Racial and Ethnic Disparities in Community-Based Pharmacies: A Scoping Review

As pharmacy practice shifts its focus toward population health care needs that serve public health, there is a need to understand community-based pharmacies’ contributions to the reduction in health disparities. A scoping review was conducted to identify what community-based pharmacies in the United States are doing to target racial and ethnic disparities in community-based pharmacies. Forty-two articles revealed that community-based pharmacy services addressed racial and ethnic inequities in a variety of ways, including the types of interventions employed, as well as the ethnicities and conditions of the sample populations. Future work should focus on ensuring interventions are carried out throughout pharmacy practice and accessible to all racial and ethnic minoritized populations.


Introduction
Racial and ethnic healthcare disparities are prevalent throughout the United States [1]. While this issue has received considerable attention from researchers, health practitioners, academics, and policymakers, disparities between White people and Black, Indigenous, and People of Color (BIPOC) persists-particularly in access to health care, disease incidence and prevalence, and mortality [2][3][4][5][6][7]. Over the past several decades, there have been various calls to change how race and racism are examined in healthcare [8]. In 2003, in Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, the Institute of Medicine (IOM) identified potential sources of racial and ethnic disparities in healthcare and provided recommendations for healthcare professionals, health systems, and policy makers [9,10]. However, racial and ethnic disparities in the United States continue. According to the 2018 National Healthcare Quality and Disparities Report, Black, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander patients continue to receive poorer care than White patients on 40% of the quality measures included, with little to no improvement over the previous decades.
For health systems, the IOM recommendations include developing and implementing interventions that promote the use of evidence-based guidelines, structuring payment systems that ensure equitable access, cultivating communication and trust between providers and patients, employing language interpretation services, and engaging in multidisciplinary treatment and preventative care teams [11]. While many health systems have incorporated these recommendations, the novel coronavirus (COVID-19) pandemic exposed and compounded serious flaws in the American health care system [12].
One healthcare setting largely overlooked by researchers in the deployment of equitable services is the community pharmacy. Pharmacy practice models have highlighted community pharmacies' unique position in connecting individuals to care [12][13][14]. Yet, little research has been performed in this setting to understand its delivery of equitable care. As one of the most accessible healthcare systems, community-based pharmacies can employ many of the IOM's recommendations to target and reduce racial and ethnic healthcare disparities. As pharmacy practice shifts its focus toward population health care needs that serve public health, there is a need to understand community-based pharmacies contributions to the reduction in health disparities [15,16]. This scoping review was conducted to identify what community-based pharmacies are doing to target health and healthcare disparities in their areas. In addition to identifying interventions, we compared these interventions to the IOM recommendations for health systems to identify gaps and opportunities for community pharmacies to reduce healthcare disparities.

Materials and Methods
A scoping review with a systematized methodology was conducted, as this method offered the researchers an opportunity to report evidence of community pharmacy-based interventions that addressed racial and ethnic health care disparities [17]. Three researchers (TH, FH, JR) evaluated pharmaceutical services in community and ambulatory care pharmacies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [18]. Additionally, each intervention as described in each paper was mapped against the IOM's recommendations for health systems to reveal remaining evidence gaps that will inform practice innovation in the field and inspire future research [19][20][21].
The population for this study was community-based pharmacy. For this study, community-based pharmacy is defined as a setting where pharmacists provide care within traditional community pharmacies, physician offices, ambulatory and outpatient clinics, patient-centered medical homes, and other community-based settings [22]. The interventions studied were pharmaceutical care services whose goal was to reduce health and/or healthcare disparities between racial and ethnic minoritized groups. For the purposes of this study, the following were included as racial and ethnic minoritized groups: African Americans or Black Americans, Hispanic Americans or Latinx Americans, Asian Americans, Native Hawaiian or other Pacific Islander Americans, and American Indians or Alaska Natives.
This review was submitted for registration in PROSPERO (No. CRD42022307405) and followed PRISMA systematic review reporting guidelines [23].

Identifying Relevant Studies
The authors searched PubMed for articles using the following combination of MeSH terms, title words, and keyword synonyms, including their multiple variants: healthcare disparity OR health equity OR disparities, health status OR minority health) OR Health Care Quality, Access, and Evaluation AND African Americans OR Indians, North Care" that included recommendations for health system interventions to reduce health and healthcare disparities [9]. If a manuscript was published within the search parameters, but the intervention described within the manuscript began before the release of the IOM's statement, that paper was also not eligible. To supplement the papers obtained in our database searches, we additionally reviewed bibliographies and added previously recognized landmark studies.

Select the (Relevant) Studies
All articles identified from the search were imported into a database displaying the title, PMID, author, and abstract. Two researchers (FH and TH) separately reviewed the article titles and applied the screening tool (inclusion criteria are explained below) to determine their eligibility for full-text review. Each researcher then conducted a full-text review and selected eligible articles. Eligible studies met inclusion criteria: (1) represented an original study; (2) included at least one intervention led by a community-based pharmacist or in a community-based pharmacy setting designed to reduce racial and ethnic health or healthcare disparities; (3) presented data for racial and/or ethnic minority populations in the US; and (4) reported findings in English. We did not include conference abstracts or unpublished studies. Furthermore, articles were excluded for wrong study design if they did not detail a specific intervention led by a pharmacists or their support staff; wrong setting if they did not take place in a community-based pharmacy; and wrong patient population if they did not have majority of the sample population come from at least one minoritized racial or ethnic minoritized groups. Non-US studies and articles unavailable for full-text access were also disregarded. The team reviewed the selected articles, discussed the findings, and resolved disagreements on study selection and data extraction by consensus and through discussion.

Charting the Data
We adopted a descriptive analytical approach to the included articles. Responses were charted in an Excel database. Included articles were compared to the IOM recommendations for health systems ( Figure 1).

Select the (Relevant) Studies
All articles identified from the search were imported into a database displaying the title, PMID, author, and abstract. Two researchers (FH and TH) separately reviewed the article titles and applied the screening tool (inclusion criteria are explained below) to determine their eligibility for full-text review. Each researcher then conducted a full-text review and selected eligible articles. Eligible studies met inclusion criteria: (1) represented an original study; (2) included at least one intervention led by a community-based pharmacist or in a community-based pharmacy setting designed to reduce racial and ethnic health or healthcare disparities; (3) presented data for racial and/or ethnic minority populations in the US; and (4) reported findings in English. We did not include conference abstracts or unpublished studies. Furthermore, articles were excluded for wrong study design if they did not detail a specific intervention led by a pharmacists or their support staff; wrong setting if they did not take place in a community-based pharmacy; and wrong patient population if they did not have majority of the sample population come from at least one minoritized racial or ethnic minoritized groups. Non-US studies and articles unavailable for full-text access were also disregarded. The team reviewed the selected articles, discussed the findings, and resolved disagreements on study selection and data extraction by consensus and through discussion.

Charting the Data
We adopted a descriptive analytical approach to the included articles. Responses were charted in an Excel database. Included articles were compared to the IOM recommendations for health systems ( Figure 1).

Collating, Summarizing, and Reporting the Results
Articles were collated, quantitatively summarized, and thematically analyzed to identify patterns based on title and abstract. Spreadsheets and tables were produced that categorized each theme with a different color. To determine the effect of each type of intervention, we classified studies by intervention type and IOM categorizations. We also

Collating, Summarizing, and Reporting the Results
Articles were collated, quantitatively summarized, and thematically analyzed to identify patterns based on title and abstract. Spreadsheets and tables were produced that categorized each theme with a different color. To determine the effect of each type of intervention, we classified studies by intervention type and IOM categorizations. We also grouped studies with similar intervention components together to assess the impact of the combination of interventions because the majority of intervention techniques used more than one intervention [24]. A summary of the IOM recommendations relevant to health-system interventions appears in Table 1.  [12].

5-6
Promote the consistency and equity of care through the use of evidence-based guidelines.

5-7
Structure payment systems to ensure an adequate supply of services to minority patients and limit provider incentives that may promote disparities.

5-8
Enhance patient-provided communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice.

5-9
Support the use of interpretation services where community need exists.

5-10
Support the use of community health workers.

5-11
Implement multidisciplinary treatment and preventive care teams.

5-12
Implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions

Results
The original search yielded 1030 articles, 649 of which were deleted after reviewing the titles and abstracts. An additional 345 articles were discarded after reviewing the articles in their entirety, resulting in 36 articles. In the process of reviewing articles identified through the initial searches, one of these articles was a review article. From this review article, 7 articles were identified through cited references, bringing the total to 42 articles for this review. Table 1 details the articles found, including the study setting, identified healthcare disparity or inequity, a brief description of the intervention, racial/ethnic minority group targeted, and study findings.

Publication Years and Study Design Characteristics
In total, 4 of the 42 publications were published within five years following the IOM guidelines. Furthermore, 15 articles were published between 2008-2012, which was more than five but less than 10 years since the release of the IOM recommendations, with the remaining articles being published greater than 10 years since the release of the 2003 IOM recommendations. Among the 42 articles, 11 articles used an experimental design, 20 employed an observational design, and 11 used an implementation science design.

Study Subjects
This review's studies mostly focused on African American (n = 21) and Hispanic (n = 23) groups. Interventions were developed for American Indians and Alaskan Natives in 4 of the articles and for Asian individuals in 2 of the articles. The majority of the studies (n = 39) focused on the general population. Two studies' research participants were pediatric patients, and one studies' research participants were older adults. Majority of the studies targeted patients with diabetes (n = 17) and hypertension (n = 13). The remaining studies targeted general health literacy and counseling barriers (n = 8), vaccinations (n = 4), obesity and other weight related parameters (n = 4), asthma (n = 3), HIV (n = 2), smoking cessation (n = 2), dyslipidemia (n = 2), cancer prevention (n = 1), ophthalmic care (n = 1), and psychiatric illness (n = 1).

Pharmaceutical Care Services and Community-Based Setting
In the articles reviewed, pharmaceutical care services included medication and/or disease-state management (n = 17), patient counseling and education (n = 7), communi-cation services, including language assistance (n = 8) and health literacy (n = 2), point of care testing (n = 5), and telemedicine (n = 1). Most of the pharmaceutical care services were rendered in the traditional community pharmacy (n = 13) and community-based clinic (n = 13) setting. The remaining services were rendered in community outreach sites (n = 9), safety-net or federally qualified health systems (n = 4), patient homes or nursing homes (n = 2), and community-based health systems (n = 1). Additional information regarding the articles reviewed can be found in Table 2.

IOM Recommendations and Gap Analysis
The IOM recommendations (IOMR) most frequently addressed by the included studies were: IOMR 5-11, implement multidisciplinary treatment and preventive teams (n = 30); IOMR 5-12, implement patient education programs to increase patients' knowledge of how to best access care and participate in treatment decisions (n = 13); IOMR 5-9, support the use of interpretation services where community need exists (n = 12); IOMR 5-10, support the use of community health workers (n = 10); IOMR 5-6, promote the consistency and equity of care through the use of evidence-based guidelines (n = 9); IOMR 5-7, structure payment systems to ensure an adequate supply of services to minority patients, and limit provider incentives that may promote disparities (n = 8), addressed by less than a third of the included studies; IOMR 5-8, Enhance patient-provided communication and trust by providing financial incentives for practices that reduce barriers and encourage evidencebased practice, only addressed by one study. Evidence of the recommendations carried out by the studies are revealed in Table 3. Table 3. Evidence gaps in community-based pharmaceutical services and IOM's recommendations.

Discussion
In this scoping review, we assessed the provision of pharmaceutical care services targeted for racial and ethnic minoritized populations in community-based pharmacies. To our knowledge, this is the first study to assess whether community-based pharmacies have carried out the recommendations as laid out by the IOM in their paper Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. This research found that community-based pharmacy services address racial and ethnic inequities in a variety of ways, including the types of interventions employed, as well as the ethnicities and conditions of the sample populations. This paper also highlights the important role of community-based pharmacies in carrying out the IOM's recommendations and reveals some areas for research and progress.
Having pharmacists on the multidisciplinary healthcare team has long been established as being beneficial for patients in a variety of clinical settings [25][26][27]. As a result, it came as no surprise that our study showed that community-based pharmacies and pharmacists excel in carrying out IOMR 5-11: Implement multidisciplinary treatment and preventive team. Using medication therapy management (MTM) programs and collaborative practice agreements (CPA) with physicians, pharmacists have improved health measures such as blood pressure, blood glucose, and cholesterol levels [28,29]. Thus, it is not surprising that including pharmacists on the healthcare team in areas that provide services to historically marginalized and minoritized patients also demonstrate improved health measures. Similarly, pharmacists seamlessly integrate into preventative care teams. The ability to do so is made possible by the fact that pharmacists are frequently regarded as trustworthy members of their communities, which opens the door to offering preventive screenings. From screenings for chronic conditions such as hypertension and diabetes to undiagnosed HIV infections and diabetic retinopathy, the accessibility of community-based pharmacists creates a natural touch point for health screenings for patients who would otherwise not present to a physician's office. Our results also reveal that pharmacists are also providing screening services beyond the four walls of the pharmacy at after-school programs [30], college campuses [31], and health fairs [32]. As community pharmacy continues to expand services offered, preventive care appears to be an accessible way pharmacists can work to reduce health disparities in their communities.
Our data also revealed that community-based pharmaceutical services implemented IOM recommendations 5-12, 5-9, 5-10, 5-6, and 5-7, though to a lesser extent than IOMR 5-11. IOMR 5-9 is perhaps one of the most important recommendations that communitybased pharmaceutical services should carry out, as there is little question concerning that misinterpreting medical instructions can be fatal. Research indicates that community pharmacists do not regularly or effectively use language-access services in daily practice [33][34][35][36][37][38]. Yet, with more than 300 languages spoken or signed in the US and projections that the US will be the largest Spanish-speaking country by 2050, [39,40] access to pharmaceutical services that provide effective communication between patients and pharmacists is more crucial than ever. Community-based pharmacies must be committed to working with their communities to develop culturally and linguistically appropriate pharmaceutical care that addresses disparities in racial and ethnic minority populations.
For IOMR 5-12, the evidence supports that community-based patient education programs that allow underserved minorities to be a part of their own treatment eventually lead to improvements in the population health of such groups [41]. Many of these studies resulted in overall improvements for BIPOC patients with diabetes [42][43][44]. According to our findings, the use of IOMR 5-10 for community-based pharmaceutical services is still relatively new, but it has the potential to enhance medication adherence and health outcomes in patients who have limited access to healthcare. Community health workers (CHW) are lay community members who share similar socioeconomic positions, racial or ethnic identities, and linguistic experiences to the patients they serve [45]. While there are limited studies evaluating the value of CHW and community-based pharmacist collaborations, the effectiveness of CHW and pharmacist-provided care independently have been demonstrated in the literature and may be dependent on the role of the CHW and the needs of the patient population [46][47][48][49].
While this study highlights the many contributions community-based pharmaceutical services make in reducing racial and ethnic healthcare disparities, gaps in recommendations did appear. Though carried out, more work is needed in accomplishing IOMR 5-6: Promote the consistency and equity of care through the use of evidence-based guidelines. The employment of evidence-based strategies has long been essential in the provision of pharmaceutical care [50][51][52]. Studies have found that pharmacists face barriers as a result of limited access to resources related to evidence based medicine and patient overload [52,53]. Furthermore, gaps in care for other vulnerable populations have been identified using national consensus guidelines [54]. This suggests that more needs to be performed to ensure that evidencebased practices are promoted throughout pharmacy practice, but especially for vulnerable groups such as racial and ethnic minorities who continue to experience substandard outcomes in the delivery of care received. In their statement on racial and ethnic disparities in health care, the American Society of Health-System Pharmacists encourages pharmacists to use evidence-based guidelines for patient care and to confront the cultural divide that exists between the demands of their profession and the deeply held beliefs of their patients. Further stating that this will provide the advantages of "consistency, predictability, and objectivity", particularly in cases where there is evidence of various outcomes or reactions among racial and ethnic minoritized groups. Additionally, while this statement came out in 2008 and the IOM recommendations in 2003, our data continues to suggest that more work is needed to promote this recommendation throughout community-based pharmacy practice.
In this scoping review, only one study focused on IOMR 5-8: Enhanced patientprovider communication and trust by providing financial incentives for practices that reduce barriers and encourage evidence-based practice. This is not surprising since community-based reimbursement models are traditionally attributed to the prescription product rather than to patient education. There are numerous challenges in the current pharmacy reimbursement system that does not allow for incentives for patient education [55]. Innovative models of care are being piloted to change the system so that it empowers the profession of pharmacy to improve lives for patients across the country [56]. Emerging research that investigates these novel community pharmacy practice models provides realworld examples of these models and discusses reimbursement and sustainability pathways is a step in the right direction to challenge the current system and ensure that barriers to care for patients in greatest need are reduced for community-based pharmacists.

Conclusions
This study highlights the many contributions community-based pharmaceutical services provide in reducing racial and ethnic healthcare disparities. Community-based pharmacies employ many of the Institute of Medicines' recommendations to target and reduce racial and ethnic healthcare disparities, but more progress may be needed. Future work should focus on ensuring that the IOM's recommendations are carried out throughout pharmacy practice and are accessible to all racial and ethnic minoritized populations.

Conflicts of Interest:
The authors declare no conflict of interest.