Nkem P. Nonyel, PharmD, MPH, BCPS
Jennifer G. Smith, PharmD, BCPS
Imbi Drame, PharmD
Cultural competence/cross-cultural care
At the end of this activity, students will be able to:
- Identify health-related barriers for non-English speaking patient populations
- Discuss challenges that pharmacists may encounter when working with non-English speaking patient populations
- Propose strategies that pharmacists may use to overcome barriers when assisting non-English speaking patient populations seeking healthcare
- Identify resources that may be relevant for pharmacists when working with non-English speaking patient populations
Language barriers have been identified as a determinant of health and a risk factor for adverse events. In the United States, non-English speaking patient populations encounter several health-related barriers in managing the dynamics of transcultural or cross-cultural care. Patients may be uncomfortable or distrustful of healthcare professionals, whether from previous negative experiences, cultural differences in expectations, or lack of trust in the healthcare professionals or the system itself. Issues related to transitions of care, medication adherence, patient counseling, health literacy, health disparities, and healthcare access issues also exist. Examples may include misunderstanding of directions for taking medication, instructions or need for follow-up appointments, or disease state education. To address these language-related issues to advance health equity, improve healthcare quality, and eliminate healthcare disparities, the United States Department of Health and Human Services Office of Minority Health (OMH) developed national standards for ensuring the provision of Culturally and Linguistically Appropriate Services (CLAS).1
A systematic review of 14 studies within eight countries, which included 300,918 cross-cultural participants, studied the impacts of language barrier in healthcare. The researchers found that a language barrier between patients and healthcare professionals resulted in miscommunication, thereby resulting in dissatisfaction of both parties, decreased quality of healthcare delivery and patient safety, and increased the cost and time of care delivery.2 The authors concluded that the use of online translation tools (e.g., Google Translate and MediBabble) may improve not only patient and healthcare professional satisfaction but also the quality of healthcare, although it comes with an increase in indirect cost of care due to the additional interpreter services.2 On the other hand, practical experience has shown that these online translation tools are not always accurate and should be used with caution.
Pharmacists encounter variable challenges when working with non-English speaking patient populations, and these depend on the knowledge and self-efficacy of the pharmacist. Some pharmacists may feel uncomfortable or insecure with using medical translators to provide pharmaceutical care due to inexperience with the third-party communication. Pharmacists can become better equipped to overcome these challenges by gaining the skills and tools necessary for cultural humility when dealing with the non-English-speaking patient populations.
CC: “I’m here for my colonoscopy results”
HPI: XZ is a 50-year-old Chinese male (70 in, 87.5 kg) visits the GI clinic for a follow-up. A Chinese language interpreter assists with his encounter. The physician notes that during his last visit three months ago, XZ received a colorectal cancer screening, which was limited by poor colon preparation. Five polyps were found throughout his rectum. However, he was recommended for a repeat procedure in 6-12 months with better preparation. He currently has no concerning symptoms such as rectal bleeding or pain.
PMH: HBV infection with cirrhosis; AUD; overweight
- Father: HBV (chronic)
- Alcohol use (1-2 beers daily)
- Caffeine use (mostly green or black tea)
- Denies illicit drug use
- Smokes cigarettes (unable to ascertain quantity or frequency of use)
- Abdominal ultrasound three months ago: Suspected small polyp on gallbladder similar to exam one year prior; the liver was unremarkable in appearance
- Colonoscopy three months ago
ROS: XZ reports no changes since his last visit and no current complaints. He recently started a new job and has lost a few pounds.
- BP 136/93 mmHg
- HR 93 bpm
- RR 18/min
- Temp 97.8°F
- BMP normal
- CBC normal except platelets 115 thou/L (reference: 177-406)
|Type||Lab||Result (five months ago)||Normal range|
|Liver panel||Serum creatinine||1.05 mg/dL||0.6-1.2 mg/dL|
|GFR||74 mL/min/1.73 m2||≥60 mL/min/1.73 m2|
|Albumin||4.85 g/dL||3.2-5.5 g/dL|
|Total bilirubin||0.8 mg/dL||0.2-1.2 mg/dL|
|ALT||33 IU/L||0-55 IU/L|
|AST||25 IU/L||0-50 IU/L|
|Alk phos||52 IU/L||30-130 IU/L|
|HBV panel||HBV surface antigen||positive||negative|
|HBV viral DNA||Not detected||<10 IU/mL|
|Tumor marker||Alpha fetoprotein||3 ng/mL||0-8.3 ng/mL|
- Entecavir 0.5 mg tablet once daily
- PEG-3350/Electrolytes 236 gm as directed for colonoscopy
Additional context: XZ previously demonstrated very limited English proficiency and has notes in his chart requesting a Chinese interpreter at his visits. He occasionally had an English-speaking family member accompany him to clinic visits, but they were not always able to attend appointments. The patient often appeared more anxious during visits without his family member present, even though a medical interpreter was provided.
Also of note, the patient’s sister had a challenging and extended hospital stay approximately two years ago due to severe pneumonia and heart failure exacerbation. During her hospitalization, the family was concerned that she was not receiving appropriate treatment. They had difficulty obtaining information about her progress due to lack of consistent language interpretation services at the facility. The experience was frustrating for XZ and likely contributed to his development of a level of distrust of healthcare providers.
1. How might language create a barrier for XZ in achieving optimal adherence to his HBV regimen? To the colon preparation instructions?
2. What are potential outcomes if XZ is not able to fully understand instructions for medications and procedural instructions?
3. How should the pharmacist approach contacting XZ utilizing CLAS standards?
4. What role can a pharmacist play in addressing XZ’s poor adherence?
5. What are some best practices for communication via medical interpreter to ensure optimal patient care during the patient’s visit? What questions or preferences could the pharmacist discuss with a trained medical interpreter prior to meeting with a non-English speaking patient to better prepare for a patient visit?
Non-English speaking patients suffer the burden of language barriers including miscommunication and high cost of care due to additional services. Pharmacists must make conscious efforts to ensure healthcare equity for non-English speaking patient populations by seeking and implementing evidence-based strategies to minimize the negative medication-related impacts of language barriers for the non-English speaking patient populations.
Some pharmacists may lack the time to provide highly needed extended patient appointments or may be unaware of other available resources to improve quality of care for this population. Patients’ lack of health insurance, inadequate health insurance coverage, or access to other healthcare resources may affect the pharmacist reimbursement and discourage the provision of the additional services, including interpretation services to the non-English speaking patient population. Pharmacists can overcome these barriers by advocating for hiring staff from diverse language backgrounds, especially if the pharmacy serves patients from specific language communities.
Patient Approaches and Opportunities
Counseling non-English speaking patients effectively through a medical interpreter requires some adjustments. When possible, plan extra time for the interaction. Speak slowly and clearly but avoid yelling. Use short sentences to provide a manageable amount of information for translation and avoid use of complicated medical terms, slang, or abbreviations. Be aware of nonverbal communication and use a caring tone of voice and facial expression. Even if you do not understand the patient’s words, actively listen to the patient while he or she is talking. Similarly, speak to the patient and not the interpreter (e.g., “How can I help you today?” instead of asking the interpreter “How can I help her today?”). This is often difficult as our tendency is to look toward the interpreter, but addressing the patient directly helps reinforce the relationship with the patient and perception of care. As with all patients, use open-ended questions to ensure understanding, and when possible, use pictures or gestures to aid understanding.3
Along with the CLAS standards, Joint Commission standards require accredited hospitals to provide information in a way that patients understand, which includes providing information in their preferred language.4 Availability of in-person versus telephone or video interpretation varies, but healthcare providers should be aware of the resources available at their practice sites to ensure they can provide equitable care to patients regardless of their preferred language. Use of online or smartphone app-based translation may be helpful in emergency situations if no other service is available, but otherwise is discouraged, unless it has been designed and tested for reliable translation of medical information.
Pharmacists can play a key role in overcoming barriers encountered by non-English speaking patient populations seeking healthcare services. Commitment to ongoing cultural competence and awareness of these challenges are vital for providing high-quality care for non-English speaking patient populations.
Related chapters of interest:
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Communicating health information: hidden barriers and practical approaches
- Ethical decision-making in global health: when cultures clash
- Equity for all: providing accessible healthcare for patients living with disabilities
- The Sustainable Development Goals and pharmacy practice: a blueprint for health
- You say medication, I say meditation: effectively caring for diverse populations
- Experiences of a Caribbean immigrant: going beyond clinical care
- The great undoing: a multigenerational journey from systemic racism to social determinants of health
- Barnga. https://sites.lsa.umich.edu/inclusive-teaching/barnga/
- BaFa BaFa.
- United States Department of Health and Human Services, Office of Minority Health. Culturally and linguistically appropriate services standards. . Accessed December 16, 2020.
- Shamsi HA, Almutairi AG, Mashrafi SA, Kalbani TA. Implications of language barriers for healthcare: a systematic review. Oman Med J 2020;35(2):e122. .
- International Medical Interpreters Association. IMIA guidelines for working with medical interpreters. . Accessed December 7, 2020.
- The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. 2010. . Accessed December 7, 2020.