Abstract
Medication adherence is a major public health concern that results in poor health outcomes and significantly increased health care costs. Medication nonadherence rates appear to be higher in non-white patients, including Latino patients. Spanish-speaking patients may receive insufficient care and incur greater negative health outcomes because of language barriers, and medication nonadherence is a contributing factor to this problem. The effect of language barriers on medication adherence will be discussed as well as practitioner considerations for addressing the challenge.
‘Poor adherence is a major public health concern that results in poor health outcomes and significantly increased health care costs.’
When medications are necessary in the prevention and treatment of disease, medication adherence is a key mediator in achieving successful outcomes. Poor adherence is a major public health concern that results in poor health outcomes and significantly increased health care costs. A study by the National Association of Chain Drug Stores found that for every 100 prescriptions written, around 50 to 70 are actually taken to a pharmacy of which only 48 to 66 are filled and go home with the patient. 1 Furthermore, once the prescription is in the possession of the patient only, 25 to 30 are taken properly and just 15 to 20 are refilled as prescribed.
Adherence is complex and multifactorial, but nonadherence rates appear to be higher in non-white patients, including the Latino population. This trend in non-adherence in the Latino population has been identified across the lifespan and as well as in the management of several specific disease states, including chronic conditions such as depression, cardiovascular disease and asthma.2-4
More than half of the total US population growth between 2000 and 2010 was because of an increase in the Latino population. 5 With the Latino population comprising the second largest ethnic group in the United States, it is important that the health care system adjusts to meet the needs of a rapidly changing treatment demographic. Of the 37.6 million people residing in the United States who report speaking Spanish in their home, nearly 47% indicated they speak English less than “very well.” 6 Spanish-speaking patients may receive insufficient care and incur greater negative health outcomes because of language barriers and medication nonadherence is a contributing factor to this problem.
Language Barriers to Medication Adherence
Language is a significant barrier to medication adherence in the Spanish-speaking population. Lack of language concordance between physician and patient is associated with a higher likelihood of miscommunication and shorter, less patient-centered office visits. 7 Spanish-speaking patients with poor English skills are less likely to receive medication side effect information from their physicians and are more likely to have adverse reactions to medications because they do not understand the instructions for medication use.8,9 A large observational study in Northern California assessed the effect of patient and physician race/ethnicity and language concordance on adherence to cardiovascular disease–related medications. 10 The study found that overall adherence in the Latino population (49%) was significantly lower than in Caucasian patients and that Spanish-speaking patients were less likely than English-speaking patients to be in good adherence (51% vs 57%, respectively). This particular study found that only 24% of Spanish-speaking patients were linguistically concordant with their doctors. Language concordance with the physician was associated with improved medication adherence (51% vs 45%), while race/ethnic concordance had no effect on adherence rates.
A second study assessed the effects of ethnicity on adherence to psychotropic medications. 3 One of the study’s secondary findings suggested that while medication adherence was lower in monolingual Latinos than Caucasians, adherence was not statistically different between bilingual Latinos and Caucasians. The authors hypothesized this difference may be due to differing levels of acculturation but caution the interpretation of the findings, because of the small sample size.
Language barriers encountered at the pharmacy can also affect medication adherence rates in the Latino population. While most pharmacies carry software capable of translating medication instructions to Spanish, the accuracy of these translations has been called into question. A study of pharmacies in the Bronx, New York (a county in which 44% of residents are Spanish speaking) found that only 73% provided medicine labels in Spanish. 11 These labels were most commonly generated through translation software (86%), followed by translation through lay staff members (11%) or through a professional interpreter (3%). Of the 76 medicine labels assessed in the study, 32 contained incomplete (containing both Spanish and English words) or inaccurate translations. Six labels included misspellings or grammatical errors. This resulted in an overall error rate in label translation of 50%. While these labels were generated for the purpose of research only, the errors could contribute to nonadherence to medications and are potentially harmful when applied to medications with narrow therapeutic indices.
A second pharmacy-based study found that only 44% of Latinos with limited English proficiency receive written medication information in Spanish when they pick up a new prescription from their pharmacy and only 47% received medicine bottles labeled in Spanish. 12 The same study found that patients who used an interpreter at the pharmacy were more likely to receive important medication counseling, including the purpose of the medication and information on adverse effects.
In the United States, 17.9% of pharmacies report employing one or more full-time Spanish-speaking pharmacists and 35.6% report employing one or more full-time Spanish-speaking technicians. 13 These statistics indicate there is still a great need for better resources to our Spanish-speaking patients.
Practitioner Considerations
Patients are more likely to adhere to both medical advice and drug regimens if they trust the health care system, feel an affiliation with their providers and are capable of having open and effective communication with their providers.14-16 Each of these variables can be addressed by having more Spanish-speaking individuals embedded within the health care system. It appears as though patient–provider race/ethnicity concordance does not play a role in medication adherence but language barriers do. Having translators or interpreters available to assist in patient counseling is one way of overcoming this challenge, especially in the case of monolingual Latinos and Latinos with limited English proficiency.
Pharmacies also need to find better ways of translating medication information to the Spanish language. Prescription software systems need to become more sophisticated in their translating accuracy for medication labels and pharmacy staff need to be more diligent about providing written medication information in Spanish to patients with limited English-speaking skills.
Because medication adherence is a problem, even in the Caucasian population, incorporating global strategies to promote adherence on the part of the practitioner is also of paramount importance. Outside of differences in language, the most common reasons for medication nonadherence include drug regimen complexity (number of medications, frequent dosing), denial of illness, poor comprehension of the benefits of taking the medication and medication costs. Providers should attempt to simplify the patient’s regimen, keep medication costs to a minimum, ensure the patient’s understanding of the benefits of treatment, and involve the patient in making treatment decisions.
Conclusions
The United States treatment demographic is rapidly changing and Latino patients have become the second largest ethnic group in the country. Medication nonadherence presents a significant challenge to our health care system and is more prevalent among Latinos. Language barriers play a large role in this problem. It is important that we address nonadherence through incorporation of strategies that target this population. Examples include increased access to Spanish-speaking translators throughout the health care system, improved computer-generated translation software, and increased use of written Spanish medication information within the pharmacy.