Language Access in Pharmacies

1. Language Access in Pharmacies Linda Weiss, PhD The New York Academy of Medicine Emily M. Ambizas, PharmD St. John’s University, College of Pharmacy and Allied Health Professions New York State Conference on Increasing Language Access in Healthcare April 2007

2. 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

3. 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.

4. 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.

5. New York City:LEP by Neighborhood

6. 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.

7. 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%)

8. 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%

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%)

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

11. Adjusted Odds for Daily Translation of Medication Labels

12. 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.

13. 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.

14. 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

15. 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)

16. 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

17. 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

18. Planned Next Steps: Improvement in language access at pharmacies through: • Continuing education classes for practicing pharmacists • Pilot interventions at selected pharmacies • Review of label translations for accuracy and reliability • Outreach to LEP populations

19. Next Step Objectives Increased: • 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 Decreased: • Use of “ad hoc” interpreters

20. 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

21. Contact information: Linda Weiss, PhD Senior Research Associate The New York Academy of Medicine lweiss@nyam.org, tel: 212-822-7298 Emily Ambizas, PharmD Assistant Clinical Professor St. John’s University, College of Pharmacy and Allied Health Professions arweilee@stjohns.edu, tel: 718-990-2753