Geriatric education for pharmacy students: A scoping review.

BACKGROUND: Comprehensive medication management for older adults requires specific knowledge and skills. Therefore, pharmacy curricula should include appropriate strategies to prepare students for care of this population. This scoping review aimed to identify how geriatric concepts, such as geriatric topics and competencies, are included in pharmacy curricula, and to map current literature on preferred teaching and assessment methods related to geriatric pharmacy education. METHODS: Four databases were searched to identify papers involving pharmacy learners, education, and geriatrics. Selection process was a two-step approach, involving independent title/abstract screening by two reviewers, then full-text retrieval for eligibility assessment. All types of articles were considered except opinion papers. Data extraction included details on methodology, participants, setting, educational activity, teaching method, and outcomes assessed. RESULTS: A total of 2537 articles were identified from which 189 met the inclusion criteria: 221 documents after citation and gray literature searching. Articles were grouped for analysis as education-related intervention articles (studies, n = 100 or descriptive articles/case reports, n = 49), studies not including an education-related intervention (n = 49), and others (e.g., reviews, position papers/statements, n = 23). Various teaching methods were reported including experiential, didactic, interprofessional, or simulation. Most articles reported positive outcomes on skills, knowledge, or attitudes, but few articles used a validated assessment tool. Curricula and student's surveys were consistent with suboptimal geriatric education, with few programs offering mandatory dedicated geriatric courses or rotations. CONCLUSIONS: Gaps remain regarding geriatric inclusion in pharmacy curricula despite decades of evidence, advocacy, and frameworks to guide its development. A wide diversity of teaching methods has been described and their combination may be considered for skills and competency development. There is a need for the scholarship of teaching and learning to be applied to pharmacy programs in order to prepare future pharmacists for an aging society.

Antihypertensive deprescribing in frail long-term care residents (OptimizeBP): protocol for a prospective, randomised, open-label pragmatic trial.

INTRODUCTION: Although antihypertensive medication use is common among frail older adults, observational studies in this population suggest blood pressure (BP) lowering may convey limited benefit and perhaps even harm. This protocol describes an antihypertensive deprescribing trial in frail older adults powered for mortality and morbidity outcomes. METHODS AND ANALYSIS: Design: Prospective, parallel, randomised, open-label pragmatic trial.Participants: Long-term care (LTC) residents ≥70 years of age, diagnosed with hypertension, with mean systolic BP <135 mm Hg, ≥1 daily antihypertensive medication and no history of congestive heart failure.Setting: 18 LTC facilities in Alberta, Canada, with eligible residents identified using electronic health services data.Intervention: All non-opted-out eligible residents are randomised centrally by a provincial health data steward to either usual care, or continually reducing antihypertensives provided an upper systolic threshold of 145 mm Hg is not exceeded. Deprescribing is carried out by pharmacists/nurse practitioners, using an investigator-developed algorithm.Follow-up: Provincial healthcare databases tracking hospital, continuing care and community medical services.Primary outcome: All-cause mortality.Secondary outcome: Composite of all-cause mortality or all-cause unplanned hospitalisation/emergency department visit.Tertiary outcomes: All-cause unplanned hospitalisation/emergency department visit, non-vertebral fracture, renal insufficiency and cost of care. Also, as assessed roughly 135-days postrandomisation, fall in the last 30 days, worsening cognition, worsening activities of daily living and skin ulceration.Process outcomes: Number of daily antihypertensive medications (broken down by antihypertensive class) and average systolic and diastolic BP over study duration.Primary outcome analysis: Cox proportional hazards survival analysis.Sample size: The trial will continue until observation of 247 primary outcome events has occurred.Current status: Enrolment is ongoing with ~400 randomisations to date (70% female, mean age 86 years). ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of Alberta Health Ethics Review Board (Pro00097312) and results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05047731.

Evidence for the use of cannabis-based medicines in osteoarthritis: a scoping review.

The purpose of this study was to conduct a scoping review to describe the evidence on the efficacy and safety of using cannabis-based medicines for osteoarthritis. The review was conducted following the framework proposed by Arksey and O'Malley and reported following PRISMA extension for scoping reviews guidelines. We conducted a comprehensive search across various databases including MEDLINE, Embase, Cochrane Library, CINAHL, Scopus, and Proquest, spanning from inception of each database to March 2023. We retrieved 2533 citations, and after deduplication, title and abstract screening, and full-text screening, 10 articles were included for analysis. These studies were composed of randomized-controlled trials (n = 4/10), cross-sectional surveys (n = 3/10), case studies (n = 2/10), and a cohort study (n = 1/10). Evidence for using cannabis-based medicines was mixed, with just 60% (n = 6/10) of included studies reporting statistically significant improvements in pain. Studies with larger samples sizes and longer durations of exposure did not find significant benefits for pain. The few adverse effects reported were generally mild and affected a minority of participants. Several studies also discovered that cannabis-based medicines were associated with a reduction in opioid use. Currently available data on the use of cannabis-based medicines in osteoarthritis is insufficient to make recommendations. Future research should address concerns regarding small sample sizes and short treatment durations to provide a more robust evidence base. Key Points • Current evidence remains mixed; studies that found a positive benefit with using cannabis-based medicines had limitations with small sample sizes and short durations of exposure • The use of cannabis-based medicines in osteoarthritis appears to be generally well tolerated, adverse effects are mild and experienced by a minority of participants • Cannabis-based medicines may decrease the use of opioids in patients with osteoarthritis • Future research should address the gaps in long-term efficacy and safety data.

Case mapping of geriatrics: Looking beyond age in skills laboratories.

BACKGROUND AND PURPOSE: Development of competencies related to care of older adults is necessary in pharmacy education. Skills laboratories as an essential part of the curriculum represent an important setting to teach geriatrics. The purpose of this research was to describe geriatrics cases in skills/simulation activities of an undergraduate pharmacy program. EDUCATIONAL ACTIVITY AND SETTING: A retrospective review of one academic year of skills laboratories from the pharmacy program at the Faculty of Pharmacy of University of Montreal was performed. Sessions including cases aged ≥65 years were selected. Content was extracted for characteristics relating to the patient, health, medications, and care context. A framework including geriatric considerations such as geriatric syndromes, frailty status, and potentially inappropriate medications was developed for data collection. FINDINGS: In total, 210 patient cases were extracted. Older adults (≥ 65 years) were represented in 51 cases (24%), with 8 cases (4%) aged ≥80 years. Geriatric syndromes were documented in 8%, functional status in 10%, and mobility in 12% of the cases. The median number of comorbidities and medications were 4 and 7, respectively. Regarding polypharmacy, only 10 cases had >10 medications, and none had >15 medications. Potentially inappropriate medications were found in 47% (n = 24) of the cases but were addressed in only 14% (n = 7) cases. SUMMARY: This mapping of skills laboratories highlights gaps in geriatrics content. Inclusion of the oldest patients and geriatrics issues were incorporated in a minority of cases and lacked many characteristics essential for geriatrics care.

Development and evaluation of shared decision-making tools in rheumatology: A scoping review.

INTRODUCTION: Shared decision-making (SDM) tools are facilitators of decision-making through a collaborative process between patients/caregivers and clinicians. These tools help clinicians understand patient's perspectives and help patients in making informed decisions based on their preferences. Despite their usefulness for both patients and clinicians, SDM tools are not widely implemented in everyday practice. One barrier is the lack of clarity on the development and evaluation processes of these tools. Such processes have not been previously described in the field of rheumatology. OBJECTIVE: To describe the development and evaluation processes of shared decision-making (SDM) tools used in rheumatology. METHODS: Bibliographic databases (e.g., EMBASE and CINAHL) were searched for relevant articles. Guidelines for the PRISMA extension for scoping reviews were followed. Studies included were: addressing SDM among adults in rheumatology, focusing on development and/or evaluation of SDM tool, full texts, empirical research, and in the English language. RESULTS: Of the 2030 records screened, forty-six reports addressing 36 SDM tools were included. Development basis and evaluation measures varied across the studies. The most commonly reported development basis was the International Patient Decision Aids Standards (IPDAS) criteria (19/36, 53 %). Other developmental foundations reported were: The Ottawa Decision Support Framework (ODSF) (6/36, 16 %), Informed Medical Decision Foundation elements (3/36, 8 %), edutainment principles (2/36, 5.5 %), and others (e.g. DISCERN and MARKOV Model) (9/31,29 %). The most commonly used evaluation measures were the Decisional Conflict Scale (18/46, 39 %), acceptability and knowledge (7/46, 15 %), and the preparation for decision-making scale (5/46,11 %). CONCLUSION: For better quality and wider implementation of such tools, there is a need for detailed, transparent, systematic, and consistent reporting of development methods and evaluation measures. Using established checklists for reporting development and evaluation is encouraged.

Factors influencing the effects of policies and interventions to promote the appropriate use of medicines in high-income countries: A rapid realist review.

BACKGROUND: The appropriate use of medicines has long been recognized as a fundamental component of medicine policies. We aimed to extract lessons from published research on how policy contexts and mechanisms can affect the outcomes of national- or health-system level interventions to promote appropriate medicine use (defined as an increase in underutilized medications or decrease in inappropriate medication use). METHODS: We conducted a rapid realist review of published evidence concerning system-level policies to promote the appropriate use of medicines in high-income countries with universal prescription drug coverage. We searched MEDLINE and Embase to identify relevant publications. We used a realist evaluation framework to identify contexts, mechanisms, and outcomes for each intervention and to hypothesize which policy contexts and mechanisms supported successful outcomes in terms of relative changes in the prevalence of use of the specific medication classes targeted. RESULTS: From 1,318 identified studies, 18 met our inclusion criteria. 13 distinct policies were identified. Three main policy-related factors underpinned successful interventions: involving providers and patients through program interventions; central coordination through national agencies dedicated to medicine policies; and the establishment of an explicit and integrated national medicine policy strategy. CONCLUSION: Policymakers can improve coordination of national pharmaceutical policies to reduce harms from inappropriate medicines use, thus improving health outcomes through cost-effective programs.

The Aging Care 5Ms Competencies: A Modified Delphi Study to Revise Medical Student Competencies for the Care of Older Adults.

PURPOSE: To revise the 2009 Canadian Geriatrics Society (CGS) Core Competencies in the Care of Older Persons for Canadian Medical Students by applying current frameworks and using a modified Delphi process. METHOD: The working group chose the Geriatric 5Ms model and CanMEDS framework to develop and structure the competencies. National (i.e., Canadian) Delphi participants were recruited, and 3 Delphi survey rounds were conducted from 2019 to 2021. Each survey round collected quantitative data using a 7-point Likert scale (LS) and qualitative data using free-text comments. The purpose of the first round was to establish the importance of the components of the proposed competencies (categorized into 13 subsections) and identify additional themes. The second round assessed agreement with 31 proposed competencies organized into 7 themes: aging, caring for older adults, mind, mobility, medications, multicomplexity, and matters the most. The third survey-rated agreement levels after further revisions to the competencies were applied. The final 33 competencies were shared with survey participants for feedback and other stakeholders for external validation. RESULTS: Mean LSs for the importance of the 13 competency component subsections on the first survey varied from 5.11 to 6.54, with an agreement level of 73%-93%. New themes emerged from the qualitative comments. Mean LSs for the 31 competencies on the second survey ranged from 5.57 to 6.81, with an agreement level of 80%-97%. Mean LSs for the revised competencies on the third survey ranged from 5.83 to 6.65, with an agreement level of 83%-95%. CONCLUSIONS: The authors developed the 33 Aging Care 5Ms Competencies for Canadian medical students using a consensus process. The competencies fulfill an important need in medical education, and ultimately, society. The authors strongly believe that the competencies can be woven into existing undergraduate medical curricula through purposeful integration and collaboration, including with other specialties.

Perceptions of Cannabis Use: A Qualitative Descriptive Study of Rheumatology Patients.

INTRODUCTION/OBJECTIVES: Some rheumatology patients use or contemplate using cannabis, however, may not be transparent about use with their providers. The objective of this qualitative descriptive study was to describe beliefs, perceptions, and learning needs of adults with rheumatic conditions regarding the use of cannabis products. METHODS: Purposive sampling was conducted through a rheumatology clinic and sought participants who were using or thinking about using cannabis. Two online focus groups based on cannabis use patterns (non-users and users) were conducted separately. Interviews were audio recorded and transcribed. Three research team members read the transcripts independently to identify initial codes and themes. Data saturation was reached with the interviews. RESULTS: We recruited 12 participants between 52 and 85 years old. The first theme was pain and desperation. Stigma was the second theme with a perception of physician opposition to cannabis, and the reluctance of many participants to discuss cannabis use with physicians. The final theme was a need for information and a general lack of trustworthy and credible sources. Users were willing to try cannabis even if they still had questions. CONCLUSION: Rheumatology patients are open to using cannabis due to the burden and suffering associated with pain. They remain silent on the topic, however, because of stigma and lack of engagement from health care professionals, particularly physicians. Patients voiced a strong need for information regarding cannabis and want healthcare providers to initiate discussion. These findings are clinically relevant to the management of rheumatic conditions and the promotion of therapeutic relationships.

A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing.

Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01704-9.

Interprofessional peer-assisted learning for pharmacy and physical therapy students using inhalers and inhalation devices.

BACKGROUND: Peer-assisted learning (PAL) is exchanging knowledge between learners often from similar professional levels. Limited evidence exists on the effectiveness of PAL between different healthcare professions. The purpose of this study is to evaluate the knowledge, confidence, and perception of students engaged in an interprofessional PAL activity with pharmacy students instructing physical therapy students on the proper technique, cleaning/storage and therapeutic knowledge on inhaler devices for treatment of pulmonary conditions. METHODS: Pharmacy and physical therapy students completed a survey before and immediately after the PAL activity. As instructors, pharmacy students rated their experience with inhalers, their confidence if they were to assist clients on the use of inhaler devices and confidence in teaching peers. Physical therapy students completed surveys on inhaler knowledge with 10 scenario-based multiple-choice questions, and their confidence if they were to assist clients with inhaler devices. The knowledge questions were grouped into three categories: storage and cleaning of inhalers (3 questions), technique of using inhalers (4 questions), and therapeutic knowledge of drugs given by inhalation (3 questions). RESULTS: 102 physical therapy and 84 pharmacy students completed the activity and surveys. For the physical therapy students, the mean improvement of the total score for knowledge-based questions was 3.6 ± 1.8 (p < 0.001). The question with the fewest number of correct answers (13%) before the PAL activity had the highest number of correct answers post-activity (95%). Prior to the activity, no physical therapy students felt certain/very certain about their knowledge on inhalers, yet after PAL activity this proportion increased to 35%. The percent of pharmacy students reporting their confidence as "certain" and "very certain" in teaching peers increased from 46% before the activity to 90% afterwards. Pharmacy students rated the monitoring and follow-up of inhaler devices as the lowest expectation for physical therapists to play a role. Steps taken to prepare for this PAL activity were also discussed. CONCLUSIONS: Interprofessional PAL can increase knowledge and confidence of healthcare students reciprocally learning and teaching in joint activities. Allowing such interactions facilitate students to build interprofessional relationships during their training, which can increase communication and collaboration to foster an appreciation for each other's roles in clinical practice.

Older age, kidney concordant diseases and the dilemma of adherence to guidelines: A narrative review.

Evidence-based medicine is pivotal to contemporary clinical practice, and the excellence of a healthcare institution is measured by the adherence of its clinical staff to the clinical practice guidelines (CPGs) among other standards and policies. Following the recommendations of CPGs in older adults poses different challenges to prescribers. In this narrative review we explore research studies that assessed clinicians' adherence to CPGs when prescribing to older adults with chronic kidney disease and its concordant disorders, and to discuss the potential barriers and facilitators to better adherence to CPGs. Our review of the literature found that the adherence level to CPGs differed according to country, disease condition and healthcare setting. Clinicians' attitudes toward older adults and the CPGs, the unfamiliarity with the CPGs, and the lack of time, were commonly cited barriers. Interventions suggested to improve adherence to CPGs include direct mentoring, educational activities, and the integration of CPGs recommendations within hospital protocols and policies.

Well-being Content Inclusion in Pharmacy Education Across the United States and Canada.

Objective. To describe the landscape of well-being content inclusion across schools and colleges of pharmacy in the United States and Canada through identification of content implementation, incorporation, and assessment.Methods. A cross-sectional survey was distributed to all accredited schools and colleges of pharmacy in the United States (n=143) and Canada (n=10). Survey questions included curricular and cocurricular timing, frequency, assessment strategies, and support for well-being initiatives, using a framework of eight dimensions (pillars) of wellness to categorize content.Results. Descriptive data analyses were applied to 99 completed surveys (65%), 89 (62%) in the United States and 10 (100%) in Canada. Well-being content was most prevalent within the cocurricular realm and incorporated into didactic and elective more than experiential curricula. The most content came from intellectual, emotional, and physical pillars, and the least content came from financial, spiritual, and environmental pillars. Less than 50% of schools and colleges of pharmacy include well-being within their strategic plans or core values. Funding is primarily at the level of the university (59%) or the school or college of pharmacy (59%). Almost half of respondents reported inclusion of some assessment, with a need for more training, expertise, and standardization.Conclusion. Survey results revealed a wide range of implementation and assessment of well-being programs across the United States and Canada. These results provide a reference point for the state of well-being programs that can serve as a call to action and research across the Academy.

Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology.

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

The effect of renin-angiotensin-aldosterone system inhibitors on continuous and binary kidney outcomes in subgroups of patients with diabetes: a meta-analysis of randomized clinical trials.

INTRODUCTION: Diabetic nephropathy is the leading cause of kidney failure. Clinical practice guidelines recommend prescribing renin-angiotensin aldosterone system inhibitors (RAASi) to prevent diabetic nephropathy at any stage. We conducted this systematic review and meta-analysis to compare the effects of RAASi with placebo and other antihypertensive agents in adults with diabetes on continuous and binary kidney outcomes to provide a comprehensive review of the class effect of RAASi on several subgroups. METHODS: A systematic electronic search to identify randomized clinical trials of a duration of ≥ 12 months that recruited ≥ 50 adult participants with type 1 or 2 diabetes with any stage of chronic kidney disease and proteinuria was conducted in MEDLINE, CINAHL, EMBASE, and Cochrane library with no language restriction. Studies were screened against the inclusion and exclusion criteria by two reviewers independently. RESULTS: In this meta-analysis, evidence was drawn from 26,551 patients with diabetes from 46 studies. Our analysis shows that RAASi were better than placebo in reducing SrCr (the raw mean difference [RMD] = -13.4 µmol/L; 95%CI: -16.78; -10.01) and albuminuria levels (standardized mean difference [SMD] = -1; 95%CI: -1.57, -0.44, I2 = 96%). When compared to other active treatments, RAASi did not reduce SrCr (RMD = 0.03 µmol/L; 95%CI: -6.4, 6.10, I2 = 76%), caused a non-significant reduction of GFR levels (RMD = -1.21 mL/min; 95%CI: -4.52, 2.09, I2 = 86%), and resulted in modest reduction of albuminuria levels (SMD = -0.55; 95%CI: -0.95, -0.16, I2 = 90%). RAASi were superior to placebo in reducing the risks of kidney failure (OR = 0.74; 95%CI: 0.56, 0.97) and doubling of serum creatinine levels (SrCr; OR = 0.71; 95%CI: 0.55, 0.91), but not in promoting the regression of albuminuria (OR = 3.00; 95%CI: 0.96, 9.37). RAASi, however, were not superior to other antihypertensives in reducing the risks of these outcomes. Patients with type 2 diabetes, macroalbuminuria and longer duration of diabetes had less risk of developing kidney failure in placebo-controlled trials, while longer duration of diabetes, normal kidney function, and hypertension increased the probability of achieving regression of albuminuria in active-controlled trials. CONCLUSION: While our findings revealed the non-superiority of RAASi over other antihypertensives and portrayed a class effect on several subgroups of study participants, it raised a challenging question on whether RAASi deserve their place as first-line therapy in managing diabetic nephropathy.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens.

Purpose of review: The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults. Results: Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making. Conclusion: Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.

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

Objective. To determine how US and Canadian pharmacy schools include content related to health disparities and cultural competence and health literacy in curriculum as well as to review assessment practices.Methods. A cross-sectional survey was distributed to 143 accredited and candidate-status pharmacy programs in the United States and 10 in Canada in three phases. Statistical analysis was performed to assess inter-institutional variability and relationships between institutional characteristics and survey results.Results. After stratification by institutional characteristics, no significant differences were found between the 72 (50%) responding institutions in the United States and the eight (80%) in Canada. A core group of faculty typically taught health disparities and cultural competence content and/or health literacy. Health disparities and cultural competence was primarily taught in multiple courses across multiple years in the pre-APPE curriculum. While health literacy was primarily taught in multiple courses in one year in the pre-APPE curriculum in Canada (75.0%), delivery of health literacy was more varied in the United States, including in a single course (20.0%), multiple courses in one year (17.1%), and multiple courses in multiple years (48.6%). Health disparities and cultural competence and health literacy was mostly taught at the introduction or reinforcement level. Active-learning approaches were mostly used in the United States, whereas in Canada active learning was more frequently used in teaching health literacy (62.5%) than health disparities and cultural competence (37.5%). Few institutions reported providing professional preceptor development.Conclusion. The majority of responding pharmacy schools in the United States and Canada include content on health disparities and cultural competence content and health literacy to varying degrees; however, less is required and implemented within experiential programs and the co-curriculum. Opportunities remain to expand and apply information on health disparities and cultural competence content and health literacy content, particularly outside the didactic curriculum, as well as to identify barriers for integration.