Discretion at the margins: An observational study of community pharmacists' adaptive practices in supporting migrant and ethnic minority health

Migrants and ethnic minorities (MEM) often face health challenges and structural and social barriers in accessing primary care. Pharmacists, as accessible healthcare professionals with expertise in medication management can address some of these barriers, however, their roles in serving MEM remain underexplored. This study explored the adaptive communication and care practices of community pharmacists in responding to MEM clients in Flanders, Belgium. We conducted 42 h of non-participant observation and short reflective consultations with pharmacy staff of seven community pharmacies in two cities during February and March 2025. Field notes were structured using a semi-structured topic guide covering duration and content of pharmacist-client interactions; modes of communication; and delivery of pharmaceutical care. Framework analysis was used to code and categorize field notes according to micro-, meso-, and macro-level factors identified as influencing interactions between pharmacy staff and MEM clients. Community pharmacy staff bridge healthcare gaps for MEM clients through multiple strategies, shaped by the dual logics of retail and healthcare. They were observed to accommodate diverse languages and proficiency levels; support medication and health (systems) literacy; address socio-economic challenges; and show sensitivity towards socio-cultural dynamics of care-seeking. Reflecting pharmacists' personal and professional motivations, these adaptive practices are shaped by meso-level factors such as staff composition, pharmacy layout, and social norms, as well as pharmacy-level discretionary actions within the Belgian health system and migration policy contexts. While well positioned to guide MEM clients through a fragmented health system, community pharmacists require systemic policy support to serve diverse population needs effectively. • Observations reveal pharmacists' care work with migrant and ethnic minority clients. • Pharmacists extend roles to address gaps in clients' health and medicines literacy. • Adaptive practices reflect individual motivation and discretionary decision-making. • Systemic policy support is needed to bolster pharmacists' delivery of equitable care.