Culture well

Community pharmacists and Arabic speaking Australians – communicating capably to build health partnerships.

Culture and its impact

Australia is considered one of the most diverse countries globally. Nearly half (49%) of the population was born overseas or may have one or both parents born overseas.¹ Further, the census data indicate more than 300 languages are spoken at home and Australians identify with more than 300 ancestries.¹ This suggests a multiversity of socio-cultural health beliefs, pre-migration experiences, and linguistic proficiencies with English form the cultural fabric of contemporary Australian society. 

Culture may be conceptualised as not only ‘habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values’.² Clearly, culture can impact health outcomes both from the provider and patient’s perspective.³ 

Different understandings about health and wellbeing, the role of health professionals, expectations about treatment, and health literacy between patients and providers lead to a disengagement of culturally and linguistically diverse (CALD) patients with the healthcare system. Indeed, the disparities in health outcomes for people from CALD backgrounds are increasingly noticeable in Australia’s health statistics.³ Cultural capability therefore needs to be a key part of community pharmacy practice given pharmacy venues are highly accessible and often a consumer’s first port of call for an acute or continuing illness.⁴ 

Yet, in recent research, community pharmacists report challenges in communicating effectively across the cultural spectra of their clientele.⁴ Conversely, CALD patients report the same issue in effectively engaging with community pharmacy and receiving satisfying healthcare. In a recent University of Sydney study with Arabic-speaking people who had asthma, study participants reported low level communication with pharmacists about asthma, relying more on doctors to explain medicine or inhaler use.⁵ 

Asthma education needed

Although the prevalence of asthma in specific populations groups is not known, overall 11.2% Australians (2.7 million) have asthma.⁶ Current estimates are around 400 deaths and almost 40,000 hospitalisations occur annually from asthma, with 80% of such hospitalisations considered potentially preventable.⁶ Prevention in adults and children is achieved through regular use of inhaled anti-inflammatory medicines, as inflammatory processes propel asthma symptoms.⁷ 

Reliever medicines are now recommended to be used only when symptoms occur, and whilst they affect bronchodilation, they do not address the underlying pathophysiology.⁷ Given these relievers (short-acting b₂ agonists (SABAs) are available as Schedule 3, many patients including CALD patients may rely more heavily on them, given easy access, a sense of immediate symptom relief and non-awareness of why asthma symptoms occur.⁷

For adults, Australian guidelines suggest that symptoms experienced more than twice a month warrant regular use of preventers and most adults should be on regular low-dose preventers (inhaled corticosteroids).⁷ There is mounting evidence of harm from overuse of SABAs – use of more than three cannisters a year is associated with an increased risk of exacerbations,⁸ and using more than 12 cannisters a year is associated an increased risk of mortality.⁹ 

Unfortunately, in the study with Arabic-speaking patients with asthma cited above, it was evident there was a reliance on relievers and an underuse of preventers. Parents reported the need to attend emergency departments frequently. Pharmacists, therefore, have a key role in providing asthma education, ensuring adherence to preventers and appropriate use of inhaler devices and encouraging self-management skills in patients. Research studies over the last 2 decades show that community pharmacists can cost effectively deliver such services to improve clinical outcomes for their asthma patients.^10–11

The Culture Well Project

Recently, Asthma Australia, a peak not-for-profit consumer body advocating for the needs of people with asthma, partnered with World Wellness Group, a health social enterprise, and One Health Organisation, a systems change agent, to deliver the Culture Well Pilot.

Funded by the Commonwealth Department of Health, the pilot program’s vision was to work with three communities (Arabic, Samoan and Vietnamese-speaking) to understand community perspectives around health and wellbeing, barriers and enablers in engaging with local health service providers and finally to co-design, implement and evaluate initiatives to address drivers of poor health.¹²

The project began with 72 members from the three communities in focus group discussions. These community members were asked to map and interlink all the ‘systems’ that impacted their health and wellbeing, and plot their wellbeing across several domains using the well-known wellbeing wheels method.¹³ In the outputs, it was clear that consumer participants have a social lens when defining quality of life which is quite independent of a health condition they may have.¹² 

The Samoan, Vietnamese and Arabic-speaking communities each created different wellbeing wheels to represent the most important areas of life that contribute to their health and wellbeing. Physical health or specific health issues were not a major focus. Emphasis was placed on family and friends, money and work, mental health, hobbies, spirituality or religion, safety and food.¹² 

The project also engaged in a workshop with local service providers to discuss addressing barriers faced by these communities to improving their health and wellbeing, and enablers actioned. Among the interesting results across the three communities were how the Arabic speakers with chronic conditions wanted their healthcare professional (HCP) to respect their socio-cultural beliefs and be actively involved in their healthcare.¹²

Finally, co-design workshops were held,which involved Arabic-speaking community members and key stakeholders collaboratively designing interventions/programs. They focused on how to develop:

• a user-friendly health care system 
• community connection and
• skills recognition and migrant employment opportunities, for, in this case, the Arabic-speaking community.

Community ideas for creating user-friendly health care systems

Results of the ‘co-design’ process showcased two key aspects. One was two-way community and health profession training, i.e. the community educates relevant health professionals about their unique needs, health experiences and access barriers. In turn, health professionals conduct community outreach and educate the community about their roles and relevant health issues. Secondly, cultural humility and insight were an expectation the community had about their health professionals. An interesting suggestion was for health professionals to be awarded continuing professional development points for their efforts to engage in outreach health education programs. 

Arabic-speaking community members were keen to engage with community pharmacists and community pharmacy featured specifically as a repeatedly mentioned healthcare venue.

Actioning the project vision – emphasising the ‘community’ in community pharmacy!

To action these ideas, 15 pharmacists were invited to participate from a diverse range of cultural backgrounds in Brisbane and Adelaide.¹² A cultural capability program was designed by the project team. Once trained, participating pharmacists took part in community sessions with Arabic-speaking Australians to exchange views and familiarise themselves with perceptions about each other to forge methods for better future engagement.¹²  The sessions named Meet a Community Pharmacist – Your Everyday Health Care Professional were run by each pharmacist in their local area (nine sessions in Adelaide and six in Brisbane in late 2021) with 184 members of the Arabic-speaking community (see Figure 1).¹² 

Figure 1 – Key topics covered at the ‘Meet a Pharmacist’ community sessions

What was learnt from the community?

Of the 184 participating Arabic-speaking community members attending the sessions, 87% reported visiting a community pharmacy for over the counter or prescription medicine at least once a year, yet 45% reported never having discussed a medicine-related issue with their pharmacist.¹² Community participants rarely discussed lifestyle issues with the pharmacist, e.g. diet, exercise, sleep or smoking. However, half of them wished they had done so, particularly around diet/exercise issues.¹² Community participants very strongly agreed that the session was ‘valuable’ and 90% later felt more confident in asking for medicine or health-related advice from their community pharmacist.¹²

The community outreach activity clearly served to enhance ‘trust’ in pharmacists and facilitated a view of pharmacists as ‘approachable’ members of the healthcare system. From a marketing science perspective, the investment in running such community outreach sessions can clearly ‘create’ demand for pharmacists’ advice, whilst benefitting community health. 

What was learnt from pharmacists?

1. Community pharmacists frequently interact with people from CALD backgrounds. Participating pharmacists estimated 5–50% (average 24%) of their clientele were from CALD backgrounds. About half the pharmacists reported at least weekly interactions with CALD patients.¹²
2. Community pharmacists often find interacting with CALD patients difficult. This was particularly so around medical history-taking and counselling patients on proper use of medicines.¹² Several systemic constraints were mentioned by participating pharmacists in this regard e.g. time/task pressures, time spent organising interpreting services and being underconfident about their own personal cultural knowledge.¹²
3. Pharmacists try to use pragmatic workarounds. About 15% of pharmacists reported using measures such as ad-hoc interpreters (e.g. pharmacy staff, patients’ family) to communicate. Multilingual medicine pack labels were rarely provided.¹² 

Information gathered after the pharmacists had undertaken the cultural capability training and run the community program indicated that whilst pharmacists had improved awareness of their personal and professional culture, they were unsure about making practice changes that would make their pharmacies more accessible for CALD consumers.¹² Undertaking the cultural capability training improved their knowledge about accessing interpreters, effectively utilising translation services, accessing and providing translated materials, and referring CALD consumers to appropriate support services.¹²

The project team then used a method known as the Social Return on Investment (SROI).¹⁴  This is a sophisticated technique, where outcomes expected from a program or intervention are mapped, the proportion of participants reporting outcome achievement are collated, a monetary value attributable to the outcome of interest is calculated and, finally, the ‘social value’ created for each stakeholder group is worked out and compared to the costs of the initiative.¹⁴

Using this method, the project analysts calculated the overall SROI for the project was $117,000. Of this, the value created for pharmacists was $33,110, the value for the Arabic-speaking community members was $39,834 and the value for the government/healthcare system was $44,556. The program running cost was $171,000, which suggested that for each dollar invested there was a ‘social outcome’ return of $0.68. A higher uptake by community members would have increased this return; though this figure is also quite promising.

What does this all mean?

See Table 1 for suggestions to enhance culturally capable healthcare delivery based on learnings from this project and established cultural competence models.¹⁵

Table 1 – Actioning cultural capability criteria in practice

Conclusion 

Community entrenched projects and partnerships are effective in creating bidirectional value for health professionals and consumers. As frontline professionals, pharmacists frequently service consumers from a diverse socio-demographic pool, regardless of the location of the pharmacy. Building cultural capabilities has dual benefits; bringing returns to the business and enhancing health outcomes for patients, aside from professional fulfilment. 

References

1. Australian Bureau of Statistics. 2024.0 – Census of population and housing: Australia revealed. 2016. At: www.abs.gov.au/ausstats/abs@.nsf/mf/2024.0
2. Napier AD, Ancarno C, Butler B, et al. Culture and health. Lancet 2014;384(9954):1607–39.
3. Australian Institute of Health and Welfare. Australia’s Health 2018 in brief. At: www.aihw.gov.au/reports/australias-health/australias-health-2018-in-brief/contents/all-is-not-equal
4. Alzayer R, Svedin E, Rizvi SA, et al. Pharmacists’ experience of asthma management in culturally and linguistically diverse (CALD) patients. Res Social Adm Pharm 2021;17(2):315–25.
5. Alzayer R, Chaar B, Basheti I, et al. Asthma management experiences of Australians who are native Arabic speakers. J Asthma 2018;55(7):801–10.
6. Australian Institute of Health and Welfare (AIHW). Asthma Web Report, 2020. At: www.aihw.gov.au/reports/chronic-respiratory-conditions/asthma/contents/asthma
7. Australia Asthma Handbook. At: www.asthmahandbook.org.au/
8. Stanford RH, Shah MB, D’Souza AO, et al. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol 2012;109(6):403–7.
9. Suissa S, Ernst P, Boivin JF, et al. A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Am J Respir Crit Care Med 1994;149(3 Pt 1):604–10.
10. Saini B, Krass I, Smith L, et al. Role of community pharmacists in asthma – Australian research highlighting pathways for future primary care models. Australas Med J 2011;4(4):190–200.
11. Serhal S, Saini B, Bosnic-Anticevich S, et al. A targeted approach to improve asthma control using community pharmacists. Front Pharmacol 2021;12:798263. Epub 2021 Dec 27.
12. Asthma Australia. Evaluation of the Culture Well Project. A report prepared by the Incus Group, 2021.
13. Robotham D. Evaluating DIY Happiness: a guide. UK: The McPin Foundation and South London and Maudsley NHS Foundation Trust (SLaM);2018:18.
14. Mulgan G. Measuring Social Value. Stanford Social Innovation Review. 2010;38–43. At: https://ssir.org/pdf/2010SU-Feature_Mulgan.pdf
15. Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: a model of care. J Transcult Nurs 2002;13(3):181–4.

PROFESSOR BANDANA SAINI University of Sydney School of Pharmacy; Affiliate Staff and Research Leader, Woolcock Institute of Medical Research.

Ms NERA KOMARIC World Wellness Group, Board Director – Medical Clinic; Adjunct Senior Fellow, School of Clinical Medicine – Primary Care Clinical Unit, University of Queensland.

Ms JANINE PHILLIPS Projects and Partnerships Manager, Asthma Australia.

Ms MICHELLE DAVIS Health Projects and Partnerships Officer, Asthma Australia; Cultural Communication/Applied Linguistics Specialist.