Addressing ethnic inequalities in medicine use in Denmark: selected theory‑based interventions

477 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS Review ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS Lourdes Cantarero-Arévalo, Janine Traulsen, Lotte Stig Nørgaard Faculty of Health and Medical Sciences, Department of Pharmacy, Section for Social and Clinical Pharmacy, University of Copenhagen Corresponding author: Lourdes Cantarero-Arévalo (email: Lou.cantarero@sund.ku.dk) ABSTRACT Objectives: We share the experiences gathered and lessons learnt in medicine use by ethnic minorities by the Section for Social and Clinical Pharmacy-Copenhagen University (SCP-KU) research group, and provide an overview of theory-based interventions conducted for and with ethnic minorities. Methodology: We conducted a review of the scientific and grey literature on ethnic minorities and their access to and use of medicines. Because the aim was to share the philosophy behind the work of SCP-KU (based on inclusion of the user’s perspective and the use of theory), only studies conducted with that orientation were selected. Results: A total of 24 studies were selected and analysed. The following successful practices were identified: (i) building trust between the pharmacist and the user/patient; (ii) involving ethnic minorities in all phases of the intervention (design, implementation and follow-up); (iii) developing an ethnically sensitive culture among pharmacists based on openness, curiosity and respect; and (iv) when possible, involving family, friends and the close social network of the patient, especially when there is a need for behaviour change related to medicine use or lifestyle habits. Conclusions: Shaping ethnically sensitive pharmacy-related services requires the involvement and empowerment of ethnic minorities in all phases of the intervention research. Caution is needed when classifying social groups based on migrant and ethnic premises. Keywords: DENMARK, ETHNIC MINORITIES, INTERVENTION STUDIES THEORY, MEDICINE USE, MIGRANT, PHARMACY PRACTICE INTRODUCTION Pharmaceutical products (commonly known as medicines or drugs) are the most frequently used medical technology, and their consumption is on the rise worldwide (1). The health and societal benefits of treatment with medicines are well known. However, there are still many challenges that deserve the careful attention of all policy- and decision-makers. These challenges include issues related to access to appropriate treatment, self-medication/ self-management and medicine-related problems (MRPs), to name a few. These challenges are often magnified among particular ethnic and migrant populations. Non-structural barriers to health care, such as language, cultural differences and unmet expectations, play a crucial role in the way migrants and ethnic minorities access and use medicines. Patients from ethnic minorities (including migrants, asylum seekers, refugees and descendants of migrants) typically suffer from more diseases than those from the ethnic majority, take more medication and for a longer period of time, and suffer from more MRPs (2–4). Medicine-use behaviour is strongly influenced by the habits acquired in the country of origin, where there may be a lack of or a lax health-care regulation system, which allows for more frequent and indiscriminate use of over-the-counter medications (5). The psychosocial stressors experienced during the migration process and the early years of residence in the host country also influence medicine-use behaviour. Indeed, studies show that medicines can be used as tools to cope with stress resulting from alienation, discrimination and racism (6). Finally, using both imported medicines and traditional remedies, and 478 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS sharing prescribed medications increase the risk of side-effects due to drug interactions and MRPs (7, 8). In the Nordic countries, where access to health care is universal and the cost of medicines is reimbursed to a large extent, structural barriers that hinder access to medicines among the migrant population are not a major public health issue (2). Moreover, most of the Nordic countries have traditionally had high-quality integration policies, which provide socioeconomic support to families ranging from health, education and residence benefits to work subsidies. However, one might expect problems in the future in some Nordic countries, for example in Denmark, where the non-friendly political rhetoric towards migrants and the highly restrictive migration policy can have ripple effects on migrants’ health (9). RESEARCH ON ETHNICITY AND MIGRATION: A VITAL PART OF THE USER PERSPECTIVE Addressing ethnic equity in quality of care and treatment is a challenge for policy-makers and concerned health-care professionals. Health systems especially need to be ethnically sensitive and take into account cultural diversities (10, 11). Policies and interventions are rarely successful unless the user perspective is acknowledged and understood, and the voices of patients from ethnic minorities are listened to and taken into consideration. User perspectives, theory foundation and qualitative methods For almost four decades, the Section for Social and Clinical Pharmacy, University of Copenhagen (SCP-KU) has focused its research and teaching on the role of medicines in society, comprising three essential ingredients: theory-based research; a primary use of qualitative methods; and a central focus on the user perspective. Multidisciplinary groups consisting of pharmacists and social scientists have addressed a variety of issues concerning medicine’s role in society, particularly access to medicines and the goals of rational use of medicines. Early on, this research identified a huge gap between how rational use of medicines was understood by the health-care system and health-care professionals and by patients (or citizens or users) (12). Theory has always played an important part in this research – based on the belief that in addition to providing structure for study design and data analysis (thus increasing transparency), applying theory helps in interpreting and explaining practices, events and patterns occurring in the world of pharmacy, and in understanding the behaviour and practices of patients. FIG 1. INTEGRATING THE MIGRANT AND ETHNIC MINORITY PERSPECTIVE FOR FUTURE PHARMACISTS AND RESEARCHERS IN MEDICINE USE. Students as researchers (approx. 70% belonging to ethnic minorities) Research master thesis project Pharmacy practice internship Pharmacy master students (approx. 40% belonging to ethnic minorities) Applied knowledge: counselling ethnic minorities about medicines and treatment regimes Teaching session on migrant and ethnic issues related to the use of medicines and pharmacy services Ethnically sensitive pharmacists and researchers in medicine use Further research Community Pharmacies Other public positions or private sector 479 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS Examples of theories used in this research include theories of risk perception, risk communication, policy, social stigma, ethnicity and race, communication, medication behaviour and interdisciplinary cooperation (13). The use of qualitative methods permits a dialogue between researcher and patient where the goal is to give the patient a voice. These methods include observations, interviews and focus groups and, more recently, intervention studies. Focusing on the user perspective provides insights into how medicines are perceived differently by lay people than by experts – including something as basic as how patients define medicines (14, 15), their knowledge of medicines and their risk perceptions (16). The relative growth of ethnic minorities in Denmark has added culture as a new and necessary dimension to the misunderstandings that are already common among lay people with regard to access to and compliance with medication. It would be natural to include migrant and ethnic differences as a necessary part of the patient perspective for research and teaching. Since 2008, we have taught more than 1300 pharmacy students on ethnic minorities and medicine use in the pharmacy internship courses. Figure 1 shows how SCP-KU has integrated migrant and ethnic issues into its teaching and research to contribute to the creation of an ethnically sensitive body of pharmacists and researchers on medicine use. AIMS The proposed agenda for action included in the WHO Regional Office for Europe outcome document of the High-level Meeting on Refugee and Migrant Health held in Rome in November 2015 highlights that: [t]he effective provision of health care, health promotion and preventive measures requires health systems that can adapt and respond to the needs of a changing population and take account of cultural, religious, linguistic and gender diversity. Training of health professionals and relevant non‑health actors is a key element to achieve this purpose. Moreover, this document further states that “appropriate measures should be taken to promote continuity and quality of care for migrants … and equal quality standards of care defined, delivered and monitored” (11). Therefore, in this review, we aim to share the lessons learnt and best practices gathered by the SCP-KU research group by providing an overview of the empirical and theory-based intervention studies conducted in the field of ethnic minorities and medicines, with the final goal of serving as an inspiration to researchers, practitioners and policy-/ decision-makers in shaping ethnically sensitive pharmacy-related services. METHODS SETTING Health care in Denmark reflects the Nordic welfare model. The Danish health-care system is tax-financed and provides free access (i.e. no payment) to hospitals and general practices (17). There is progressive reimbursement for prescribed medications (a need-dependent reimbursement system): the more expenses one has for prescribed medicines, the more reimbursement one will receive. In addition, municipalities may cover part of the expenses of chronic disease-related medication once the public reimbursement has been deducted (e.g. due to low income and large drug consumption). The health authorities determine the number of pharmacies and branch pharmacies as well as their locations. DATA SOURCES AND INCLUSION CRITERIA For this review, we included scientific articles and reports that focused on research on ethnic minorities and migrants legally residing in the country, and their access to and use of medicines (but not access to broader medical services), with the aim of identifying inequalities or/and developing theory-based interventions to reduce MRPs. All scientific articles were written in English. However, some reports that were originally written in the Danish language were included. Studies were included if they were conducted during the past 15 years. Short communications, conference proceedings, posters and teaching materials were not included. In total, we included 10 qualitative studies (4, 5, 18–25), 9 quantitative studies (26–34) and 5 intervention studies (35–39) in this review. Because the goal of this review was to share the philosophy of the work being done at SCP-KU based on the characteristics described above (the user’s 480 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS perspective and use of theory), we selected only those studies conducted with that orientation. The methodological approaches of the included studies were varied because they were selected based on the nature of the research question in each study. In the qualitative studies included, primarily semistructured interviews were used alone or in combination with medicine reviews (4, 5, 19, 22, 25). Other qualitative methods used were focus groups, observations and minutes from meetings (20, 21). The study designs of the quantitative studies included cohort (32–34) and cross-sectional studies (27–31). The two systematic reviews included in Table 1 followed the PRISMA guidelines (40). The data sources for the quantitative studies were registers and population-based surveys. Finally, the theory-based intervention studies combined different methods, including individual interviews, focus groups, medicine reviews, test–retest, and process and outcomes evaluations (35–39). For the intervention studies especially, the interviews and medicine reviews were often conducted by pharmacists with the same ethnic background and/or a researcher who could speak the same language as the participants. ANALYSIS Data extraction and analysis took into account the main priorities of the special issue on migration of the WHO Regional Office for Europe journal Public Health Panorama. Key messages on equity, innovative solutions, successful practices and lessons learnt were therefore the characteristics according to which the data were organized. All three authors read the studies and worked collectively to identify and select the main best practices. ETHICAL CONSIDERATIONS OF THE SELECTED STUDIES According to Danish law, no ethical approval was needed for these studies as they do not involve human subjects or human biological material such as tissue, ova or cells. However, specific measures were taken for the different types of studies and these are mentioned in each study. RESULTS STUDY CHARACTERISTICS Tables 1, 2 and 3 present the characteristics of the 24 selected qualitative, quantitative and intervention studies, respectively, included in this review (4, 5, 18–39). The non-Western ethnic minority groups included in the studies were Turkish (5, 24, 28, 29, 31–39), Iranian (20, 22, 24, 28, 29, 39), Iraqi (5, 24, 28, 29, 31–34), Pakistani (21, 25, 28, 29, 32, 34, 36) and Lebanese (mostly Palestinian) (5, 28, 29, 31, 33). These ethnic groups are the most common ones living in Denmark (http://www. statbank.dk/statbank5a/default.asp?w=1366). With the exception of neonates, all age groups were addressed in the 24 studies. The sample covered a 16-year period (2000–2016). A total of seven studies mainly aimed to identify inequalities in medication use (24, 28, 29, 31–34), three studies focused on investigating how ethnic minorities perceive pharmacy services (19, 21, 27), and most of the qualitative studies attempted to understand the dynamics taking place in encounters between ethnic minority customers and pharmacists and/or pharmacy assistants working in community pharmacies. Three studies analysed the complex issue of categorizing, defining and grouping ethnic minorities, and the implications for accurately identifying risk factors related to medicine use (18, 20, 28). Five research-based intervention studies focused on reducing MRPs among ethnic minorities (26, 35–38). Other issues examined and explored in randomized controlled trials for asthma medication included the presence of ethnic minority groups (24), the use of traditional medicines (25) and the effect of living in the host country versus the home country (22). Table 4 summarizes the key messages from each study on equity, successful practices and innovative solutions identified. 481 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 1 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D Q U A LI TA TI VE S TU D IE S A N D P R O JE C TS N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s 1 20 03 B is se ll et a l. To r ai se th e pr of ile of q ue st io ns a ro un d et hn ic it y w ith in ph ar m ac y pr ac tic e re se ar ch D en m ar k an d U ni te d K in gd om D is cu ss io n pa pe r N /A Al l Al l B ot h Th e pa pe r pr ov id es a  c ri tic al re vi ew o f h ea lt h se rv ic es a nd s oc ia l sc ie nc e re se ar ch e xp lo ri ng r ac e an d et hn ic it y in p ha rm ac y pr ac tic e 2 20 08 K am al & Sh ua n To id en tif y ho w Ir aq i c us to m er s ex pe ri en ce en co un te rs w ith ph ar m ac ie s an d ph ar m ac is ts C op en ha - ge n C ap ita l re gi on , D en m ar k Se m is tr uc - tu re d in te r- vi ew s 20 08 Et hn ic K ur ds fr om Ir aq A du lt po pu la tio n 9 pa rt ic ip an ts (6 w om en an d 3 m en ) - Ir aq i c us to m er s an d D an is h ph ar m ac is ts u se a nd p er ce iv e ph ar m ac y se rv ic es d iff er en tly a nd ha ve d iff er en t e xp ec ta tio ns ; - Al l m ig ra nt s ca nn ot b e lu m pe d to ge th er – r es pe ct d iv er si ty 3 20 11 M yg in d et al . To e xp lo re h ow et hn ic m in or iti es at r is k of v ita m in D  d ef ic ie nc y ar e co ns tr uc te d in D an is h po lic y do cu m en ts D en m ar k P ol ic y do cu - m en t a na ly - si s 20 09 N on -W es te rn im m ig ra nt an d et hn ic m in or iti es Al l a ge s N ot ap pl ic ab le A hi gh d is pa ri ty in th e w ay e th ni c m in or it y gr ou ps a re d ef in ed h in de rs th e id en tif ic at io n of c au se s le ad in g to v ita m in D  d ef ic ie nc y 4 20 11 Sh ah ee n To e xp lo re di ff er en ce s an d si m ila ri tie s be tw ee n M R P s an d co gn iti ve il ln es s an d m ed ic at io n pe rc ep tio ns be tw ee n et hn ic m aj or it y D an es a nd P ak is ta ni p at ie nt s w ith ty pe 2 d ia be te s D en m ar k Se m is tr uc - tu re d in - te rv ie w s in cl ud in g m ed ic at io n re vi ew s 20 11 P ak is ta ni an d D an is h pa tie nt s w ith ty pe 2 di ab et es 53 –7 9 ye ar s 5 w om en (2 P ak is ta ni ) an d 2 m en (1 P ak is ta ni ) - In te rv ie w s w ith P ak is ta ni p at ie nt s re ve al ed h ow in te rp re te rs a nd / or fa m ily m em be rs c on st itu te d a  la rg er p ar t o f t he m ed ic at io n de ci si on -m ak in g pr oc es s th an is th e ca se a m on g th e D an is h m aj or it y po pu la tio n; - Th er e ar e m or e M R P s am on g et hn ic m aj or iti es th an a m on g et hn ic m in or iti es (9 .5 M R P s/ et hn ic m aj or it y pa tie nt v s 5 M R P s/ et hn ic m in or it y pa tie nt ) 5 20 13 M ol in e t a l. To e xp lo re th e pe rc ep tio ns o f di se as e et io lo gy an d th e ef fe ct of o ne ’s o w n be ha vi ou r on he al th a m on g po ly ph ar m ac y pa tie nt s D en m ar k Se m is tr uc - tu re d in te r- vi ew s an d ex te nd ed m ed ic at io n re vi ew s A pr il– Se pt em be r 20 08 N on -W es t- er n im - m ig ra nt an d et hn ic m in or iti es A du lt po pu la tio n (a ge d > 50 ye ar s) 17 w om en an d 9 m en - La te nt a nd c on tin ue d st re ss du e to th ei r im m ig ra nt s ta tu s w as of te n pe rc ei ve d as th e ca us e of pa rt ic ip an ts ’ d is ea se s; - P ar tic ip an ts fe lt th at th ei r ow n ef fo rt s ha d lit tl e im pa ct o n th ei r he al th s ta tu s 482 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 1 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D Q U A LI TA TI VE S TU D IE S A N D P R O JE C TS N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s 6 20 13 M yg in d et al . To e xp lo re p at ie nt pe rs pe ct iv es o n m ed ic in e us e du ri ng R am ad an C op en ha - ge n C ap ita l re gi on , D en m ar k Se m is tr uc - tu re d in te r- vi ew s an d ex te nd ed m ed ic at io n re vi ew s A pr il– M ay 20 10 Et hn ic P ak is ta ni s A du lt po pu la tio n (a ge d > 42 ye ar s) 5 w om en an d 1 m an D ec is io n- m ak in g on w he th er to fa st du ri ng R am ad an r ar el y in cl ud ed he al th -c ar e pr of es si on al s. In st ea d, fr ie nd s an d re la tiv es , e sp ec ia lly th os e w ith th e sa m e ty pe o f d is ea se w er e of te n co ns id er ed 7 20 14 B as ir i To e xp lo re si m ila ri tie s an d di ff er en ce s in m ed ic in e us e am on g et hn ic Ir an ia n ad ol es ce nt s liv in g in D en m ar k an d th os e liv in g in Ir an C op en ha - ge n C ap ita l re gi on , D en m ar k & S hi ra z, Fa rs P ro v- in ce , I ra n Se m is tr uc - tu re d in te r- vi ew s 20 14 Et hn ic Ir an ia ns an d na tiv e Ir an ia ns A do le sc en ts (a ge d 15 –2 0 ye ar s) 14 ad ol es ce nt s (7 g ir ls a nd 7 bo ys ) Et hn ic Ir an ia n ad ol es ce nt g ir ls liv in g in D en m ar k re po rt ed u si ng m or e an al ge si cs to c op e w ith s tr es s th an a do le sc en t g ir ls li vi ng in Ir an 8 20 15 Fe rn án de z de C as ad e- va nt e et a l. To a na ly se th e de te rm in an ts o f H P VV u pt ak e in Eu ro pe Eu ro pe Sy st em at ic re vi ew , 23  s tu di es 20 08 –2 01 4 Im m ig ra nt w om en po pu la tio ns re si di ng in Eu ro pe an co un tr ie s A do le sc en t an d ad ul t po pu la tio n (a ge d 12 –4 4 ye ar s) W om en (u ns pe ci fie d) H ig he r H P VV u pt ak e w as a ss oc ia te d w ith e th ni c m aj or it y po pu la tio ns , hi gh er s oc io ec on om ic s ta tu s, re gu la r ce rv ic al s cr ee ni ng pa rt ic ip at io n by th e m ot he r, an d ha vi ng r ec ei ve d pr ev io us c hi ld ho od va cc in at io ns 9 20 16 H u & C an ta re ro - A ré va lo To e xa m in e th e re la tio ns hi p be tw ee n et hn ic ba ck gr ou nd a nd A D R s to a st hm a m ed ic at io ns M ul tic ou n- tr y Sy st em at ic re vi ew , 26  s tu di es 19 98 –2 01 4 Im m ig ra nt an d et hn ic po pu la tio ns in cl ud ed in R C Ts Al l a ge s M en a nd w om en (u ns pe ci fie d) D es pi te th e hi gh er p re va le nc e of a st hm a am on g sp ec ifi c et hn ic m in or it y gr ou ps , f ew s tu di es h av e di sa gg re ga te d in fo rm at io n by e th ni c ba ck gr ou nd , a nd r ep or ts o f A D R s to a st hm a m ed ic at io ns in d iff er en t et hn ic g ro up s ar e ra re 10 20 16 R am za n et al . To e xp lo re pe rc ep tio ns , kn ow le dg e an d at tit ud es r eg ar di ng th e us e of m ed ic in al pl an ts a m on g P ak is ta ni s liv in g in C op en ha ge n C op en - ha ge n, D en m ar k Se m is tr uc - tu re d in te r- vi ew s an d pl an t c ol le c- tio n Ju ne 2 01 6– Se pt em be r 20 16 Et hn ic P ak is ta ni s A du lt po pu la tio n (a ge d 30 –8 0 ye ar s) 14 w om en an d 2 m en U se o f m ed ic in al p la nt s is c om m on am on g et hn ic P ak is ta ni s liv in g in D en m ar k A D R : a dv er se d ru g re ac ti on ; H P V V: h um an p ap ill om av ir us v ac ci ne ; M R P : m ed ic in e- re la te d pr ob le m ; R C T: r an do m iz ed c on tr ol le d tr ia l. 483 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 2 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D Q U A N TI TA TI VE S TU D IE S N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s 1 20 09 H an se n & Sø nd er - ga ar d To e xa m in e op tim al d ru g us e am on g no n- et hn ic D an es , i nc lu di ng co ns um pt io n, at tit ud es a nd co m pl ia nc e D en m ar k Su rv ey 20 05 –2 00 6 C om pa ri so n be tw ee n et hn ic D an es a nd no n- W es te rn m ig ra nt s A do le s- ce nt s, yo un g ad ul ts a nd ad ul t p op u- la tio n B ot h - A si gn ifi ca nt ly s m al le r po rt io n of n on -e th ni c D an es th an D an es (3 1. 6% v s 39 .6 % ) re gu la rl y us ed m ed ic in es - 60 % o f n on -W es te rn im m ig ra nt s, c om pa re d w ith 52 % o f e th ni c D an es , s ta te d th at th ey h ad e xp er ie nc ed M R P s - A la rg er p ro po rt io n of im m ig ra nt w om en u se ov er -t he -c ou nt er m ed ic in es 2 20 13 M yg in d et al . To e xp lo re th e ch al le ng es in s er vi ng im m ig ra nt cu st om er s at D an is h co m m un it y ph ar m ac ie s 55 c om m u- ni ty p ha r- m ac ie s in 5 co un ci ls , D en m ar k Q ue st io n- na ir e- ba se d st ud y A pr il 20 09 N on -W es t- er n im m i- gr an t a nd et hn ic m i- no ri tie s Al l a ge s 85 w om en an d 13 m en - P ha rm ac is ts a nd ph ar m ac is t a ss is ta nt s as se ss th ei r co un se lli ng to et hn ic m in or it y gr ou ps a s su bo pt im al - Fr eq ue nt u se o f u nd er ag e ch ild re n as in te rp re te rs 3 20 13 C an ta re ro - A ré va lo e t al . To a na ly se w he th er th er e ar e in eq ua lit ie s in a st hm a tr ea tm en t a nd , i f so , w he th er th is va ri es b et w ee n ho us eh ol d in co m e gr ou ps D en m ar k R eg is te r- ba se d st ud y 20 08 Im m ig ra nt an d de sc en da nt ch ild re n an d ad ol es ce nt s C hi ld re n an d ad ol es ce nt po pu la tio n (a ge d 0– 17 ye ar s) 1  09 2  88 6 ch ild re n (5 1. 2% bo ys ) - C om pa re d w ith e th ni c D an es , i m m ig ra nt c hi ld re n ha d th e lo w es t O R fo r re de em in g a  pr es cr ip tio n fo r as th m a m ed ic at io n, b ot h re lie f ( O R : 0 .3 7; 9 5% C I: 0. 20 –0 .6 8) a nd p re ve nt iv e m ed ic at io ns (O R : 0 .3 7; 9 5% C I: 0. 22 –0 .5 9) - Si m ila r as so ci at io ns w er e fo un d am on g de sc en da nt ch ild re n (O R fo r re lie f tr ea tm en t: 0. 82 ; 9 5% C I: 0. 79 –0 .8 9; O R fo r pr ev en tiv e tr ea tm en t: 0. 68 9 5% C I: 0. 61 –0 .7 5) . T he p at te rn o f t he as so ci at io n re m ai ne d af te r st ra tif yi ng fo r ho us eh ol d in co m e 484 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 2 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D Q U A N TI TA TI VE S TU D IE S N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s 4 20 14 a C an ta re ro - A ré va lo e t al . To a na ly se w he th er e th ni c di ff er en ce s in th e us e of an tia st hm at ic m ed ic at io n am on g ch ild re n va ri es b y pl ac e of re si de nc e C op en ha - ge n C ap ita l R eg io n, D en m ar k R eg is te r- ba se d st ud y 20 08 Im m ig ra nt an d de sc en da nt ch ild re n w ith T ur ki sh , Ir aq i a nd Le ba ne se ba ck gr ou nd s C hi ld re n an d ad ol es ce nt po pu la tio n (a ge d 0– 17 ye ar s) 34 2  40 3 ch ild re n (5 1. 3% bo ys ) - C hi ld re n liv in g in lo w -i nc om e pl ac es o f re si de nc e ha d lo w er o dd s of be in g pr es cr ib ed p re ve nt iv e an tia st hm at ic s co m pa re d w ith c hi ld re n liv in g in hi gh er -i nc om e pl ac es o f re si de nc e (O R : 0 .8 7; 9 5% C I: 0. 84 –0 .9 1) 5 20 14 b C an ta re ro - A ré va lo e t al . To e xa m in e th e as so ci at io n be tw ee n im m ig ra nt ba ck gr ou nd a nd m ed ic in e us e fo r ac he s D en m ar k Q ue st io n- na ir e- ba se d st ud y 20 08 N on -W es t- er n im m i- gr an ts a nd de sc en da nt s C hi ld re n an d ad ol es ce nt po pu la tio n (a ge d 11 , 13 a nd 1 5 ye ar s) 95 14 p up ils (4 67 4 bo ys an d 45 40 gi rl s) - A m on g ad ol es ce nt s in D en m ar k, th e ri sk o f m ed ic in e us e fo r he ad ac he an d st om ac h- ac he w as hi gh er fo r im m ig ra nt s an d de sc en da nt s th an fo r et hn ic D an es , w ith th e ex ce pt io n of m ed ic in e us e fo r he ad ac he am on g gi rl s 6 20 14 c C an ta re ro - A ré va lo e t al . To e xa m in e th e ro le o f f ee lin g sa fe a t s ch oo l re ga rd in g th e us e of m ed ic in es fo r ac he s D en m ar k Q ue st io n- na ir e- ba se d st ud y 20 08 N on -W es t- er n im m i- gr an ts a nd de sc en da nt s C hi ld re n an d ad ol es ce nt po pu la tio n (a ge d 11 , 13 a nd 1 5 ye ar s) 95 14 p up ils (4 67 4 bo ys an d 45 40 gi rl s) - Se lf- re po rt ed m ed ic in e us e fo r co m m on h ea lt h pr ob le m s is h ig h am on g ad ol es ce nt s w ith m ig ra nt b ac kg ro un ds , pa rt ic ul ar ly a m on g fir st -g en er at io n im m ig ra nt gi rl s - Fe el in g sa fe a t s ch oo l pa rt ia lly m iti ga te d th e as so ci at io n be tw ee n m ig ra nt ba ck gr ou nd a nd a do le sc en ts ’ m ed ic in e us e 485 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 2 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D Q U A N TI TA TI VE S TU D IE S N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s 7 20 16 C an ta re ro - A ré va lo e t al . To e va lu at e w he th er m at er na l co un tr y of b ir th ac cu ra te ly id en tif ie s ad ol es ce nt s w ith in ap pr op ri at e an tia st hm at ic m ed ic at io n us e Sk ån e C ou nt y, Sw ed en R eg is - te r- ba se d co ho rt s tu dy 20 05 –2 00 8 Et hn ic m in or it y ch ild re n re si di ng in Sk ån e A do le sc en t po pu la tio n (a ge d 17 ye ar s) fr om 52 d iff er en t co un tr ie s 43 9  59 0 ad - ol es ce nt s (g en de r un sp ec i- fie d) - C at eg or iz at io n by m at er na l c ou nt ry o f bi rt h is in ac cu ra te fo r id en tif yi ng th e in ap pr op ri at e us e of a nt ia st hm at ic m ed ic at io n am on g Sw ed is h ad ol es ce nt s, a s w ith in -g ro up he te ro ge ne it y is v er y hi gh 8 20 16 Fe rn án de z de C as ad e- va nt e et a l. To e xa m in e et hn ic it y- re la te d di ff er en ce s in th e up ta ke o f a  te m po ra ry fr ee -o f- ch ar ge H P VV c at ch -u p pr og ra m m e an d co m pa re it w ith th e pr ev io us se lf- pa ym en t sy st em in p la ce D en m ar k R eg is - te r- ba se d co ho rt s tu dy Au gu st 20 12 to D ec em be r 20 13 Et hn ic m in or it y w om en Yo un g ad ul t fe m al e po pu la tio n 27 4 15 4 w om en - Th e fr ee p ro gr am m e in cr ea se d th e va cc in at io n up ta ke m or e am on g D an is h w om en th an a m on g de sc en da nt o r im m ig ra nt w om en - Th e lik el ih oo d of H P VV pr og ra m m e in iti at io n am on g im m ig ra nt s w as h ig he r fo r im m ig ra nt s liv in g in D en m ar k fo r 16 –2 0 ye ar s co m pa re d w ith th os e liv in g in D en m ar k fo r 6– 10 y ea rs 9 20 16 H u et a l. To in ve st ig at e et hn ic d iff er en ce s in c on tin ui ty of th e us e of m ai nt en an ce m ed ic at io ns fo r C O P D C op en ha - ge n, D en - m ar k R eg is - te r- ba se d co ho rt s tu dy 20 10 N on -W es t- er n im m i- gr an t e th ni c ba ck gr ou nd A du lt po pu la tio n 48 0 w om en an d 64 9 m en - In di vi du al s w ith e th ni c m in or it y ba ck gr ou nd s te rm in at ed C O P D m ed ic at io n us e m or e of te n th an e th ni c D an es (H R : 1 .4 0; 9 5% C I: 1. 03 –1 .9 0; P  = 0 .0 3) C I: co nf id en ce in te rv al ; C O P D : c hr on ic o bs tr uc ti ve p ul m on ar y di se as e; H P V V: h um an p ap ill om av ir us v ac ci ne ; H R : h az ar d ra ti o; M R P : m ed ic in e- re la te d pr ob le m ; O R : o dd s ra ti o. 486 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 3 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D T H EO R Y- B A SE D IN TE R VE N TI O N S ST U D IE S N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s & c on cl us io n 1 20 09 G re ge rs en To in ve st ig at e ho w p at ie nt ed uc at io n fo r no n- D an is h- sp ea ki ng pe rs on s w ith ty pe 2 di ab et es c on tr ib - ut es to h el pi ng p a- tie nt s ha ve th e be st po ss ib le k no w le dg e an d th e be st p os si - bl e to ol s to m an ag e th ei r di se as e C op en ha - ge n H ea lt h C en te r at N ør re br o, D en m ar k Ac tio n- re se ar ch de si gn (in cl ud in g do cu m en ta ry m et ho d, o b- se rv at io ns an d in te r- vi ew s) 20 09 P ak is ta ni an d D an is h ty pe 2 di ab et es pa tie nt s Al l a ge s 21 (f or m er ) pa tie nt s (9 et hn ic m in or it y pa tie nt s – 5 fe m al e an d 4 m al e) a nd 1 2 et hn ic D an es + 2 he al th -c ar e pr ac tit io ne rs - In di vi du al iz e th e te ac hi ng of n on -D an is h- sp ea ki ng pa tie nt s w ith ty pe 2 di ab et es b y in vo lv in g th ei r pe rs pe ct iv es o n m ed ic in es an d he al th in pa tie nt ed uc at io n pr og ra m m es 2 20 09 H au gb øl le et a l. To r ed uc e th e nu m be r of M R P s th ro ug h th e im pl em en ta tio n of m ed ic at io n re vi ew D en m ar k C om m en - ta ry o n th e re se ar ch - ba se d in te r- ve nt io n 20 09 N on -W es t- er n im - m ig ra nt an d et hn ic m in or iti es A du lt po pu la tio n (a ge d >5 0 ye ar s) 23 p at ie nt s (1 7 w om en a nd 6 m en ) - A co lla bo ra tiv e ap pr oa ch th at in cl ud es p ha rm ac is ts , fa m ily d oc to rs a nd p at ie nt s he lp s re du ce M R P s - M or e fr eq ue nt m on ito ri ng m ee tin gs w ith pa tie nt s en ha nc es p at ie nt sa tis fa ct io n, tr us t i n he al th -c ar e pr of es si on al s an d m ot iv at io n to c om pl y w ith m ed ic in e re gi m en s 3 20 14 d C an ta re - ro -A ré va lo et a l. To r ed uc e M R P s am on g A ra bi c- sp ea ki ng et hn ic m in or iti es C op en - ha ge n, D en m ar k R es ea rc h- ba se d in te r- ve nt io n 20 12 N on -W es t- er n im m i- gr an ts A du lt po pu la tio n (a ge d 21 – 60 y ea rs ) 30 p ar tic ip an ts (2 7 w om en a nd 3 m en ) - P ar tic ip an ts e xp re ss ed fr us tr at io n du e to co m m un ic at io n pr ob le m s w ith D an is h do ct or s - Th e pr og ra m m e he lp ed br id ge th e ga p be tw ee n pa rt ic ip an ts a nd d oc to rs - Th e co m m on al it y of th e cu lt ur e, la ng ua ge an d ge nd er s ha re d by th e re se ar ch er , p ha rm ac is t a nd pa rt ic ip an ts e nh an ce d th e su cc es s of th e pr og ra m m e 487 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 3 . C H A R A C TE R IS TI C S O F TH E SE LE C TE D T H EO R Y- B A SE D IN TE R VE N TI O N S ST U D IE S N o. Ye ar Au th or s Ai m Lo ca tio n St ud y de si gn D at a co lle ct io n da te Et hn ic a nd m ig ra nt gr ou ps Ag e ra ng e Se x K ey m es sa ge s & c on cl us io n 4 20 15 D am e t a l. To im pr ov e m ed ic in e ad he re nc e, h ea lt h st at us a nd w or k ab ili ty th ro ug h in di vi du al iz ed ph ar m ac is t co un se lli ng o n sa fe an d ef fe ct iv e us e of m ed ic in es 4 D an is h m un ic ip al i- tie s R es ea rc h- ba se d be fo re an d af te r in te rv en tio n O ct ob er 20 11 to D ec em - be r 20 13 N on -W es t- er n et hn ic m in or iti es re ce iv in g un em pl oy - m en t o r si ck ne ss be ne fit s A du lt po pu la tio n (a ge d 25 – 63 y ea rs ) 82 p at ie nt s (6 4 w om en a nd 1 8 m en ) - In di vi du al iz ed in te rv en tio ns d el iv er ed b y ph ar m ac is ts w ith a  fo cu s on sa fe a nd e ff ec tiv e m ed ic al tr ea tm en ts im pr ov ed se lf- re po rt ed a dh er en ce an d co m pl ia nc e w ith th e re gi m en fo r ap pr ox im at el y ha lf of th e pa tie nt s 5 20 16 M yg in d et al . To in vo lv e ph ar m ac is ts a s pr of es si on al p ee rs in a n ex te nd ed m ed ic at io n re vi ew in te rv en tio n D en m ar k R es ea rc h- ba se d in te r- ve nt io n Au tu m n 20 15 N on -W es t- er n im - m ig ra nt et hn ic m in or iti es Al l a ge s 12 p ha rm ac is ts (m al e an d fe m al e) - In vo lv in g he al th -c ar e st af f w ith e th ni c m in or it y ba ck gr ou nd s as p ro fe ss io na l p ee rs in en co un te rs w ith e th ni c m in or iti es h as p ot en tia l f or th e ad ap ta tio n of s er vi ce s to e th ni ca lly d iv er se po pu la tio ns , t hu s im pr ov in g ac ce ss to a nd q ua lit y of ca re M R P : m ed ic in e- re la te d pr ob le m . 488 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS TA B LE 4 . K E Y SU C C E S SF U L P R A C TI C E S A N D IN N O VA TI VE S O LU TI O N S LE A R N T FR O M 1 0 SE LE C TE D E M P IR IC A L A N D IN TE R VE N TI O N S TU D IE S Fo cu s of s tu dy B is se ll et al . ( 20 03 ) K am al & S hu an (2 00 8) G re ge rs - en (2 00 9) H au g- bø lle e t al . ( 20 09 ) Sh ah ee n (2 01 1) M yg in d et a l. (2 01 3) M ol in et a l. (2 01 3) C an ta re ro - Ar év al o et al . ( 20 14 d) D am et a l. (2 01 5) M yg in d et a l. (2 01 6) D es ig n In vo lv e pa tie nt ’s p er sp ec tiv e on m ed ic in es           R ec og ni ze p at ie nt ’s v al ue s   In te gr at e pa tie nt ’s e xp ec ta tio ns in p ha rm ac y co un se lli ng     D is tin gu is h be tw ee n di ff er en t e th ni c ba ck gr ou nd s an d in cl ud e ch ar ac te ri st ic s ot he r th an c ou nt ry o f b ir th w he n gr ou pi ng pa tie nt s, s uc h as r el ig io n, la ng ua ge o r re gi on s w ith in th e ho m e co un tr y           In cl ud e in te rv en tio ns in w hi ch fa m ily m em be rs a re in vo lv ed o r ev en in te rv ie w r el at iv es d ur in g m ed ic in e re vi ew s   D es ig n pr og ra m m es in w hi ch d oc to rs ta ke p ar t f ro m th e st ar t   W or k w ith p ha rm ac is t w ith th e sa m e et hn ic b ac kg ro un d as th e us er (s )/ pa tie nt (s )     Ta ke in to a cc ou nt th e ps yc ho lo gi ca l s tr es s du e to th e m ig ra tio n an d in te gr at io n pr oc es se s   Im pl em en ta tio n R ec ru it th ro ug h ch an ne ls o th er th an th e ph ar m ac y co un te r (a s is p ro bl em at ic d ue to m is tr us t i n th e us e of th e in fo rm at io n) : u se so ci al n et w or ks a nd /o r la ng ua ge s ch oo ls      Tr ai n he al th -c ar e pr of es si on al s in c ro ss -c ul tu ra l u nd er st an di ng     U se p ro fe ss io na l i nt er pr et er s or b ili ng ua l p ha rm ac is ts to a vo id fr eq ue nt u se o f u nd er ag e ch ild re n as in te rp re te rs  In di vi du al iz e te ac hi ng p ro gr am m es to th e sp ec ifi c ne ed s of et hn ic m in or iti es         A co lla bo ra tiv e ap pr oa ch in cl ud in g ph ar m ac is ts , f am ily d oc to rs an d pa tie nt s (p ay s pe ci al a tt en tio n to R am ad an fo r M us lim pa tie nt s)    R ei te ra tiv e in te rv ie w s, in w hi ch m ut ua l k no w le dg e de ve lo ps , a re he lp fu l   Fo llo w -u p Fr eq ue nt m on ito ri ng m ee tin gs to e nh an ce p at ie nt ’s s at is fa ct io n an d tr us t i n he al th -c ar e pr of es si on al s an d m ot iv at io n to c om pl y w ith m ed ic in e re gi m en s  En ha nc e se lf- ef fic ac y ba se d on o w n cu lt ur al v al ue s  489 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS KEY MESSAGES ON EQUITY Despite the present Danish universal health-care system, inequalities in access to and use of medicines have been detected. These are mainly due to non-structural barriers to health care, including issues related to lack of language skills and different expectations between the health-care professional (doctors and pharmacists) and patients, resulting in the encounter creating frustration and therefore affecting the level of trust between the two parties (4, 5, 19, 21, 23, 26, 27, 36–38). This mistrust hinders the counselling process and affects the way ethnic and migrant populations use medicines (35). Socioeconomic and sociodemographic characteristics also have an impact on equity between the majority and migrant populations (23, 24, 28–35); these characteristics include length of stay in the host country, ancestry (i.e. either first generation or descendant), country of origin, educational background, income level, gender and age (children, young adults and adult populations). These differences have been found in accessing over-the-counter medication (30, 31), vaccination programmes (23, 33) and treatment for chronic conditions (28, 34). The impacts of discrimination and daily psychological stressors have been identified by migrant populations as causes affecting their health and their use of medications (5, 22), among both young (22) and adult populations (5). Crucial issues arise when migrants travel back and forth from the country of origin to the host country. Seasonal travelling (2–4-month visits to the home country each year are not unusual) poses challenges for maintaining continuity of treatment, and this is especially relevant for chronic patients and those on polypharmacy (5). Finally, using both imported medicines and traditional remedies, and sharing prescribed medication can potentially increase the risk of side-effects due to interactions and MRPs (25). SUCCESSFUL PRACTICES AND INNOVATIVE SOLUTIONS Among the key components of the success of theory-based interventions conducted by SCP-KU were building trust between the pharmacist and the user/patient, and involving ethnic minorities in all phases of the intervention (design, implementation and evaluation) (35–39). The development of an ethnically sensitive culture among pharmacists based on openness, curiosity and respect facilitated a cross-cultural understanding that appeared to be the main component for the success of the intervention projects. When possible, it is important not only to cooperate individually with the patient but also to involve the family, friends and close social network, especially when there is a need to change a specific behaviour related to either medicine use or lifestyle habits (38, 39). Moreover, a collaborative approach that includes pharmacists, family doctors and patients contributes to reducing MRPs and improves adherence and compliance (35–39). For the Muslim population, it was found that special attention should be given during Ramadan (4). Ethnic sensitivity during Ramadan and the will to find ways of accommodating medicine regimens appeared to increase patient satisfaction and maintain stable compliance, especially among chronic patients. OTHER LESSONS LEARNT Using different methodological approaches, Bissell et al., Mygind et al. and Cantarero-Arévalo et al. showed the limitations and pitfalls faced when operationalizing the terms ethnicity or migrant (19, 20, 28), and highlighted the importance of exerting prudence when classifying ethnic groups. The way ethnic groups and migrants are defined and categorized has implications for the way we identify causes of diseases and health behaviours. To actually identify those groups in need, a sensitive and simultaneously flexible definition that captures the subtleties of belonging to a specific ethnic or migrant group is needed. DISCUSSION This review provides insight into the work conducted by the research group at SCP-KU. The 24 empirical and theory-based intervention studies included show, first, that in Denmark there are inequities in access to and use of medicines for infectious diseases, chronic conditions and minor ailments across different age groups, in both men and women and in different ethnic minority groups. Second, theory-based interventions that involve ethnic minorities as patients and researchers in their design, implementation and evaluation contribute to improving compliance with medicine regimens and reducing MRPs (18). This effect is further enhanced by involving relatives and friends and the larger social 490 VOLUME 2 | ISSUE 4 | DECEMBER 2016 | 401-588PUBLIC HEALTH PANORAMA ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS network of the patient, and by engaging different health-care professionals, especially the family doctor. The impact of the SCP-KU studies and interventions have not been evaluated, but it is obvious that this body of work, combined with on-the-floor, day-to-day work experiences of pharmacists and allied professionals in community pharmacies and hospitals, has resulted in an increase in awareness among health-care personnel in Denmark. Today, the ethnically sensitive services provided by pharmacists and pharmacy personnel have improved the quality of care. This development can be attributed to two clear demographic shifts: first, to the increase in the number of non-Western migrants; and second, to how this development over time resulted in a significant increase in people from ethnic minorities becoming students at the school of pharmacy. Another major shift is attributed to the SCP-KU tradition of research-based teaching. This tradition has fostered the active participation and empowerment of pharmacy students by including them in all stages of research in this area. Ultimately, this approach has led to students from ethnic minorities initiating and carrying out their own studies. The response to the recent influx of immigrants and refugees to Europe creates challenges for many countries who find themselves unprepared when they suddenly have to provide pharmaceutical services for a group of patients and medicine users who not only do not speak the same language but also do not understand the culture and procedures of the health-care services of the host country. We therefore argue that the relevance of this article lies in the fact that in Denmark these challenges are part of the road to integration and are not regarded as a permanent state of affairs. Seeing and understanding this progression, in our opinion, attacks two common pitfalls in research, teaching and interventions. The first pitfall is that the term ethnicity does not have a single definition: several of the studies included here note that even migrants from the same country or those who share a common religion and/or language are very different and have different needs. A second pitfall is placing a special focus on ethnicity as a problem to be addressed in either research or when confronted by students of non-Western origin. Caution is advised to avoid stigmatizing migrants (both in the population and as students of pharmacy). There are a few limitations of this body of work. First, one might question the relevance of these studies for other countries, as this research was carried out in Denmark, a small country with a relatively short history of and limited experience with non-Western ethnic minorities. Indeed, the SCP-KU research group has had little contact with, and therefore no published work on, asylum seekers living in Danish refugee camps. Thus, the current results can be extrapolated only with difficulty because the level of migration and influx of refugees in Denmark are low compared with other European countries, and with countries such as Turkey and Jordan. The strengths of our paper lie in the fact that SCP-KU has worked with ethnic minorities on medicine use and on a wide range of different issues related to these population groups for almost two decades: from a user’s perspective, both qualitatively and quantitatively, and using different yet relevant theories. These facts, we believe, increase the validity of our study. IMPLICATIONS FOR PRACTICE For academic institutions, in particular, we suggest making use of the pharmacy internship period and encouraging students to develop research projects aimed at addressing inequalities in medicine use. We also strongly recommend inviting students from ethnic minorities to counsel patients with whom they share ethnic backgrounds. For public bodies active at the local or regional levels, we encourage the development of an outreach programme aimed at providing basic orientation to newly arrived migrants about what types of services are available, what can be expected when visiting a community pharmacy and the specificities of the health-care services of the host country with the object of reducing misunderstanding and frustration. In the case of pharmacy services, this is especially crucial with regard to which medicines are to be purchased over the counter. For clinical pharmacy reviews, we recommend conducting medicine reviews by pharmacists with the same ethnic background as the patients to further reduce MRPs and improve compliance. RESEARCH PRIORITIES A first priority of research is to examine ethnic inequalities in access to and use of medicines across the WHO European Region by conducting a multicountry survey. This approach will eventually allow assessment of the effect of different types of 491 ТОМ 2 | ВЫПУСК 4 | ДЕКАБРЬ 2016 Г. | 401-588ПАНОРАМА ОБЩЕСТВЕННОГО ЗДРАВООХРАНЕНИЯ ADDRESSING ETHNIC INEQUALITIES IN MEDICINE USE IN DENMARK: SELECTED THEORY-BASED INTERVENTIONS health-care systems on the quality of care for ethnic minorities. A second priority of research is to address the impact of different migrant statuses (refugee, asylum seeker, and undocumented, labour and circulatory migrant) on access to and use of medicines, as well as the impact of various migrant statuses on compliance with medicine regimens among chronic patients. Finally, the third research priority is to gain an in-depth understanding of self-medication, the use of traditional medicines and other medicine-use behaviours among specific ethnic minority groups across several European countries. CONCLUSION Ethnically sensitive pharmacy-related services ease the counselling process on the use of medicines and ultimately contribute to a reduction in MRPs. Components of successful interventions include the involvement of ethnic minorities in all phases of the intervention. Currently, academic institutions may use their teaching sessions as an entry point to raise awareness among future health-care professionals of the importance of acknowledging and recognizing the need for an ethnically sensitive approach. In addition to the need for applying the user’s perspective in research and interventions, the use of theory paves the way for more sound interventions. Acknowledgements: We would like to acknowledge and thank the authors of the different articles included in this review, former colleagues working in the field of migration and use of medicines, and all the students interested in and contributing to this crucial and relevant research area. 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