Pharmacies May Not Always Translate Prescription Labels for Non-English Speaking Patients

Laurie Barclay, MD

April 27, 2007

April 27, 2007 -- Many New York City pharmacies fail to translate prescription labels for patients who do not understand English, despite widespread capability to do so, according to study results presented today at the annual meeting of the Society for General Internal Medicine held in Toronto, Ontario, Canada.

"Inadequate comprehension of medical instructions is associated with poor adherence and negative health outcomes, which may include adverse events and drug resistance," presenter Linda Weiss, PhD, a senior research associate at the New York Academy of Medicine in New York City, told Medscape. "Research suggests that limited English proficient (LEP) patients do have poorer knowledge of medication and dosing instructions and that they have significantly greater problems with medication adherence. The provision of oral and written medication information in the patients' language has been linked to improvements in health outcomes."

Current legislation mandates that all healthcare providers receiving federal funds offer language services to LEP patients. Although these laws have been enforced at hospitals, clinics, nursing homes, and Medicaid agencies, Dr. Weiss' group is also evaluating whether the requirements for translation services also extend to pharmacies.

"Pharmacists have an important role in ensuring that all their patients understand how to take their prescription drugs," Dr. Weiss said. "Guidelines and regulations regarding pharmacist provision of comprehensible written information and medication counseling reflect the fact that this is an essential part of their job."

More Than One Quarter Never Translate

In the current study, the authors randomly selected 200 pharmacies from the 2186 New York City pharmacies licensed in 2006, including independent drugstores, chains, and outpatient hospital and clinic pharmacies. Although 88% of surveyed New York City pharmacists reported serving LEP customers daily, and 80% reported that they had the capability to translate labels, only 34% reported translating labels daily, and an additional 26% reported never translating labels.

"Health literacy is the strongest predictor of a person's health status," Ann Zweber, RPh, director of assessment and senior instructor of pharmacy practice at Oregon State University in Corvallis, told Medscape in response to a request for independent commentary. She was not involved with this study.

"If patients do not understand their medical condition and how to manage it, including how to use their medications, they are more likely to suffer from poor health outcomes," Dr. Zweber said.

Of 8.2 million New York City residents, 2.9 million are foreign-born, speaking a total of 130 languages. Estimates suggest that 25% of adult New York City residents neither speak nor read English well, and that 46% speak a language other than English at home. Nationwide, the latter figure is 17.9%, but in many communities this is much higher, exceeding 70% in some counties in Texas, for example.

Problem May Be National

Despite the paucity of research on whether this problem is of national scope, there is good reason to believe it extends beyond New York City. From 1990 to 2000, immigrant populations grew in 45 states, according to Dr. Weiss, and in 2000, about 21 million people in the United States were LEP, representing a growth rate during the past decade that exceeded 50%.

"In our survey, the concentration of LEP residents in a neighborhood was associated with more frequent label translation," Dr. Weiss said. "One could therefore hypothesize that LEP populations living in areas outside of immigrant-dense cities like New York face greater barriers to translated information."  

Of the New York City pharmacists surveyed, 77% reported the ability to print labels in Spanish; 12% said they could print labels in Chinese, Russian, or other languages; and 52% acknowledged that they could provide translated patient information sheets.

Barriers to Improved Language Access

However, barriers to improved language access cited by pharmacists included the need for additional translation tools (24%), lack of bilingual personnel (20%), insufficient time (7%), and cost constraints (7%). Five percent reported legal concerns that they would be held liable if they printed medication information in a language foreign to them and failed to spot errors in translation.

"Knowledge and attitudes represent significant barriers to translation," Dr. Weiss said. "Language issues have not received significant attention within pharmacy education or pharmacy practice, and several of the pharmacists surveyed said they didn't translate because they never thought about it. A small number expressed the view that they did not feel an obligation to translate, because 'people in the U.S. should learn English' — possibly not thinking through the clinical implications of such attitudes."  

Of those pharmacists who did offer translated labels and pamphlets, 54% did so if they noticed that a patient was having difficulty with English, and 33% did so if specifically asked. More than 80% of New York City pharmacies surveyed lacked systems to identify patients who need translated labels, or even to alert patients that translated labels are available; less than 10% had posted signs to inform customers that they could receive translated labels upon request.

"The lack of software to print labels in other languages is certainly one barrier, but even if that technology is available, pharmacy personnel may not be proficient with it," Dr. Zweber said. "And, of course, it may be uncomfortable for pharmacists to provide medication information that they cannot check for accuracy."

Additional discussion with pharmacists outside the survey context revealed that some had complaints about the mechanics of the translation, specifically that they cannot print 2 languages on a single label, according to Dr. Weiss. Because English instructions are required in New York State, they need to print the label twice to provide instructions in 2 languages.  

Alternatives to Translation Software

"Despite the gaps, there are pharmacists and pharmacies making good efforts to meet the language needs of their patients," Dr. Weiss said. "For example, some pharmacists, either lacking or distrustful of commercial translation software, handwrite translated instructions or have developed automated translation programs. Walgreens seems to be the leader at the chain level, with an impressive system for translating labels and providing multilingual counseling over the phone, and they're apparently testing a video component as well."  

Additional measures recommended by Dr. Zweber are that pharmacists identify a language barrier by asking open-ended questions during counseling, then make adjustments to the written material or use a trained interpreter to assist with verbal counseling. Many dispensing software programs can select a patient's preferred language.

Pharmaceutical companies often have printed or Web-based patient medication information in Spanish, if not other languages, but that information is not specific to any given patient's regimen.

"Since diabetes is prevalent in the Latino population, some manufacturers of brand-name diabetes medications will provide materials in Spanish," Dr. Zweber said. "Web-based information from pharmaceutical companies may be a practical way to disseminate information to patients and pharmacies; however, many pharmacies limit employee access to the Internet. A feasible way to provide directions in a language other than English would need to include electronic access to the materials."

In Dr. Weiss' survey, some pharmacists said they preferred to translate medication instructions verbally, rather than using printed labels, because they felt it was more personal. However, the survey showed that verbal information was sometimes provided by someone with inadequate language skills or lack of qualification in medication counseling. Three quarters of the New York City pharmacies surveyed had Spanish-speaking staff, but only 22% had Spanish-speaking pharmacists or pharmacy interns legally qualified to provide medication counseling in New York state.

Study Addresses Important Gap in Research, Awareness

"The most significant strength of the study is that it begins to address an important gap, not only in research, but in awareness," Dr. Weiss said. "It is obvious that comprehension of instructions is necessary for medication adherence and that LEP patients will not understand instructions written in English. Translation of instructions appears feasible, but few people are doing it, relative to need, and few people are calling attention to the problem."  

Methodological strengths of the study include use of a random sample and of a single, well-trained and carefully monitored interviewer; good response rate of 76.3%; and guidance by a multidisciplinary community advisory board with representation from pharmacy practice and education, medicine, nursing, health education, adult literacy, and immigrant rights, and from a wide range of New York City institutions.

Study limitations are that data were collected through a relatively brief telephone survey (shorter than 5 minutes), preventing probing any item in detail; and reliance on self-report, which most likely biases the findings toward overestimation of pharmacy translation practices.

"It would be worthwhile to further examine the barriers to providing language-appropriate services and study the outcomes of implementing a model system to ensure patients understand how to use their medications, regardless of their language," Dr. Zweber said.

Future Research Directions

Directions for future research cited by Dr. Weiss are to develop and evaluate a continuing education curriculum focused on language access; pilot intervention studies; confirmation of these findings by gathering data on actual practice rather than relying on self-report; and studying the implications of these findings, including medication adherence, errors, and adverse events among LEP patients.  

"Research on medication adherence suggests that medication counseling provided as part of medical care is very important," Dr. Weiss concluded. "Beyond that, internists and other providers should indicate on their prescriptions that the patient requires a translated label, they should inform their LEP patients that translated labels are available from many pharmacies and that they should ask for them, and they should ask LEP patients about language access in their neighborhood pharmacies so they can pass on that information to other LEP patients. Physicians working in or affiliated with hospitals that have outpatient pharmacies should advocate for adequate language access in those hospital pharmacies."

The Altman Foundation funded this study. Dr. Weiss and Dr. Zweber report no relevant financial relationships.

Society for General Internal Medicine 2007 Annual Meeting: Abstract 172022. Presented April 27, 2007.

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