC is conceptualised, developed and embedded in pre-qualification pharmacy education.

Method
The protocol was registered with PROSPERO on 7th December 2021, Reference CRD42021295875 [14] in accordance with the PRISMA guidelines [15].

Inclusion criteria
Studies were considered eligible for inclusion if they were: Conference papers, abstracts, book chapters, dissertations, literature reviews and systematic reviews were excluded.Studies that focused on CC in postgraduate or post-registration pharmacy education or in areas other than pharmacy education were excluded.

Search strategy
A systematic search was conducted between December 2021 and January 2022 on six databases: Medline, Scopus, PsychInfo, Web of Knowledge, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Embase.The full search terms and key words used are shown in Supplementary material 1. Search results were exported to the Rayyan systematic review application [16] for screening and to remove duplicate papers.Reference lists of included papers and relevant systematic reviews on CC were screened for additional papers.Searches were carried out by author RJ and quality checked by RL and WML.Screening of titles and abstracts were conducted by authors RJ, WML, RL, and a random sample of 20% were cross-checked by RL and WML.Screening of full texts for relevance was done by RJ and WML with a further 20% cross-checked by RL.Any discrepancies were resolved by discussion between authors until consensus was reached.

Risk of bias and quality assessment
Risk of bias was assessed using the Mixed Methods Appraisal Tool (MMAT) (Supplementary material 3) [17].All studies were evaluated by RJ and 20% (10 papers) was independently evaluated by RL [18].Studies were not excluded based on the MMAT results because the focus of the review was on the nature of the interventions rather than their effectiveness.
The guideline for reporting evidence-based practice educational interventions and teaching (GREET) checklist which contains 17 criteria [19] was used to evaluate the quality of the educational intervention reporting.Criteria were attributed 1 or 0 points for compliance or non-compliance, respectively, and the total score for each paper was then calculated.The final quality scores were categorised arbitrarily by the authors as follows: a score ≥ 9 points (50%) indicated good quality and a score < 9 was considered low quality.Author AAN assessed the included papers using the GREET checklist and 20% was cross-checked by RL.

Data synthesis
Extracted data were uploaded to NVivo where authors RJ, APR, AAN thematically analysed the data using the method outlined by Thomas and Harden [20]: 1) identify study characteristics, 2) identify study findings in descriptive themes that capture and summarise the findings of the literature, 3) identified analytic themes, to go beyond the original findings of the literature and add new knowledge.A deductive synthesis was used throughout, which focused on conceptualisations of CC and how CC teaching was embedded and delivered within pre-qualification pharmacy education curricula.The synthesis process was iterative and included discussions with WML, RL and CR.

Paper selection
The paper selection process is summarised in the PRISMA Diagram (Fig. 1).The search identified 6,708 records.After the removal of duplicates, 5,056 papers were retrieved and included in the screening of titles and abstracts which excluded 4,975 papers.Eighty-one papers were included in the full text review with 40 papers remaining for inclusion.Seven additional papers were found for inclusion after screening the reference lists of relevant systematic review papers and included studies.A total of 47 papers (46 studies) were included.

Study characteristics
Forty papers assessed educational interventions to teach CC and six papers reported frameworks for teaching CC in pharmacy programmes.Forty papers focused on pharmacy student only as research participants, whilst the remaining seven included students from multiple healthcare disciplines (including pharmacy).Most papers were conducted in the United States (n = 39), followed by Aotearoa New Zealand (n = 2), Canada (n = 2), Germany (n = 1), Qatar (n = 1), United Arab Emirates (n = 1) (Table 1).

Quality of included papers
The results of the risk of bias assessment using MMAT tool is reported in Supplementary material 3.All the papers had clear research questions and the data collected addressed the research questions.However, for quantitative studies and mixed-methods studies, there were more papers with unclear reporting of sampling and risk of bias.
The educational quality of the studies was assessed using the GREET checklist [19].Seven paper were not assessed as they reported educational frameworks (Supplementary material 4).Of the 40 included papers, 18 were of good quality (complied with > 9 criteria).All papers complied with item 1 by providing a description of the education intervention for the participants involved.25 papers (62.5%) complied with item 3 by describing the learning objectives, but none recorded information about the process used to determine that the teaching materials/strategies/sessions were delivered as originally planned (item 16 and 17).

Characteristics of CC educational interventions
This section summarises the education, teaching and training interventions reported in the literature and how they were delivered in pre-qualification pharmacy education.
Educational intervention topics included different languages, cultures, ethnicities, religions practices, sexualities and groups with special needs.Most of the institutions that hosted research activities were based in the US (n = 39).Others involved international placements in the Dominican Republic, Guatemala, Kenya, and South Africa (Table 2).
Educational interventions were evaluated using a range of learning outcome measures.'Attitude' was most used outcome measure (n = 29), followed by 'knowledge' (n = 24), and 'skills' (n = 18) (Table 3).There was variation in the methods used to collect and analyse the effect of educational intervention, which means it is not possible to compare interventions directly.Of the 41 papers, only 2 papers reporting no difference in outcomes measures following the educational intervention.Further work may be needed to encourage researchers to disseminate findings transparently, including negative and neutral findings.(2) How is it done?Several approaches to deliver teaching were reported, such as lectures, workshops, group activities and placements (Table 4).Most papers (n = 35) used didactic modes of teaching, either independently or combined with other activities, such as discussion groups.Most (n = 24) reported educational interventions lasting longer than one week, with the remaining papers reporting contact time of less than one day (n = 14).
An integrated approach to delivering CC curricula was reported (n = 25), where content was delivered as an element within a wider module e.g.modules concerning disease pathophysiology, therapeutics or wider aspects of public health.Some (n = 14) reported delivery of CC content within a stand-a-lone CC module.Additionally, approximately half (n = 21) reported that CC curricula was compulsory or part of a compulsory module, whilst 18 reported the content was covered within elective modules and one reported that it was delivered as part of compulsory and/or elective modules [21].Hasan's study incorporated CC as part of communications skills and counselling teaching, but did not specify whether participation was compulsory [22].No reports included inter-professional collaboration with disciplines outside pharmacy (e.g.medicine).Collectively, this finding demonstrates heterogeneity of modes and duration of CC education in pharmacy.

Conceptualisation of cultural competency in pharmacy education
The terms and models in the literature to describe CC and their application varied.Findings are presented below, which identify 'how' CCs was conceptualised, as a knowledgebased (Theme 1), skill-based (Theme 2) or behaviour-based (Theme 3) construct.Although CC was the most commonly used term (n = 22), several alternative terms including culture sensitivity, culture humility, culture intelligence, and culture proficiency were also used.These terms were either used interchangeably with CC or were chosen by some authors to emphasise a certain aspect of a wider spectrum.

Theme (1) Knowledge-based
This theme focused on knowledge about specific cultures, such as language for Spanish-speakers, slang for Aboriginal Australians, historical events for First Nation Canadians, or complementary and alternative medicines used in certain cultures [23][24][25][26].This proposition focused on knowledge about differences in constructs between cultures at an individual, familial and community level, which enabled students to recall and recognise specific cultures.The focus was not adapting one's own behaviours but knowing the cultural needs of another and how to meet those needs, for example, by using an interpreter or recognising the importance of non-verbal communication.

Theme (2) Skill-based
Cultural sensitivity was another commonly used term; several studies referred to culture sensitivity as a standard skill set in Centre for the Advancement of Pharmaceutical Education (CAPE) and Accreditation Council for Pharmacy Education (ACPE) [27,28,33,[42][43][44][45][46].In some instances, cultural sensitivity was not defined or compared with the concept of CC.When a definition was provided, it indicated cultural sensitivity entails the recognition of social determinants of health, adaptability to patients' cultural beliefs without stereotyping, and providing a healthcare plan that considers patients' own culture while being able to communicate effectively [28,47].While it seems cultural sensitivity might be synonymous with CC, some studies indicated there is a difference and cultural sensitivity could be a part of becoming culturally competent [21,34,48].We suggest that these studies demonstrate cultural sensitivity as an action or skill, which creates opportunity for students to 'show how' they can be culturally sensitive and are working towards being culturally competent.

Theme (3) Behaviour-based
Studies also referred to models conceptualising CC as a continuum from cognitive factors, for example knowing about other cultures, languages and what is important to people from a given culture, to behavioural factors, such as asking patients about their individual, familial or community cultural needs within everyday practice [28,29,38,39].This conceptualisation reflects a broader transformational behaviour change, which continually adapts through processes and perceptions.Diaz-Cruz [48] used the term 'cultural proficiency' and described this as an adaptation to differences in values and practices requiring personal transformation; the authors described that pharmacists can only strive for the goal of becoming culturally proficient, as this is a never-ending process of learning about and with cultures, where full competence cannot be achieved [48].This conceptualisation positions CC as behaviours which are performed and practiced over time.

Statement of key findings
Overall, the findings show CC was conceptualised as knowledge-, skill-and behaviour-based constructs.Conceptualisations of CC in the literature was heterogeneous with different terms, outcomes, modes and durations of teaching and training implemented in pre-qualification pharmacy education.Although most studies used the term 'cultural competence' to guide their educational interventions, variations in conceptualisation and terminology [25,46,49,50], made it unclear if the learning outcomes should be knowledge-, skill-or behaviour-based, which can potentially mean differences in the design of educational interventions.Therefore, it would be difficult to understand and compare the effects of those interventions.This has further implications for other educators who wish to design and implement CC interventions for their own programme.Specific terms to describe different conceptualisations of CC are needed to reflect the spectrum from a knowledge-based learning outcome where they know about different cultures, towards behavioural capability outcome, which enables them to adapt to different cultures in their practice [46,48,51].

Strengths and limitations
A robust and systematic approach was used to search, identify, screen, and evaluate literature for this review in line with the PRISMA guidelines [15].Although screening, data extraction and quality assessment was independently conducted by one author, to ensure robustness of the review, one to two other authors were involved in assessing a sample of selected papers at each stage in order to determine whether further samples would need to be checked.Another limitation was the inclusion of only papers written in English, which may have inadvertently excluded relevant papers published in other languages.Grey literature was also excluded, which is often used to disseminate pedagogical research.

Interpretation of findings
There is variation in the way CC is conceptualised in pharmacy education resulting in diverse CC educational interventions.This variation aligns with Miller's triangle of competence that maps development from 'knows' to 'does' and is commonly used in pharmacy education and practice The following symbols are used to denote the effects shown on the learning outcome: + beneficial effect., ?unclear or mixed effect, 0 no effect,-negative effect, † mixed-methods study, ‡ qualitative study standards.Mapping our findings with Miller's triangle [52], Campinha-Bacote's [7] and Well's model of CC [53], provides a model of conceptualisation of CC in pharmacy education (Fig. 2).This variations can also be found in nursing and medical education [54,55].Cai [56] also found ambiguity of the definition of CC used in nursing contributed to variation in the instruments used to measure CC and thus made it difficult to assess their effectiveness.

Future research
Almost half of studies were non-compliant to the GREET checklist for reporting educational interventional studies [19].Although most studies were conducted before the GREET checklist publised, poor reporting of methods to document educational interventions may limit transferability.Future work should report educational interventions in compliance with an accepted set of standards, to facilitate quality assessment, replicability and validity.
In addition, most studies evaluated the effect of educational interventions on a short-term basis.Studies that reviewed the longitudinal impact of educational interventions reported a reduction in CC scores assessed after a lengthier gap [35].This highlights that CC educational interventions designed in most studies cater to short-term competence needs of students and may not necessarily address the long-term learning needs or have a sustained impact on practice.Further research is needed into the longer-term implementation of educational interventions and the assessment of the effectiveness, especially given the heterogeneous outcomes currently measured.•Example: a seminar in ethnic pharmacology.

Conclusion
There is variation in how CC is taught and assessed in prequalification pharmacy education.Heterogeneity could be a consequence of differences in conceptualisation of CC.Therefore, further research is needed to develop a unified understanding of CC and how it should be taught to pharmacy students.
(i) Published between 1st of January 2012 and 31st of December 2021 so as to include literature most relevant to contemporary pharmacy education.(ii) Published in a peer-reviewed journal.(iii) Written in English.(iv) Described or explained educational interventions (or alternative terms with the same meaning) to improve cultural competency in pre-qualification pharmacy education.

Fig. 1
Fig. 1 PRISMA diagram An initial data extraction form was drafted by author RJ and piloted on 10 included papers.RL and WML revised the data extraction elements and the initial extraction.

Table 1
Characteristics of included studies

Table 2
Focused topics and cultures of interventions

Table 3
Summary of learning outcomes assessed and effect of cultural competence educational interventions NB:

Table 4
Delivery of interventionsLevel 3, i.e. 'does' •Descriptor: an ongoing openness and desire to meet the needs of patients within their own cultural context.•Intervention: longitudinal, transformative continuums of practice.•Example: clinical placements where students have opportunities to repeatedly practise cultural competence (8, 68).Level 2, i.e., 'shows how' •Descriptor: knowledge and skills of clinical practice of people from different cultural groups •Intervention: opportunities for students to demonstrate patient-centred, culturally appropriate practice.•Example: intergroup dialogue communication sessions, OSCEs in different cultural settings.Level 1, i.e., 'know how' •Descriptor: (self-)awareness of one's own culture, bias, and prejudice.•Intervention: knowledge of diseases relevant to different cultural groups.