Language Access in Pharmacies

Linda Weiss, PhDThe New York Academy of Medicine

Emily M. Ambizas, PharmDSt. John’s University, College of Pharmacy and Allied Health Professions

New York State Conference on Increasing Language Access in Healthcare

April 2007

Presentation Focus The availability of prescription medication instructions

in languages other than English, including: Pharmacist provision of written prescription medication

information Counseling in languages other than English

Improving language access Methods for providing multilingual medication information Barriers to and facilitators of change

Will be discussing our recent research, as well as more general information on language issues in a pharmacy context

Language Access in NYS Pharmacies: Legal Considerations As recipients of federal funds in payment for medications,

pharmacies may be subject to the requirements of Title VI of the 1964 Civil Rights Act.

Pharmacies may be required to provide language access services to comply with the branding and counseling provisions governing pharmacy practice.

Branding: Medical labels or printed information must be rendered in a way that “is likely to be read and understood by the ordinary individual under customary conditions of purchase and use.”Counseling: A pharmacist or pharmacy intern providing prescription services shall be required to personally counsel each patient or person authorized to act on behalf of a patient.

Hospital-based pharmacies may be required to follow the directives of the NYS Language Access and Patients Rights regulations adopted in September 2006

NYS pharmacies are required to print labels in English. They can print labels in a second language as well.

New York City Demographics: Foreign Born and LEP

Approximately 2.9 million immigrants live in NYC, accounting for 36% of the City’s population

Currently, immigrants and their children account for nearly 2/3 of the NYC’s population.

More than 1 in 4 adults in NYC do not speak English at all or do not speak it well. Almost ½ of LEP New Yorkers live in homes where

no one speaks English well.

New York City:LEP by Neighborhood

Current Practice in NYC: Results from a Survey of Pharmacists Conducted a telephone survey of 200 randomly selected

pharmacies from a list of all NYC pharmacies (2100+) provided by the Office of Professions, NYS Education Department.

Interviews were conducted with a pharmacist on duty. Survey included questions on:

Frequency and language of LEP customers Languages spoken by pharmacy staff Ability to print translated medication labels and

leaflets Frequency of translations Other policies and practices regarding multilingual

medication information Interviews were conducted between February and

August 2006 and took about 5 minutes each to complete.

Pharmacist & Pharmacy Characteristics

Pharmacy Type Independent 119 (59.5%) Chain 71 (35.5%) Hospital outpatient 7

(3.5%) Clinic 3 (1.5%)

Pharmacist Birthplace USA/Canada/Puerto Rico 76 (38%) Africa/Middle East 10 (5%) Asia & Pacific Islands 75 (38%) Caribbean/S. America 11 (6%) Europe 20 (10%) Missing 8 (4%)

Limited English Proficient Pharmacy Patients

Pharmacist Self-Report Daily LEP, any language 176 (88%)

Daily Spanish 156 (78%) Daily Chinese 31 (16%) Daily Russian 27 (14%)

Less than daily LEP 14 (7%) No LEP customers 10 (5%)

Percent LEP in pharmacy census tract Mean 24.4% Median 22.3% Range 3.2% - 62.9%

Frequency of Translation of Written Materials

Sample with LEP customers daily (n = 176) Daily translation 63 (35.8%) Weekly translation 22 (12.5%) < Weekly translation 39 (22.2%) Never translate 44 (25.0%) Don’t know/missing 8 (4.5%)

Bivariate Associations with Daily Translation:Pharmacies with Daily LEP Customers (n = 176)

Characteristics

Pharmacist genderMale 1.00Female 0.62 (0.32,1.19)Missing

Pharmacist license date 2000-present 1.00

1990-1999 0.91 (0.40, 2.03)1980-1989 1.13 (0.41, 3.09)<1980 1.59 (0.63, 3.99)Missing

Pharmacist birthplaceUSA/Canada 1.00Africa/Middle East 0.71 (0.13, 3.84)Asia/Pacific Islands 2.70 (1.31, 5.56)**Europe 1.25 (0.43, 3.63)South America/Caribbean 0.36 (0.04, 3.16)Missing

Pharmacist positionOwner 1.00Manager 0.56 (0.24, 1.32)Staff 0.52 (0.21, 1.29)Other -- --Missing

Pharmacy typeChain 1.00Independent 7.06 (2.92, 17.05)**Hospital outpatient/Clinic 6.43 (1.47, 28.05)*

Daily LEP patients at pharmacya

Any language 1.00Spanish language 0.64 (0.25, 1.63)Chinese language 1.76 (.0.81, 3.86)Russian language 0.39 (0.15, 1.03)

LEP in census tract, mean % (range)Any language 1.05 (1.03, 1.08)**Spanish language 1.08 (1.05, 1.11)**Other European language 0.93 (0.88, 0.99)*Asian language 1.01 (0.99, 1.04)

* p < .05 in logistic regression

** p < .01 in logistic regression

Odds of daily translation

Pharmacies with daily LEP patients

Adjusted Odds for Daily Translation of Medication Labels

CharacteristicPharmacist birthplace

USA/Canada/Puerto Rico 1.00Asia/Pacific Islands 1.50 (0.64, 3.52)South America/Caribbean 0.15 (0.01, 1.97)Africa/Middle East 0.22 (0.03, 1.49)Europe 1.20 (0.32, 4.39)

Pharmacy typeChain 1.00Independent 4.08 (1.55, 10.74)**Clinic/Outpatient hospital 6.43 (1.27, 32.48)*

Pharmacy neighborhood characteristicsLEP in pharmacy neighborhood, Spanish speaking 1.09 (1.05, 1.13)**LEP in pharmacy neighborhood, other Eur. Language 0.99 (0.92, 1.06)LEP in pharmacy neighborhood, Asian language 1.03 (0.99, 1.06)

*p <.05 in multivariate logistic regression** p < 0.01 in mutivariate logistic regression

Adjusted Odds Ratio & (Confidence Interval)

Pharmacy Capacity to Provide Medication Information in Languages other than English

Most pharmacies (75%) have dispensing software with translation capabilities. 2 respondents said they developed their own translation software. 9 respondents said they handwrite the translations.

Main label 143 (71.5%) 24 (12.0%) 19 (9.5%) 159 (79.5%)Patient information sheet 103 (51.5%) 9 (4.5%) 8 (4.0%) 103 (51.5%)Warning label 88 (44.0%)

Yes 149 (74.5%) 28 (14.0%) 24 (12.0%) 177 (88.5%)By pharmacist 44 (22.0%) 23 (11.5%) 17 (8.5%) 86 (43.0%)By other staff 117 (58.5%) 6 (3.0%) 10 (5.0%) 133 (66.5%)

Telephone interpretationYes 27 (13.5%)No 172 (86.0%)

Verbal information in languages other than English

Translated labels & patient information sheets

Any LanguageRussiann (%)

Spanishn (%)

Chinesen (%) n (%)

Translated Medication Labels: Determining Who Gets Them

Can tell through interaction 108(54.0%) Language in customer record 20 (10.0%) Customer requests translation 66 (33.0%) Indicated on the prescription 14 (7.0%) Sign in pharmacy 15 (7.5%) Word of mouth 21 (10.5%)

Four pharmacists reported that translated labels are provided to all patients except those requesting English only.

Understanding Medication Information: Why it is important Information may be complex, including:

Dosing, frequency and duration Special instructions regarding food, liquids, and storage Side effects

Implication of medication errors: Reduced efficacy, side effects, drug resistance

The significance of prescription medications for treatment of illness: 1.3 billion medications were prescribed or provided during

medical visits in 2002 alone

Patients have day-to-day responsibility for medication management and recognition of adverse events

Efforts Made to Provide Information in Multiple Languages (more common)

Utilization of dispensing software with translation capabilities

Handwritten translated instructions Staffing with bilingual employees and/or

language study Telephone interpreting using language lines Telephone medication counseling by

bilingual pharmacists in other pharmacies On-line medication and health information

in multiple languages (e.g. walgreensespanol.com)

Efforts Made to Provide Information in Multiple Languages (less common & more costly) In-stores kiosks with health information in

multiple languages Video-based interpretation services

Direct video link between the patient and a remote translator

“Talking” medication bottles with verbal instructions

Barriers to Increased Language Access Pharmacists concerned about translating into languages

they don’t understand – concerned about liability if there is an error

Inadequacies in translation software Programs may only print one language at a time. May need

to print two labels to have English and a second language Translations may be awkward, not grammatically correct

Demands on pharmacists’ time are already very high. Some feel there is not time for translation

Shortage of qualified bilingual staff

Pharmacists attitudes and level of awareness

Planned Next Steps:

Continuing education classes for practicing pharmacists

Pilot interventions at selected pharmacies Review of label translations for accuracy and

reliability Outreach to LEP populations

Improvement in language access at pharmacies through:

Next Step Objectives

Availability and awareness of dispensing software with translation capabilities

Availability and awareness of telephone interpreting services

Inclusion of patient language preference in the patient profile

Signage and proactive efforts to inform patients of available language services

Increased:

Decreased: Use of “ad hoc” interpreters

Project Staff & Community Advisory Board Members

Emily Ambizas, St. John’s University, College of Pharmacy and Allied Health Professions

Elana Behar, The New York Academy of Medicine Tamar Bauer, Nurse – Family Partnerships Sebastian Bonner, The New York Academy of Medicine Olveen Carrasquillo, Columbia University Department of Medicine Francesca Gany, New York University School of Medicine Adam Gurvich and Maysoun Freij, The New York Immigration Coalition Holly Lee, Charles B. Wang Community Health Center Robert A. Mangione, St. John’s University, College of Pharmacy and Allied Health

Professions Priti Patel., St. John’s University, College of Pharmacy and Allied Health

Professions Peri Rosenfeld, Visiting Nurse Services of New York Elyse Rudolph, Literacy Assistance Center Linda van Schaik, Bellevue Hospital Center Lauren Schwartz, NYC Poison Control Center Karen Scott Collins, NYC Health and Hospitals Corporation Iman Sharif, Albert Einstein College of Medicine/Montefiore Medical Center Linda Weiss, The New York Academy of Medicine

------ Kate Liebman, Program Officer, Altman Foundation

Contact information:

Linda Weiss, PhDSenior Research AssociateThe New York Academy of Medicinelweiss@nyam.org, tel: 212-822-7298

Emily Ambizas, PharmDAssistant Clinical ProfessorSt. John’s University, College of Pharmacy

and Allied Health Professionsarweilee@stjohns.edu, tel: 718-990-2753