APhA 2025: A Pharmacist’s Guide to Culturally Competent and Inclusive Care

Pharmacy Times interviewed Sally Arif, PharmD, BCCP, is a clinical pharmacy specialist-cardiology at Rush University Medical Center, a diversity, equity and inclusion coach and facilitator at The Nova Collective, principal CEO and founder at The Equity-Minded Collective, and professor of pharmacy practice at Midwestern University in Chicago, Illinois, on her presentation at the American Pharmacists Association (APhA) Annual Meeting & Exposition, taking place March 21 to 24, 2025, in Nashville, Tennessee.

In her APhA presentation titled “Red Solo CUP: Communicating with Underserved Patients,” Arif highlighted the key challenges pharmacists face when providing care to underserved populations who may face economic disadvantages, language barriers, health literacy issues, and mistrust in the health care system. Arif emphasized the importance of utilizing interpretive services, cross-cultural communication tools like the LEARN mnemonic, and the teach-back method to improve patient understanding and adherence.

Pharmacist talks to patient. Image Credit: © Zamrznuti tonovi - stock.adobe.com

Arif also discussed pharmacoequity, stressing the need for shared decision-making to ensure all patients, regardless of socioeconomic status or geography, have access to necessary medications. She concluded by discussing her book Shift: A Practical Guide to Cultivating Equity and Inclusion in Healthcare Education, which provides actionable strategies for fostering equity and inclusion in both patient care and health care education.

Pharmacy Times: What populations are often considered underserved in the United States?

Sally Arif, PharmD, BCCP: Typically, in the United States, underserved populations would include individuals that often experience barriers to receiving health access or health care access that leads to often disparities that we see in health outcomes. So, this typically ends up being along the lines of populations that have economic disadvantage, that struggle with health care costs in general, racial and ethnic minoritized groups that have disparities in their health outcomes, and rural residents. We know 25% of individuals in the United States live in what we call a health care desert. Individuals also who have limited English proficiency, and often individuals that have disabilities fall into these kinds of underserved groups.

Pharmacy Times: What are some common cultural, linguistic, or communication barriers that pharmacists might encounter when working with patients from underserved communities?

Arif: So, often for multiple settings, pharmacists frequently encounter linguistic differences, where they have trouble communicating across language lines with a patient in front of them. And this is really where we need interpretive services, which is something that we should be offering to all patients.

Also limited health literacy—this comes up a lot as well and is one of the key components we need to keep in the back of our minds. Then we have patients that often could have cultural beliefs that may affect how they want to adhere with their medications or what medications they feel comfortable taking.

Additionally, we have to also consider sometimes mistrust that patients have in the health care system, or even some of the logistical barriers when we think about negative social determinants of health. So, this could be patients that have a lack of transportation or insurance to be able to pay for their medications, and that could really complicate how patients want to engage in their care and how much they are willing to come to a health care provider for help.

Pharmacy Times: How can pharmacists best assess a patient's health literacy without making them feel uncomfortable?

Arif: There is a lot of shame around patients who do have limited or low health literacy, and our goal as pharmacists shouldn't be to make that increase in any way. So, I think often it's really about active listening, and I find an effective approach that we all learn about in pharmacy school, but sometimes in the midst of a quick day, we forget that open-ended questions are really a great way to unlock a lot of information from our patients and understand where they might have misunderstandings about their medication.

So, asking simple things like, Can you walk me through how you would plan to take this medication? This is sometimes referred to as that teach-back method, where pharmacists may have to counsel the patient, and they're really looking again for those gaps in patient knowledge. It's not about quizzing the patient. I always say it's about us checking ourselves and seeing how well we communicated with a patient who might have limited health literacy.

I often also think about validated tools out there that assess how much literacy someone might have around their health. One is called the single item literacy screening tool, which is really just asking the patient, Do you have any trouble when you're filling out forms at the doctor's office or at the pharmacy? And if a patient answers at times or often or always, they do that validated way of confirming that they do have some limited health literacy. So, kind of incorporating a question like that into your interview with a patient can really help you see if you need to take a little bit more time with a patient and call out that they have limited health literacy, but make sure that you are still addressing it.

Pharmacy Times: What verbal and non-verbal communication techniques can pharmacists use to build trust with patients from diverse backgrounds?

Arif: So, there's a lot of really great, validated tools out there that are called cross-cultural communication tools that can be used. One is called the LEARN [Listen, Explain, Acknowledge, Recommend, Negotiate] mnemonic. The LEARN mnemonic starts with listening actively to the patient, and then going into explaining or educating the patient, from our lens as clinicians, what is going on with their medications or their illness. Then we move on to acknowledging with the A of that mnemonic, what the differences are between what the patient understands and what maybe we see from our biomedical lens as the pharmacist or clinician. Then we recommend a treatment plan, and then we go into the last step, which is negotiating a mutually agreed plan with that patient. So, if we find that the first line medication that we want to recommend, or the OTC product that we want to recommend, does not align with what the patient's goals are in their health, then we're negotiating together what would be the best choice. That really helps patients feel like they're being heard, especially again, if there are some of those barriers that we talked about before.

Nonverbal cues are also really important. So, thinking about eye contact, thinking about open, engaged posture, not letting technology get between us and our patients, and then obviously demonstrating cultural sensitivity, so that we are creating an environment that's welcoming and it feels supportive to the patient.

Pharmacy Times: How can pharmacists ensure patients understand their medication regimen, especially if they have low literacy or language barriers?

Arif: I think simplifying instructions is key. Thinking about sometimes less is more. Often we don't take that time to kind of look through and say, Well, we've got some duplication in therapy here, or Could we change this regimen to a once a day regimen by switching to another medication in that drug class? A lot of patients are visual learners, so using visual aids for patients that have language barriers. Obviously, translated materials in the language that they feel comfortable with is really important.

Again, that teach-back method is useful because it really helps us, again, see and ensure comprehension. It's not just about having them tell us back what they know, but also maybe show us what they would do with their inhaler or their spacer or their glucometer, whatever device they might have to be using, because we don't want to assume just because they were able to tell us the steps that they would be able to actually do those steps. We don't want to burden the patient with more than they can handle.

So really, again, looking back and checking in with their nonverbal cues. If they look confused, if they look like they're not tracking with what we're saying, we want to kind of stop and slow down the conversation.

Then also, obviously, with patients that have language barriers, making sure we are using interpreters that are medically trained, and we're not using family members or children that might introduce some bias into the conversation, and are not trained with medical terms. So, it's a really important, again, that we give that respect to our patients.

Pharmacy Times: What is pharmacoequity and how can shared decision making with patients help pharmacists achieve pharmacoequity?

Arif: Pharmacoequity was actually a term that was coined by [Utibe R. Essien, MD, MPH,] in a JAMA article in 2021, and it really refers to this idea of ensuring all patients—so regardless of their socioeconomic status, their race, their geography—have access to the optimal medications they need to achieve their optimal level of health. So, this requires us to think about shared decision making as a tool of engaging our patients in discussions about their treatment options. So, thinking about cultural realities for that patient, thinking about financial realities and tailoring our care plans or treatment plans accordingly.

This also means thinking about medication affordability and finding different ways that we can help patients get access to medications in that way. This really, again, empowers patients to see that we're all on the same team. We're all partners in this process of attaining the highest level of health.

Pharmacy Times: What insights do you share for pharmacists on this topic in your book Shift: A Practical Guide to Cultivating Equity and Inclusion in Healthcare Education?

Arif: I really am excited about this book, and I named it Shift because it really is about shifting mindsets, and sometimes it's easy to fall into a pattern where we're in autopilot around how we manage patients, and we don't shift into thinking about tailoring our approach for each patient and their needs. So, shift is really about some of the concepts we talked about today, which is actionable strategies to integrate inclusive settings of practice for patient care and also for many of us in health care that are training the future generation and rising stars as clinicians, of recognizing our own biases, helping coach on, what does it mean to practice cultural sensitivity and humility and practice, and how do we actually use cross cultural communication tools? And lastly, to think about large systemic changes that are needed in our policies and health care so that we reduce health disparities and reduce disparities in medication access. So, I see Shift as a book that is a reference guide that could be used for pharmacists and other health care professionals that are committed to fostering equity and improving patient outcomes.