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Cultural humility; Pharmacy assessment tools; Pharmacy education; Practice

Introduction

Pharmacy education and practice started adding training on cultural diversity as early as the 1990s. Since then, pharmacy programmes have included the idea of cultural diversity into their curricula, lectures, semester-long courses, and other areas of the curriculum. While some programmes highlighted the typical traits of particular races or ethnicities, others stressed culture from a more generic perspective. In [1] some programmes, this has been broadened to include chances for service-learning so that students can gain a deeper awareness of the social and cultural challenges in their communities. Additionally, to provide a more thorough examination of different cultures, some pharmacy programmes include global health rotations or outreach opportunities. Producing "culturally competent" students is the aim. The phrase "cultural humility" was later adopted by the medical education community to embrace the idea of a lifelong quest for knowledge [2] and awareness of cultural variety and to promote self-reflection among healthcare workers. 1 The adoption of the term "cultural humility" in pharmacy education indicates that the objective is to create pharmacy students and professionals who will be aware of the cultural needs and dynamics in their community, able to meet those needs, and capable of self-reflecting on interactions with patients with the goal of improving patient outcomes. 1 With the phrase "culturally-responsive education," Rockich-Winston and Wyatt1 argue for incorporating cultural humility and cultural competency in pharmacy courses. Five components are listed by [3] the authors as being necessary for culturally responsive teaching: "creating opportunities for cultural socialisation, adopting teaching strategies that meet student needs, learning the cultural diversity of students, developing culturally relevant curricula, and demonstrating cultural compassion." 1 Numerous pharmacy programmes have reviewed their curricula for cultural humility, but what they frequently forget to do is review assessment mechanisms like case studies, multiple-choice exams, and even case presentations.While race and ethnicity are significant factors when caring for patients of different backgrounds, students should be aware that these concepts are social constructions with no medical or scientific basis. Reviewing the fundamental definitions is helpful when [4] talking about race and ethnicity. Historically, the terms "ethnicity" and "race" have generally been used to describe broad groupings of people that are split arbitrarily but based on ancestry and physical traits, as well as a person's cultural identity (such as language, customs, and religion). 4 The objective of student assessment, which can take the form of MCQs, case studies, or even case presentations, is not to completely omit demographic information from vignettes and scenarios, but rather to integrate it in a way that prevents unconscious bias. 6 The overuse of racial associations with genetic illnesses, according to Amutah et al.5, Ripp and Braun6, and Braun, may result in underdiagnosis of the disease in other populations where it can also occur. Even though the topic of eliminating unconscious bias [5-7] from the curriculum has received a lot of attention, there is still little research on the subject of cultural humility in student evaluations. 6 Ripp and Braun's6 examination of 2011 questions from a question bank for Step 1 of the United States Medical Licensing Exam is one of the research that has received the most citations. They examined the test items to determine how and where descriptive characteristics like race and ethnicity were used. The distribution of the races cited was disproportional to the population of the United States, with a predominance of White/Caucasians mentioned in the 455 questions that included one or both factors. African Americans are most likely to be connected to hereditary disorders such sickle cell disease, sarcoidosis, and glucose-6-phosphate dehydrogenase deficiency, regardless of whether race was fundamental to the test question or was merely descriptive. This would imply that some of these illnesses are race-specific without taking into account additional factors that can contribute to the illness. It is important to describe these variables in a way that avoids evoking a biogenetic character when include them. Even less research has been done on unconscious prejudice in the evaluation of pharmacy students. A recent cross-sectional study, however, was conducted with 357 doctors of pharmacy (PharmD) students from six institutions of higher learning. 7 Students were given two cases: the first had a 48-year-old man who went to the emergency room after being assaulted, and the second involved a 35-year-old woman who showed up two days after surgery with indications of delirium tremens. For the first scenario, students were randomly assigned to receive either images of a Black patient or images of a White patient. For the second scenario, the patient's race was reversed for all participants. Except for the images that were provided, the patient cases' specifics were similar. Students took the Harvard Race Implicit Association Test after the initial survey (IAT). The results of the Race IAT were provided to the students in the form of preferences for White or Black people and their level of warmth or coldness toward either race. The average score on the Race IAT was 2.76, which indicates a general preference for White people of a slight to moderate strength. The average student expressed a modest explicit preference for White persons, with a mean rank of 3.73. The results of this study indicate a small amount of unconscious and explicit negative [8-11] bias among the student population, however this prejudice did not affect how the students reacted to clinical cases. This study found prejudice favouring Black patients, while more research is required. 7 Best techniques for exam item construction have been the subject of prior research8; however, there is currently little stage (Table 1) information available on unconscious bias in pharmacy MCQs. This study was designed to investigate how one pharmacy program's multiple-choice item bank employed factors such as race, ethnicity, age, and gender. The intention was to make pharmacy educators aware that, in addition to checking their courses for unconscious bias, they should also think about checking their student assessments.

Table 1:Stages of change model.

Method

The study was carried out at a four-year, private PharmD School. The researchers looked through historical data to find exam questions from the 2018–2019 school years. Exams from first-, second-, and third-year pharmacy curricula were included in the 27 pharmacy test banks that were analysed. Exams [12] were all from lectures rather than labs. 3621 questions from the 27 courses were examined and classified according to age, gender, race, and ethnicity [13-15].

Result

Race was mentioned in 40 of the 3621 exam items that were reviewed in total. Caucasians made up 25% of the population, followed by African Americans (35%), Asians (15%), Hispanics (20%), and Pakistanis (0.5%). Only two of the 40 questions, or 5% of them, were found to be racially appropriate or relevant (and related to Whites). In 39 of the 40 questions, the word "race" was used in the opening line. For African Americans, race was connected to HIV and sexually transmitted diseases in all questions when it was included for descriptive purposes.

Conclusion

These findings show that although just a few test questions made mention of race, when they did, it was not at the heart of the topic. The habitual inclusion of race in the creation of materials like question banks without a clear purpose runs the risk of fostering racial bias. For instance, all the questions about African Americans in the particular item bank examined for this study contained a STI or a sickle cell condition.

Acknowledgement

The authors would like to thank everyone who worked at the various drug information centres in Nepal for contributing the knowledge.

Disclosure

In this paper, the authors disclose no conflict of interest.

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