Inclusion of Health Disparities, Cultural Competence, and Health Literacy Content in US and Canadian Pharmacy Curriculums

Aleda M. H. Chen, PharmD, PhD; Anastasia L. Armbruster, PharmD; Beth Buckley, PharmD; Jennifer A. Campbell, PharmD; Devra Khanh Dang, PharmD; Radhika Devraj, PhD; Imbi Drame, PharmD; Akesha Edwards, PharmD, PhD; Sally L. Haack, PharmD; Qing Ma, PharmD, PhD; Natasha Petry, PharmD; Lourdes G. Planas, PhD; Cheryl A. Sadowski, PharmD; Jennifer Santee, PharmD; Latasha Wade, PharmD; Nancy Borja-Hart, PharmD


Am J Pharm Educ. 2021;85(1):8200 

In This Article

Abstract and Introduction


Objective: To determine how US and Canadian pharmacy schools include content related to health disparities and cultural competence and health literacy in curriculum as well as to review assessment practices.

Methods: A cross-sectional survey was distributed to 143 accredited and candidate-status pharmacy programs in the United States and 10 in Canada in three phases. Statistical analysis was performed to assess inter-institutional variability and relationships between institutional characteristics and survey results.

Results: After stratification by institutional characteristics, no significant differences were found between the 72 (50%) responding institutions in the United States and the eight (80%) in Canada. A core group of faculty typically taught health disparities and cultural competence content and/or health literacy. Health disparities and cultural competence was primarily taught in multiple courses across multiple years in the pre-APPE curriculum. While health literacy was primarily taught in multiple courses in one year in the pre-APPE curriculum in Canada (75.0%), delivery of health literacy was more varied in the United States, including in a single course (20.0%), multiple courses in one year (17.1%), and multiple courses in multiple years (48.6%). Health disparities and cultural competence and health literacy was mostly taught at the introduction or reinforcement level. Active-learning approaches were mostly used in the United States, whereas in Canada active learning was more frequently used in teaching health literacy (62.5%) than health disparities and cultural competence (37.5%). Few institutions reported providing professional preceptor development.

Conclusion: The majority of responding pharmacy schools in the United States and Canada include content on health disparities and cultural competence content and health literacy to varying degrees; however, less is required and implemented within experiential programs and the co-curriculum. Opportunities remain to expand and apply information on health disparities and cultural competence content and health literacy content, particularly outside the didactic curriculum, as well as to identify barriers for integration.


Racial and ethnic diversity continue to increase in the United States and Canada. According to recent projections by the US Census Bureau, 56.4% of Americans will belong to a racial or ethnic minority group by 2044 and almost 20% will be foreign born by 2060.[1] Similar trends exist in Canada, where an estimated 30% of Canada's population will be immigrants by 2036.[2–4] Recognizing that racial and ethnic minority populations experience high rates of health disparities, the US Department of Health and Human Services created an action plan to provide guidance in this area.[2] One of the goals is to "increase the diversity and cultural competency of clinicians" so they are prepared to appropriately incorporate cultural factors into the patient encounter. Along with culture, low health literacy can also negatively impact health outcomes.[3] Approximately 90 million people in the United States and 9 million people in Canada experience limited literacy.[4,5] Low health literacy disproportionately affects racial and ethnic minorities.[6]

In Canada, the Minister of Health's 2019 mandate letter provides direction to support improved research and care regarding diversity, specifically racial diversity.[7] Indigenous healthcare has received an increased focus since 2015 when the Truth and Reconciliation Commission (TRC) of Canada published 94 Calls to Action. Call to Action 24 requires that students in the health sciences take a course "dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism."[8]

As the United States and Canadian populations become more diverse, student pharmacists must be prepared to deliver culturally responsive healthcare. Preparation must extend beyond understanding the impact of race and ethnicity on health disparities and provider-patient relationships to a broader conceptualization of the diverse set of patient backgrounds that can influence decision-making and care, such as religion, health beliefs, age, gender identity, sexual orientation, income level, (dis)ability status, and immigration status. Not only is this important for providing patient-centered care, it is also necessary for recognizing, addressing, and decreasing health disparities. Various publications recommend integrating health disparities and cultural competence education and training into pharmacy curricula.[9,10] The Association of Faculties of Pharmacy of Canada (AFPC) Education Outcomes specifically reference the TRC and encourage a high priority on Call to Action 24 to be placed in curricula.[11] The Accreditation Council for Pharmacy Education (ACPE) standards highlight the responsibility of programs to prepare graduates who can recognize social determinants of health (Standard 3). The ACPE standards also list cultural awareness as a required element of the didactic curriculum.[12] The American Association of Colleges of Pharmacy (AACP) Center for the Advancement of Pharmacy Education (CAPE) outcomes note the importance of graduates' ability to modify communication strategies to meet patient needs and incorporate patient beliefs into care plans.[13] Although multiple entities recommend inclusion of these topics and some accrediting bodies require them, there is little direction on how pharmacy schools should incorporate this content or subsequently assess student learning.

A 2007 study by Onyoni and Ives examined the degree to which cultural competency concepts were incorporated into the organizational structure and curricula of accredited colleges and schools of pharmacy in the United States and Canada.[14] Their study found that didactic and case-based instruction were the prevailing pedagogical approaches for cultural competency education and training. While more than half of the responding schools affirmed revisions to their curricula in the past to include topics related to cultural competency, 49% expressed intent to add new courses and topics.[14] Since then, more than 30 new schools have been established in the United States, yet no additional large-scale surveys of cultural competency education and training in curricula have been performed.

While health literacy education has been examined in discrete courses taught in individual schools,[15–17] there has never been a comprehensive national assessment of scope of health literacy content delivery in the United States or Canada. The purpose of this study was to determine how schools and colleges of pharmacy in the United States and Canada include content related to health disparities and cultural competence and health literacy in both their curriculum and assessment practices.