Recommendations for community pharmacy to improve access to medication advice for people from ethnic minority communities: A qualitative person‐centred codesign study

Abstract Introduction Medicines‐centred consultations are vital to support medicine effectiveness and optimize health outcomes for patients. However, inequalities negatively impact ethnic minority populations when accessing medicines advice. It is important to identify opportunities to improve access for these communities however, knowledge of how best to achieve this is lacking; this study will generate recommendations to improve access to medicines advice from community pharmacies for people from ethnic minority communities. Methods A series of codesign workshops, with four groups of patient‐stakeholders, were conducted between September–November 2021; they took place in‐person or via video call (adhering to COVID‐19 restrictions). Existing evidence‐based perceptions affecting access to medicines advice were critiqued and recommendations were generated, by use of reflexive thematic analysis, to improve access for ethnic minority patients. The workshops were audio‐recorded and transcribed verbatim. QSR NVivo (Version 12) facilitated data analysis. Results Twelve participants were recruited using purposive sampling; including eight UK citizens, two asylum seekers and two participants in receipt of residency visas. In total, four different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and cocreate recommendations to improve access to medicines advice in community pharmacies. Three recommendations were developed and centred on: (i) delivering and providing culturally competent medicines advice; (ii) building awareness of accessing medicines advice from community pharmacies; and (iii) enabling better discussions with patients from ethnic minority communities. Conclusions These recommendations have the potential to support community pharmacy services to overcome ethnic inequalities affecting medicines advice; service commissioners should consider these findings to best meet the needs of ethnic minority patients. Cultural competence training for community pharmacy staff could support the creation of pharmacies as inclusive healthcare settings. Collaborative working with ethnic minority communities could enable specific tailoring of medicines‐centred services to best meet their needs. Patient or Public Contribution The National Institute for Health Research (NIHR) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualization. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and findings were reported, with cultural competence. Trial Registration Not applicable.


| INTRODUCTION
Despite reporting poorer general health when compared to their white counterparts, and being more likely to require medication to manage long-term illness, 1 evidence has demonstrated that individuals from ethnic minority backgrounds are less likely to engage in regular consultations to review the appropriateness and effectiveness of their medicines. [2][3][4] Regular reviews of medication are vital to ensure medicine effectiveness and prescribing safety, thus supporting the optimization of health outcomes for patients. 2,[5][6][7] This study focuses on the provision of medicines-centred advice for patients from ethnic minority communities, offered by pharmacists and pharmacy teams in the United Kingdom working in a community pharmacy. In the context of this study, medicines advice can include prescription, adherence or compliance reviews; this is rather than structured clinical medication reviews (which require access to clinical information and thus occur more readily in General Practice, Primary Care Networks or secondary care settings) or medication use reviews (which have been discontinued as a community pharmacy service). 8,9 Medicines advice consultations may also take the form of ad-hoc interventions made by community pharmacy teams, including the New Medicines Service, or aligned with annual long-term condition reviews 10,11 or referrals from other healthcare professionals. 12,13 These types of medicines advice consultations may differ from those in other countries or healthcare settings, for example, Australian Home Medication Reviews 14 or Swiss Polymedication Checks. 15,16 Optimization of patient outcomes is an underpinning goal in the prescribing and provision of medicines however, inequalities affecting access to such advice and support have been previously identified, particularly relating to ethnic minority communities. [17][18][19] While previous studies have demonstrated the importance of overcoming barriers related to access, specific detail about how best to achieve this is lacking. 4 Recent work has identified community pharmacies as a setting of strategic importance for the delivery of community-centred medicines-related services. 4,20 Community pharmacists are reported as the most accessible primary care healthcare provider 21 ; advantageously, medicines consultations are available without an appointment, often during the evenings and at weekends.
Pharmacists have been described as medicines experts with a wealth of knowledge that can support reviews of medications. 22 However, patients need to be adequately informed on all aspects of a medicine and the associated effects so that they can make an informed decision if, how and when to take it. 3,22 For ethnic minority communities, this means that medicines information and medicines services must be delivered in the widest sense; in formats and through services that are culturally appropriate and respectful of a person's wishes for instance, around communication, culture and religion. 23,24 When considering the value that medicines advice consultations can offer in optimizing a person's medication, it is important to (i) better understand existing barriers that may impact those from ethnic minority communities when accessing services and to (ii) identify and explore enablers that may facilitate improved access by these groups. This qualitative co-designed approach with patients seeks to build greater knowledge and understanding by involving representatives from communities whose needs may remain unmet.
Previous work has demonstrated the importance of including the participants' voice within research of this nature. 4 Through codesign workshops, this study seeks to integrate the voices of those people from ethnic minority populations to gain better insight and create ROBINSON ET AL. recommendations, on improving access to medicines advice from community pharmacies for people from ethnic minority communities.

| Recruitment and sampling
The consolidated criteria for reporting qualitative research (COREQ) checklist was followed for this study (see Supporting Information: File). 25 This study was conducted during the COVID-19 pandemic and therefore, UK governmental restrictions were followed throughout. Given the capabilities of digital strategies to support qualitative research, a blended strategy was applied to pragmatically perform and maximize participant recruitment and data collection.
Recruitment was conducted using social media (on the professional Twitter accounts of the researchers, Newcastle University School of Pharmacy, and the Connected Voice charity) and through dissemination to community leaders by charities based in the North of England. All interested participants who contacted the research team were emailed an information sheet and consent form detailing the purpose and aim of the research. Those who expressed an interest in participating in the work were asked to provide written consent and were then enroled in the study. There was no prior relationship established between the researcher and participants before study commencement or recruitment. Inclusion criteria comprised: (i) participants over 18 years of age who were from an ethnic minority group (non-White British) living in the North of England; (ii) who took one (or more) regular prescription medicine(s); and (iii) who had the capacity to consent to take part in the study.
There was no requirement to communicate in the English Language; interpreters were involved throughout the research process for participants that required them. Purposive sampling was used to recruit participants from different ethnic minority groups reflective of the communities living in the North of England, who were of different ages, and who had varying sociodemographic and immigration backgrounds (including UK citizens, those in receipt of residency visas and those who were seeking asylum). Study documentation including the social media advert, participant information sheet and consent form, were translated into different languages to promote inclusivity in the research process (reflecting the languages spoken by the communities residing in the research area, including Bengali, Polish, Punjabi, Mandarin, Romanian and Urdu); all materials were reviewed and approved by the Health Research Authority.

| Codesign workshops
Codesign workshops were conducted by two members of the research team (NO a female researcher with expertize in codesign methodology, and AR a female doctoral researcher with experience in qualitative research) between September and November 2021. The codesign workshops were purposely structured and conducted so that the individuals partaking in them were from homogenous ethnic groups 26 ; Arabic participants were further split into workshops based on their reported gender. This approach was taken to ensure participant comfort and to appreciate the challenges that may arise between cultural groups and between males and females when discussing health conditions. 27,28 All participants were offered the choice of which format of the workshop they would prefer (either using Zoom ® or in-person). An interpreter was used to aid discussions in two workshops (Group 1 and Group 3, Figure 1).
There were eight workshops conducted in total; these ran as four pairs of Workshop 1 and Workshop 2. Workshop 1 was designed in such a way as to further explore and validate the findings from two previous qualitative studies by the authors (see Figure 1 and Supporting Information: File). 4,29 It acted as an opportunity to sense check and assess the face validity of the findings, and for participants to begin identifying core concepts of what constitutes accessibility relating to seeking medicines advice from community pharmacies. 27,28 Workshop 2 facilitated the refinement of the core concepts and provided the platform for participants to generate recommendations to achieve improvements in access to medicines advice for patients from ethnic minority groups. In particular, the workshop guide explored participant understanding of medicines and taking them safely, seeking advice on what they are prescribed, perceived barriers and facilitators that affect accessing advice about their medicines and lived experiences when accessing such advice from community pharmacy teams. Conducting the workshops and analyzing the data followed an iterative process, during which time was taken for reflection and to make any adaptations from one workshop to the next. This codesign approach will enable the generation of overarching 'recommendations' and 'areas of focus' that can be adopted as interventions to be applied in community pharmacy settings, with the aim of improving access to medicines advice for people from ethnic minority communities.

| Data analysis
All codesign workshops were audio-recorded to enable data analysis.
The audio files were encrypted and transferred electronically (via a password-protected dropbox) to an external transcription company to be transcribed verbatim; all data were anonymised at the point of transcription. All transcripts were checked for accuracy and correctness by one researcher (A. R.) and participants did not provide comments on the transcripts nor feedback on the results. Any workshops that included an interpreter had their speech (translated to the English language) written in the transcript. The data generated from the first workshop was analysed using a reflexive thematic analysis approach as defined by Braun and Clarke. 30 This was done for each group separately, such that the design of workshop 2 was based on data from workshop 1; this approach enabled the perspectives from homogenous participant groups to be explored in greater detail. Findings from the second workshop were also analysed using reflexive thematic analysis. Themes were developed following all of the second workshop groups and were refined and named to best reflect participant recommendations to improve access to medicine review services for ethnic minority communities.
The principle of constant comparison guided an iterative process of data collection and analysis. 31,32 Reflexive thematic analysis was performed by two researchers (A. R. and N. O.); close and detailed reading of the transcripts allowed the two researchers to familiarize themselves with the data. Initial descriptive codes were identified in a systematic manner across the data sets; these were then sorted into common coding patterns, which enabled the development of analytic themes from the data. The themes were reviewed, refined and

| Considerations when reporting participant demographics and ethnicity
Since ethnicity in itself is a multifaceted and changing phenomenon, collecting data on a person's ethnic group is complex. There is no consensus on what constitutes an ethnic group when, often, it is something that is self-defined and subjective to an individual. Efforts were taken to report a multitude of factors (including a person's first language, religion and citizenship status) to demonstrate the layers that accompany discussions around ethnicity. The National Institutes of Health 34 and UK Office of National Statistics 35 guides informed the initial reporting of participant ethnicity for this study. Table 1 includes a column for self-identified ethnicity; this has been reported verbatim for each study participant.

| Participant demographics
Twelve participants in total were recruited and took part in the four pairs of codesign workshops for this study; each group of F I G U R E 1 An overview of the codesign workshop structure: demonstrating the first and second workshops for each homogenous group of participants, representative of different ethnic minority communities. N.B. time was taken between workshops to enable the researchers to reflect and make any adaptations from one workshop to the next, as part of the iterative methodology and process of codesign.  Hearing about it from people they trust… like the Imam, or equivalent if they aren't Muslim, that's probably going to be someone in their community they listen to and respect (Participant 5).

| Area of focus 2: Geographical and financial barriers
Physical access to a community pharmacy, as a place to discuss and review medication with a community pharmacist, was described as 'a Medicines-specific instructions were considered a significant area where verbal communication could be improved between pharmacy professionals and patients. One participant described experiences of supporting an older relative to take their medication and 'even explaining to them how to actually take it, how to take the tablet, like "swallow with a glass of water, not a cup of tea"-that's an instruction that's really important to make sure the medicine works properly, but no one had explained that to her' (Participant 6).
Supporting a person to understand any differences and equivalencies in the medicines prescribed in the UK compared to their home country was also deemed important as a point of education and reassurance.
What words would they be using for this back home

| DISCUSSION
This study adds to the growing evidence base considering access to medicines-specific advice for ethnic minority populations. [2][3][4]22,29 This codesign research provided a platform to share the voices of members from ethnic minority communities and generate personcentred recommendations to improve access to seeking medicines advice from community pharmacies. The three recommendations generated from this codesign study may act as high-level starting The authors acknowledge that the codesign workshop groups were ethnically-homogenous, however, this decision was based on cultural competence training and done to enable discussions in a safe environment for participants, whilst also respecting the cultural practices and beliefs of communities. This study focused on ethnic minority populations living in the North of England, meaning that findings may not be generalizable to those of other countries; however, the high-level recommendations generated in this study could, and should, be adopted to overcome barriers for people from ethnic minority communities worldwide. This study uses codesign with patient stakeholders and therefore, before proposed recommendations are used to inform the design and implementation of an improved medication review service, there is a need to also explore the perspectives of additional stakeholder groups.

| CONCLUSION
This study used a codesign approach with patient stakeholders to identify opportunities and generate recommendations to improve access to seeking medicines advice for people from ethnic minority communities; these centred on: (i) delivering and providing culturally