Effects of Training of Pharmacists in Japan on Reasonable Accommodations for People with Intellectual Disabilities

Abstract

With the enforcement of the Act for Eliminating Discrimination against Persons with Disabilities, the provision of reasonable accommodations in pharmacies has become mandatory in Japan. This study aimed to develop and validate the effectiveness of a training program to improve pharmacists’ ability to assist people with intellectual disabilities. The educational staff of one chain pharmacy company announced the program, and pharmacists at this company were invited to participate in the program. A 90 min online training was conducted with 15 pharmacists. The session included a lecture on reasonable accommodations and small group discussions (SGD). Before and after the training, participants answered an online survey about 1. Their basic attributes (number of years of experience and awareness of reasonable accommodations and constructive dialogue); 2. Their confidence in providing medication guidance to people with intellectual disabilities (10-point scale); and 3. Possible accommodations that could be provided by pharmacies. Training resulted in an increase in the average score for question 2 from 3.93 to 5.87. In addition, an increase in the number of keywords within the free-text descriptions and in the number of co-occurrences within the responses of mentions of possible accommodations in pharmacies was observed. Despite the shortness of the training, it changed the participants’ awareness about accommodations for people with intellectual disabilities. Further study is needed to enhance the content and evaluate changes in practice.

1. Introduction

How individuals with and without intellectual disabilities can build an inclusive society is a global issue. In 2006, the United Nations adopted the Convention on the Rights of Persons with Disabilities (CRPD). The CRPD encompasses a wide range of issues, including healthcare, welfare, and justice, and calls on signatory countries to adopt relevant domestic laws [1]. Japan has enacted the Act for Eliminating Discrimination against Persons with Disabilities, which prohibits discrimination against persons with disabilities and requires the provision of reasonable accommodations [2]. Initially, the provision of reasonable accommodations was mandatory for government agencies but was considered a voluntary effort for private businesses. In April 2024, however, this framework was partially revised, making the provision of reasonable accommodations mandatory for private businesses, which meant that pharmacies are now mandated to provide reasonable accommodations [3].

Intellectual disability is one of the most representative of a group of neurodevelopmental disorders. The onset of intellectual disability is during the developmental years and includes deficits in both intellectual and adaptive functioning in conceptual, social, and practical domains. The prevalence of intellectual disability is estimated to be 1% of the total population, which includes approximately 1 million people in Japan [4]. It has been reported that persons with intellectual disabilities use more drugs than the general population [5]. However, it has been noted that difficulties arise in drug therapy due to factors such as poor communication skills of health care providers, lack of accessible information, and the adjustment and cognitive impairments that are associated with intellectual disabilities [6]. Since pharmacies are accessed by a wide variety of people, pharmacists have the opportunity to interact with and provide medication instruction to people with intellectual disabilities. An example of reasonable accommodations in pharmacies is the provision of medical information. Medical information is highly specialized and can be particularly difficult to understand for people with intellectual disabilities [7]. For example, in 2001, Strydom et al. reported that 86% of people with intellectual disabilities were not fully aware of the adverse events of the psychotropic drugs they were taking [8]. Additionally, people with mild to moderate intellectual disabilities have been found to be more prone to prescribing errors [9], highlighting the need for pharmacist involvement. Research on the involvement of pharmacists in the treatment of people with intellectual disabilities has included medication reviews [9], pharmacist-based consulting services for nutritional rehabilitation [10], and health care economics assessments [11], but it has been pointed out that it is difficult to accurately measure the effects of these interventions due to the diversity of people with intellectual disabilities and the difficulty of defining them [12]. Blasi conducted a detailed survey of the barriers faced by pharmacists when dealing with people with intellectual disabilities, and in the course of this survey, the pharmacists surveyed pointed out the inadequacy of their education and the tendency to rely on on-the-job experience rather than education [13]. Badr surveyed barriers in providing services to patients with disabilities in Saudi Arabia, which showed that 57.5% of pharmacists encounter difficulties when caring for patients with disabilities, and 65% indicate a lack of specialized services [14]. To the best of the authors’ knowledge, no studies have been conducted in Japan on education or training for pharmacists in providing information to people with intellectual disabilities. The tendency to place too much emphasis on experience without sufficient education can lead to differences in service quality and the retention of mistaken assumptions, so the lack of education should be seen as a problem.

With the aim of solving the above problems, we have been promoting a project since 2023 to explore issues related to the provision of medical information to people with intellectual disabilities in Japan and to develop effective educational methods. Therefore, this article aims to evaluate the effects of a training session conducted as part of research to develop an educational program to provide reasonable accommodations and to examine future educational methods.

1.1. Definitions of Terms

1.1.1. Reasonable Accommodation

“Reasonable accommodation” means necessary and appropriate modification and adjustments not imposing a disproportionate or undue burden, where needed in a particular case, to ensure to persons with disabilities the enjoyment or exercise on an equal basis with others of all human rights and fundamental freedoms. This definition will also be followed in this study [15].

1.1.2. Constructive Dialogue

The Japanese Cabinet Office has issued the following statement regarding constructive dialogue.

When providing reasonable accommodation, it is important that both the person with the disability and the administrative agency, etc., or business operator engage in dialogue and consider solutions together regarding what needs to be done to remove social barriers. This type of interaction between the two parties is called “constructive dialogue” [16].

In this study, “constructive dialogue” follows this definition.

2. Materials and Methods

2.1. Implementation of Training Sessions

In November 2024, a 90 min online training session titled “Considering Reasonable Accommodations in Pharmacies for People with Intellectual Disabilities” was conducted involving 15 pharmacists who agreed to participate in the training. The pharmacists were employed by a pharmacy chain with branches in Osaka and Hyogo prefectures. The person in charge of education and training at the pharmacy chain company notified company staff in advance that training would be held, and the pharmacists were free to decide for themselves whether or not to participate. The objective of the training was to “deepen knowledge of the need for reasonable accommodations for people with intellectual disabilities and the means of providing them.” Prior to receiving the training, the participants received a participant information statement (PIS) and consent form. The lead author served as the instructor, while group assignments and participant management were carried out by education staff of the pharmacy chain company employing the participants. This training was conducted entirely via Zoom, a platform provided by Zoom Video Communications, Inc. (San Jose, CA, USA).

2.2. Details of the Training Sessions

Prior to the training sessions, we conducted semi-structured interviews with 11 pharmacists [17]. We then extracted the current conditions of and problems with pharmacists’ medication support for people with intellectual disabilities and incorporated these into the training contents. In addition, the contents of the training were checked and approved by an educational training officer who worked at a workplace that supports the continued employment of people with disabilities, is familiar with supporting people with disabilities, including intellectual disabilities, and is well-versed in the current conditions of pharmacies. The instructor began with a greeting and provided an overview of the training, including its objectives. In the first half of the training, the instructor talked about reasonable accommodation. The contents of the lecture were based on materials such as leaflets issued by the cabinet office [18], the portal page managed by the cabinet office [19] promoting understanding on the elimination of discrimination against persons with disabilities, and the guidelines prepared by Osaka Prefecture [20]. Specific contents included the following: (1) an introduction to the Convention on the Rights of Persons with Disabilities; (2) the nature, scope, and specific examples of reasonable accommodations; and (3) an explanation of constructive dialogue along with some concrete examples. After the lecture, participants engaged in small group discussions (SGD) based on a simulated case. Each SGD consisted of around five participants, with group assignments designed to ensure diversity in terms of the number of years of experience and work locations. Before the SGD, participants were instructed to designate a moderator and a presenter within their group. The moderator’s role was to encourage equal participation among all members and to ensure that no one dominated the discussion. Participants were also reminded to respect others’ opinions and avoid dismissing them outright. At the end of the SGD, the presenter from each group shared the group’s insights, providing an opportunity to exchange ideas with other groups.

In the second half of the training, an explanation of intellectual disabilities was presented that had been developed based on information from sources such as the DSM-5 Diagnostic and Statistical Manual of Mental Disorders [4], published papers [17,21,22], and other literature dealing with the definition and characteristics of intellectual disabilities and assessment methods.

Following the talk, participants took part in an SGD centered on potential accommodations that pharmacies might use.

2.3. Data Collection

Before and after the training, participants were asked to complete a web-based survey (Google Form). The pre-training survey link was sent a week before the training, with responses requested by the day of the session. At the end of the training, a Quick Response (QR) code for the post-training survey was displayed on the screen, and participants were asked to complete this survey. The data collected are managed appropriately in accordance with the Personal Information Protection Law to ensure that they cannot be viewed by anyone other than the authors.

2.4. Items Evaluated

The items on the questionnaire were prepared by the corresponding author in consultation with the other authors to ensure that they were consistent with the content of the training. The questions in the web survey are presented below.

• Their basic attributes (number of years of experience and awareness of reasonable accommodations and constructive dialogue)
• Their level of confidence in providing medication guidance to people with intellectual disabilities (mild/moderate) (Question: “How confident are you in providing medication guidance to people with intellectual disabilities (mild/moderate)?” Responses were given using a 10-point scale, ranging from “very confident (10)” to “Not at all confident (1).”)
• Potential accommodations in pharmacies (Question: “What types of accommodations do you feel could be implemented in pharmacies for people with intellectual disabilities (mild/moderate)?” Responses were open-ended.)

Item 1 was only included in the pre-training survey, while items 2 and 3 were included in both the pre- and post-training surveys, with participants asked to respond twice.

2.5. Data Analysis

The responses to Item 2 were scored and tested using a paired t-test. The effect size (Cohen’s d) was calculated for the change in scores. IBM SPSS Statistics 27 (IBM, Tokyo, Japan) was used for the analysis. For the analysis of Item 3 responses, morphological analysis was performed, followed by keyword extraction and categorization using sentiment analysis. The main reason for choosing these analyses was that it is easy to compare data before and after training. Analysis of the open-ended responses was performed with PASW Text Analytics for Surveys 3 Japanese (IBM, Tokyo, Japan) and involved four steps: 1. Pre-processing of the written responses; 2. Keyword extraction; 3. Categorization; and 4. Visualizing the co-occurrence categories. Sentiment analysis was used during the keyword extraction process. Sentiment analysis and morphological analysis were performed using the natural language processing engine (Nazuki Emotion Analyzer Library v. 1.5). Sentiment analysis is the default setting for PASW Text Analytics for Survey 3 Japanese. Sentiment analysis is also excellent at analyzing Japanese idioms, etc., because it can extract parts of sentences that express pleasant or unpleasant feelings and actions that are based on them [23]. To visualize co-occurrence, the circle layout function provided in PASW Text Analytics for Surveys 3 Japanese was used. In order to classify the resulting categories, a hierarchical cluster analysis was also conducted. Hierarchical cluster analysis is a method of grouping similar sentences in stages using a distance matrix. Unlike human-based grouping, it is not affected by the reader’s subjective impressions, so it is possible to achieve more objective grouping. The graph of hierarchical clusters is called a dendrogram [24]. In this analysis, the presence or absence of each category for each respondent was presented as a binary value: 1 (present) or 0 (absent). The average linkage method was used for the extraction, and the Jaccard distance, suitable for the analysis of binary data [24], were employed for the measurement, resulting in the creation of a dendrogram.

3. Results

All fifteen pharmacists responded to the survey. The average work experience of the respondents was 15.7 years (standard deviation of 11.5 years), and 33.3% of respondents reported having a close acquaintance with someone who has a developmental or intellectual disability. To the question, “Have you ever heard of the term ‘reasonable accommodation’?” 13.3% responded, “I have heard of it and can explain what it is about,” 60.0% responded, “I have heard of it, but I do not know what it is about,” and 26.7% responded, “I have never heard of it. ”To the question, “Have you ever heard of the term ‘constructive dialogue’?,” 6.7% responded, “I have heard of it and can explain what it is about,” 46.7% responded, “I have heard of it, but I do not know what it is about,” and 46.7% responded, “I have never heard of it.”

Effect of Training

The scores for the participants’ level of confidence in providing medication guidance to people with intellectual disabilities increased from pre-training (mean: 3.93, standard deviation: 2.28) to post-training (mean: 5.87, standard deviation: 2.07) (p < 0.01, Cohen’s d: 1.75). The largest change in score was +5 points; none of the participants’ scores decreased.

The responses obtained for Question 3, “What types of accommodations do you feel could be implemented in pharmacies for people with intellectual disabilities (mild/moderate)?” increased in both word count and variety from pre-training (324 characters, 10 categories) to post-training (693 characters, 19 categories). The frequency of occurrence for each category in the open-ended responses is shown in Figure 1.

Both before and after training, the most frequently mentioned category was “speaking,” indicating a tendency to focus on communication-related adaptations. After training, new categories that were not present in the pre-training responses appeared, such as “matching,” “medical questionnaire,” and “one-dose packaging.”

Figure 2 indicates the co-occurrence of categories. Before training, the co-occurrence of the “briefly” and “speaking” categories was 4.0, while all other co-occurrence values ranged between 1.0 and 2.0.

After training, co-occurrence was observed not only between existing categories such as “slowly”—“clearly”—“speaking” and “matching”—“speaking”; but also between new categories introduced after training, such as “accommodation”—“suggestion.” Overall, there was an increase in the number of co-occurrences.

The classification of categories obtained by cluster analysis is shown in Figure 3. Since insufficient data were collected before training to perform cluster analysis, only the results of the post-training data analysis are presented. The results of the hierarchical cluster analysis suggest that the responses could be classified into four groups by setting the minimum distance to 21, thereby not producing a single response in the dendrogram.

The first cluster included responses related to adapting language based on the person’s level of understanding, such as “Speak slowly. Choose easy-to-understand words,” and was called the “Language adaptation” cluster. The second cluster included responses such as “The accommodation varies depending on the severity of the disability, so the response should be person-specific (abbreviated),” reflecting the idea of avoiding a one-size-fits-all approach to judgment or accommodation. Therefore, this cluster was named “Person-specific responses.” The third cluster included responses related to creating an environment, such as “Creating an environment where people can easily request accommodations (abbreviated),” and was named “Creating an environment.” The fourth cluster included responses such as “(abbreviated) Sharing information among staff” and was named “Information sharing.”

4. Discussion

In this study, we examined the effects of training for pharmacists on reasonable accommodations for people with intellectual disabilities that can be implemented in their daily work. There have been reports of the effects of training for pharmacy students on how to respond to patients with hearing disabilities [25]. However, there have been no reports of training for pharmacists on how to provide reasonable accommodations for people with intellectual disabilities. Although this training was structured in a short 90 min session, it significantly increased pharmacists’ level of confidence in providing medication guidance to people with intellectual disabilities. However, the post-training score of 5.87 may not indicate sufficient confidence, and the low value prior to the training may have influenced the significant increase. Determining the significance of the increase in this value in terms of actual pharmacy practice will require data from post-training reports by pharmacists and is something that should be addressed in the future. We think that more experience in actual pharmacy practice and trial and error will be needed to further increase this value. Additionally, the increase in the number of categories in the open-ended responses suggests that the training likely increased pharmacists’ awareness of reasonable accommodations and constructive dialogue, potentially enhancing their ability to respond effectively.

The pharmacists in this training were an experienced group, with an average of 15.7 years of service in pharmacies, but only 13.3% could explain the concept of “reasonable accommodations,” and only 6.7% could explain “constructive dialogue.” Because “constructive dialogue” is a key concept in understanding “reasonable accommodations,” it is possible that some people who believed they could explain “reasonable accommodations” still had a limited understanding of the concept. Regarding awareness of reasonable accommodations, a survey conducted by the Japanese Cabinet Office in 2009 found that only 4.3% of respondents were “aware of the concept of reasonable accommodations” [26]. Although no large-scale surveys specifically concerning awareness have been conducted since then, it is possible that awareness has not expanded sufficiently over the past 15 years. This may be due not only to deficiencies in pharmacy education but also to a lack of dissemination in, for example, the media. On the other hand, the U.S. is ahead of other countries in its efforts regarding the rights of persons with disabilities. The U.S. Department of Labor reports that more than half of employers have made accommodations for their employees, and 68.4% of them responded that the accommodations were very effective [27]. Against this backdrop, trends that are beneficial for people with disabilities have been noted, such as the rising rate of victories in workplace discrimination cases in the U.S. [28].

The newly identified keyword “matching” emerged in the context of “Adaptation to the individual characteristics.” A representative example from the responses is, “Accommodations vary depending on the severity of the disability, so the response should be person-specific. I plan to provide detailed explanations and make suggestions to address concerns.” This reflects the training content, which reflected the “need to tailor responses to the unique characteristics of each person, rather than just categorizing them based on disease, etc.” This keyword is considered to correspond to “personalization,” an essential element of the process of determining the contents of reasonable accommodations, as pointed out by Katsumata et al. [29]. The category “medical questionnaire” appeared in the context of “Insertion of a section for patients to indicate their required accommodations in the medical questionnaire.” This idea was discussed and shared during the SGD to help identify the need for accommodations in the pharmacy environment. Similarly, “One dose packaging” was discussed and shared in the SGD as a measure to avoid misinterpretation of medications. One-dose packages have been reported to improve medication adherence in older adults, but in practice they should probably be considered not only for older adults but for all people who have difficulty taking their medications [30]. Since these statements and ideas can be described as physical structures that lead to the clarification of instructions to people, they are considered to align with the structuring described in the TEEACH (Treatment and Education of Autistic and Related Communication Handicapped Children) program [31]. These ideas were also supported by the participants because, among other things, they make drug therapy safer for persons with intellectual disabilities and facilitate requests for reasonable accommodations. These newly obtained descriptions, including keywords, are clearly reflected in the hierarchical cluster analysis. Assuming best practices for pharmacists working with persons with intellectual disabilities are followed, this would lead to the following outcomes: the pharmacist understanding the characteristics and abilities of the person, providing flexible and personalized care tailored to those characteristics and abilities, sharing this information with all staff members, making the entire store comfortable for each person, and making it easy for people to request accommodations. We believe that “Language adaptation,” “Person-specific responses,” “Creating an environment,” and “Information sharing,” which are the four clusters identified in this study, are critical elements in the implementation of this envisioned best practice and can guide the design of future training. The guidelines for welfare providers presented in the Japanese Ministry of Health, Labour, and Welfare’s 2024 Act for Eliminating Discrimination against Persons with Disabilities also include many descriptions that fall into these clusters [32]. Although some keywords corresponding to “language adaptation” were obtained before the training as well, they apparently did not appear as a cluster because of their vague content and lack of reference to other important factors. In a typical response, “speaking slowly and using language that is easy to understand” was mentioned. We believe that adequate individual training is necessary to make it possible to use “easy-to-understand language” for the target population. We think that previous research that has been carried out on addressing the needs of foreigners and has encompassed training on the use of “easy-to-understand language” can serve as a reference. Possible responses specific to Japan include using hiragana instead of kanji and refraining from using idiomatic expressions [29]. “Person-specific responses” corresponds to the aforementioned “personalization” [30], which we believe indicates a deeper understanding of disability by the participants. Regarding “Creating an environment,” although the responses obtained in this survey mentioned “making it easy to request accommodations,” other factors such as trying to make informational materials and descriptions of services easier to understand and flexible amendments to standards and procedures [32], etc., are also considered to fall under this category. “Information sharing” is an important point for achieving continuity of care. We believe that this category emerged because it is particularly important in pharmacies, where the same people continuously visit the facility and need to be monitored for progress but are not always handled by the same person. Taking these points into account, it can be inferred that the training led participants to recognize the need for an individual response to each person and provided an opportunity to reflect on specific methods of implementing accommodations.

We think that the strengths of this training are (1) the focus on content directly related to pharmacy practice and (2) the sufficient time that was allocated for the SGDs, which allowed for the sharing of multiple perspectives. The focus on content directly related to pharmacy practice was seen in the new categories that emerged after the training, such as “One-dose packaging” and “medical questionnaire,” which allowed participants to concretely think about methods of providing reasonable accommodations and assessing the need for accommodations in ways that fit their daily work. The sharing of multiple perspectives through the SGDs regarding the efforts and the feasibility of implementing accommodations in each pharmacy likely made the training content more practical. Additionally, the fact that participants in this training had a certain level of practical experience and were familiar with SGDs likely resulted in more practical discussions and contributed to the effectiveness of the training.

Limitations

We recognize the following limitations. First, the training session was in an online format, and Ueda has pointed out that online SGDs may have limited effectiveness [33]. However, it is important to note that the online format allowed for the inclusion of participants from remote locations. Furthermore, in cases like this, where there are many experienced participants, the negative impact of the online format may be reduced. Second, the training was short and comprised a single session, so the educational effect may be temporary. Additional research is required to determine whether this training actually resulted in the provision of reasonable accommodations in the clinical setting. Third, the quality of the measurement of training effectiveness. Although we observed changes in attitudes due to training, we cannot be sure this was an accurate measurement of the actual knowledge or attitude itself. Therefore, this corresponds to Level 2 of Kirkpatrick’s training effectiveness classification [34]. Going forward, it will be necessary to examine the impact of this training on daily work practice. Additionally, developing educational programs and materials for those who wish to learn more deeply, as well as collecting and sharing cases related to pharmacy practice, are challenges that need to be addressed. Fourth, the lead author was the instructor at this training, which may have influenced the participants’ responses to the questionnaire. Fifth, their self-reported confidence measured in this training was a self-assessment by the respondents, and it is difficult to compare it to benchmark data due to the lack of previous research. It is also not certain what services pharmacists provide when confidence is high or low. In the future, we believe that it is necessary to consider the construction of an evaluation method such as that represented by a rubric. Sixth, the participants were a small number of people from a single chain pharmacy, making generalizability problematic.

5. Conclusions

Training for pharmacists on reasonable accommodations for people with intellectual disabilities, even if conducted online for 90 min, can enhance participants’ levels of confidence in medication guidance and deepen their understanding of reasonable accommodations. The four categories of “Language adaptation,” “Person-specific responses,” “Creating an environment,” and “Information sharing” obtained by hierarchical clustering are highly compatible with the MHLW guidelines and can be used as a resource to inform future training designs. As the provision of reasonable accommodations at businesses has become mandatory in Japan, education on the provision of accommodations to persons with disabilities must be emphasized in pharmacy education at universities and after graduation. In addition, the entire pharmacy industry needs to work together to promote an environment that facilitates the provision of reasonable accommodations by pharmacists. In particular, it is important to provide SGDs with ample opportunities to facilitate the exchange of ideas on accommodations that can be implemented within the pharmacy setting. Regarding accommodations for people with disabilities, the accumulated case studies themselves could provide valuable educational materials. It is an important issue to promote the accumulation of case studies.