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Factors That Influence Medication Adherence in Non-English Speaking Patients

 

ABSTRACT

            This paper provides an overview and analysis of the factors that influence medication adherence in non-English speaking patients. It highlights the barriers to medication adherence and focuses on the barriers to medication adherence in non-English speaking patients. It examines a range of solutions that will help overcome the existing barriers to medication adherence among this group of patients. Analysis of the recent scholarly sources clarifies that the principal barriers to medication adherence in these patients are linguistic and cultural barriers.

            Patients with relatively low level of English proficiency, (e.g. immigrants from non-English speaking countries) have been found to be less adherent to scheduled ingestion of prescribed medication; whereas non-immigrants patients adhered better. The social factor has been found to act as a restrictive force to adherence. Cultural barriers also play a vital role in the non-compliant demographic, along with psychosocial factors such as fears, distrust, prejudice towards the Western medicine, and lack of provider’s interest into the perception and approach of the patients are all the more paramount to the fundamental aversion to medication adherence. Bridge building apparatus, such as interpreting services in hospitals, educational workshops and other measures would help remove the barriers. It has been also found that both parties of the process (the provider and the patient) need to improve their perception of personal accountability for adherence to medication.

Keywords: medication adherence, linguistic, cultural, perception

 

 

 

Factors That Influence Medication Adherence in Non-English Speaking Patients        Introduction

Patients with limited proficiency in English are more likely to face language barriers and miscommunication from their providers with a negligible ratio of shorter and less frequent patient-centered office visits than their English speaking counterparts. Patients’ race and ethnicity have been associated with physicians’ assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about the patients’ likelihood of risk behavior and adherence to medical advice. Language barriers may also exacerbate that misunderstanding and be used by the practitioners as an explanation to comprehend the misuse of prescribed drugs. The mutual response to race and ethnic relations may either aid or incapacitate the relationship between the health practitioners and the non-English speaking patients. Some may argue that non-English speaking patients who suffer from a mild to severe mental illness, such as depression may in part contribute to poor medication adherence (Klinge, 2001).

Prescriptions given by doctors and nurses are for the benefit of patients and usually given in relation to diagnosed illnesses. A drug becomes effective when used in strict compliance to the unadulterated doctor’s recommendations to maximize its efficacy in the healing process. Such realization in this forum becomes the focal driver to effective adherence to medication. It is undeniably indispensable for all patients to respect the instructions formulated by their physicians on the scheduled ingestion of prescribed medications. The main aim for all stakeholders is for a patient to recover from an existing condition. Generally, patients are advised to only obtain medications from an accredited medical institution and/or licensed medical doctor in order to avoid misdiagnosis, inadequate medications and abuse of drugs (Marsha et al, 2012). The purpose for this forum is to determine the factors that affect non-English speaking patients’ adherence to a medication regimen. Medication adherence is central to good patient outcomes. 

Definition of Concepts and Terms

The current relevant literature was searched by using the electronic databases CINAHL, Pubmed.  Key words and combinations searches included medicationadherence, linguistic barriers, cultural barriers, perception. Abstracts and journals were reviewed for relevance; reference lists from the obtained articles were also reviewed for any additional pertinent articles. Editorials, review articles, and abstracts were excluded.  This yielded 10 articles that were used for this review.

Medication Adherence and Non-Adherence

The intention of the use of the medications is to treat and cure diseases. However, in some instances, these medications may have adverse effect on patients if used improperly. According to Rocha (2012), the Federal Food, Drug and Cosmetic Act (FDA) provides the Joint Commission with lists of medications that health care providers can safely use to treat their patients. Researchers carry out many rigorous clinical trials to provide these safe and effective drugs. Drousel-Wood et al. (2010) suggested that throughout the clinical trial process, researchers need to keep in mind how difficult it may be for patients to take certain medications and to make every attempt to make them accessible and easy to use.

            Medications are more effective when taken as directed. Patients may fail to follow directions and be noncompliant for different reasons. Although patients may be educated on the importance of adhering to the medication regimen, they may still default. The term medication adherence has been commonly used since the 1970s by researchers and clinicians who need to describe the degree to which the behavior of the patients’ matches certain agreed medication recommendations or clinician’s instructions (Rocha, 2012).

As a case study, medication adherence has been the focus of research due to alarmingly low rates of adherence to prescribed therapies, especially among certain groups of patients. As a result, patients may not achieve anticipated medical progress. According to Dr. Yach, WHO’s Executive Director for Non communicable Diseases and Mental Health, lack of adherence to medication regimen prevents the full health benefits from being achieved (WHO 2012, p. 13). However if patients take the medications as prescribed, they would attain the goals set for improvement of population health.

Adherence problems arise in all situations when patients are required to self-administer the treatments, in particular with such diseases as asthma, diabetes, depression, HIV/AIDS, hypertension, tuberculosis, dependence on narcotic substances and tobacco. In the industrialized countries, on average, the rate of adherence to the prescribed medication therapy is fifty percent (50%), whereas in less developed countries the figures are much lower (Rocha, 2012).

            The manifestations of non-adherence to medication include: patient’s discontinuation of medication use, modification of restrictions and specific instructions, changing dosage amounts,  compromised regularity and/or time interval between dosage perturbing the rhythm and efficacy of the way the prescribed medicine should be taken; inclination to take someone else’s drug for an apparently common symptom, and contraindication of improvised compound of drugs for seemingly identical symptoms (e.g. use of old prescriptions, herbal medicines, drugs prescribed by different healthcare providers, etc…) (Jonathan, 2012).

 

Issues Contributing to Non-Adherence

Multiple factors may affect adherence to prescribed medications and treatment plans. Gilmer et al. (2009) cited the classification of factors of medication adherence suggested by Osterberg and Blaschke. It includes factors that impact both patients and providers. The patient level factors encompass such things as forgetfulness, intentional omission of prescribed doses, other priorities of patients, and emotional factors. As for the provider-level factors, these encompass such things as prescription of the complex regimen of medications, disregard for the lifestyle or economic resources of the patient, failure of the medical staff to explain side effects as well as benefits associated with the prescribed medication, and poor relationships between patients and providers (Gilmer et al., 2009).

            Non-adherence takes place intentionally or unintentionally. Reasons that are classified as intentional relate to personal attitudes, lifestyle choices, perceptions, while the demographic and economic status of people are classified as non-intentional reasons. Sorkin et al. (2008) found that medication non-adherence correlates to a set of factors including, sex, age, health status, as well as annual income. One common factor is chronic diseases. According to the data by WHO (2011), fifty percent of the population who have at least one chronic disease do not take their medications. How did they discover that? This would be a good place to stratify the study in order to collect data pertinent to the number of patients who were involved, their purpose for looking for medical assistance, demographic and socio-economic correlations from either a survey or an interview? Was its statistical significance scientifically compliant?

Across all groups of patients who do not adhere to scheduled ingestion of prescribed medications, age is a significant barrier. With the elderly, the declines in everyday functional capability make it hard for the older people to differentiate between tablet colors, remove child proof lids on medicines, read directions, and swallow the medication (Doggrell, 2010).

Financial problems is a common concern that non-English speaking migrants may face along with the U.S. citizens. Doggrell (2010) found that medicine’s high cost is a key factor why patients cannot procure and adhere to scheduled ingestion of prescribed medications. People who can pay out-of-pocket co-pays tend to be more adhering to medication than those with lower income. Little money prevents people from purchasing adequate medical insurances and use prescribed medicines.

Additionally, medication non-adherence has been found to be impacted by the use of multiple medication prescription. In the study carried out by Beusterien et al. (2008), it was reported that taking multiple medicines to treat every co-occurring medical illness increases the risk of non-adherence to prescribed medication. Pertinent material facts seem to have been omitted, (e.g. how many patients, how was it done, how many did not comply, etc…).Henriques, Costa, &Cabrita (2012) suggested that the elderly populations are not loyally taking their medications due to medical conditions. In cases where the elderly live at home alone, sometimes cause them to not remember if they have taken their medication earlier, later, a contraindicated extra dose, or not taken it at all. The elderly population sometimes have too many medications to take at one time and that could cause them to be involuntarily non-compliant. Quine et al. (2012) put forward that lack of adherence especially in anti-hypertensive medication cause more injuries to the patients and the health care system.

            Furthermore, depressive symptoms have been found as a significant barrier that prevented patients with hypertension from medication adherence (Krousel-Wood &Frohlich, 2009). The depression in these patients is thought to stem from adverse health outcomes, excessive use of healthcare resources, and poor life quality.

Cultural and linguistic barriers have been found to prevent certain minority groups from adequate medication adherence. Minority groups with limited English comprehension and low educational attainment are likely to experience the adverse effects of medication non-adherence most of all. Across all age groups, including the oldest, immigrants without knowledge of English and those for whom English is the second language have very low health literacy and are prevented from adequate medication adherence. For instance, language problems, as well as issues with health insurance coverage are typical barriers for Latino populations. This was confirmed in a study by Tripp-Reimer et al. (2001) in which it was found out that 34% of Latinos lack health insurance coverage and thus have to depend on out-of pocket payments for medications from their unreliable low incomes. They also reported that Latinos among other non-English speakers could not communicate effectively in English and this prevented access to health care.

Literature Review

Taylor et al. (2010) reported that patients of color are likely to suffer from language barriers as well as miscommunication with their healthcare providers, which prevents them from adequate adherence to medication. This is particularly true about Spanish-speaking patients: (51% versus 45%, p<0.05). This was reported on the 2166 Spanish speaking patients out of the 131, 277 patients from the Kaiser Permanente Northern California patients who were studied. The data was collected using probit models to study the effect of patient and physician ethnicity/ race and language adherence to cardiovascular disease medications after the patients’ as well as the physicians’ characteristics were controlled.

            Another factor is the subjects’ experience of having shorter and less primary symptom-centered visits to the physician and potential risk of being negatively perceived by their doctor (Traylor et al., 2010). Thus, negative physician perceptions are an additional factor, which influences how well the physician will assess the intelligence of a patient, will form affiliation towards the patient and shape certain beliefs about the likelihood of risky conduct, and will adhere to medication.

            Gilmer et al. (2009) compared the groups of Latino and Asian immigrants on the basis of their levels of English proficiency and rates of medication adherence.They found that Latino patients who had a higher level of English proficiency were less likely to adhere to schizophrenia medication treatments than those Latino patients with low levels of English proficiency were. On the contrary, among the Chinese patients who were prescribed antipsychotic drugs, those with higher level of English proficiency adhered better those with the lower of the English language knowledge. Besides, Latino and Asian patients with limited English proficiency were likely to be excess fillers. Caucasian patients were the most likely to act as excess fillers (20% vs. 15% for Latinos and 13% for Asians). Further, for both large groups of respondents with different levels of English, the probability of non-adherence increased with age, regardless of language proficiency.                          

Gilmer et al. (2009) found that Latinos with lower English proficiency, who better adhered to prescribed treatments, were less likely to get hospitalized and had better outcomes for their psychotic disorders compared to Latinos with the higher level of English proficiency. However, the researchers do not attribute this outcome solely to the language factors. Instead, they assume that these Latinos have better outcomes because of higher levels of social and familial support. “Family social support may serve as a cultural buffer, and family involvement in the client’s life and treatment plan may improve medication adherence and independently affect service utilization” (Gilmer et al., 2009). The language factor may not be the sole defining factor of medication adherence, but it goes along with familial and social support.

            Renfew et al. (2013) studied which factors acted as barriers to care for the patients of Cambodia origin who had diabetes. In a qualitative study, five focus groups were conducted with three study groups: frontline bilingual Khmer staff, Cambodian immigrants with diabetes, and health care providers. It was found that the quality of care for Cambodians was negatively affected by differences in cultural beliefs as well as barriers to language and health literacy. Psychosocial factors and patients’ fears impacted the quality of healthcare and is a challenge when interacting with the American healthcare system.

            Out of those, language barriers along with low levels of general and healthcare literacy were the key barriers to adherence. Clinicians reported inconveniences of interaction with the help of an interpreter. One cultural barrier that was reportedly important was deference to physicians and the Cambodians’ desire to please them. It was found that adherence to treatment plans was hampered by the psychosocial factors of fear of starvation (which has its roots in mass starvations under Khmer Rouge and prevents the patients from limiting themselves in eating) and close family interaction, where a few generations live in one household. It is hard for grandparents to get out to the healthcare center for a consultation, since they are caregivers to their grandchildren (Renfew et al., 2013).

Additional language barrier factors are the fears and challenges non-English speaking patients face while interacting with the American healthcare system. The Cambodian patients face difficulties when requesting for pharmacy related services especially during medication pickups and refills, which can be attributed to literacy and language barriers. Non-adherence to prescribed medication by non-English speaking patients may happen involuntarily, as a result of mistakes. Other fears include fear of medical procedures and distrust in relations to the clinicians and to the system of healthcare in general (Renfew et al., 2013).

            A special group of studies into the factors impacting adherence levels in patients with low levels of English proficiency targeted the elderly immigrant population of the Vietnamese and Chinese. In particular in the study by Johnson (2012), it was established that the Vietnamese American at the age of 65+ were likely to have poor medication adherence levels because of language barriers, lack of initiative between patients and prescribers to work out an agreement and high level of understanding of prescribed medications, poor health, and low income levels, as well as lack of counseling on the part of healthcare providers, education levels, and reliance on alternative medicine. Eighty-eight percent of the Vietnamese Americans aged over 65 years have little to no English fluency.  Similarly to the results of the previously discussed study into the factors affecting the Cambodian patients, the Vietnamese elderly patients turned out to have poor adherence levels due to their general mistrust in relations to the U.S. doctors and our healthcare as representatives of the Western medicine. Finally, lack of informative health services is a factor that affects the elderly Vietnamese patients’ adherence.

            In the study by Salt & Frazier (2011), the medication adherence barriers were researched with references to patients with rheumatoid arthritis. With this category of patients, medication adherence remains a considerable problem. In a cross-sectional descriptive study, based on self-reported data of 108 research participants, it was found that ethnicity was a crucial determinant of medication adherence: non-Caucasian (Hispanic and African-American) patients were 3-10 times less likely to be adherent to the medication that was prescribed. In addition, to ethnicity, living in remote rural areas was said to be a predictive factor of decrease adherence, along with the need to take multiple medications by prescription.

            Finally, being of Latino origin, with a low level of English proficiency, was found to be a factor of non-adherence among the subjects in the studies of Banta et al. (2009) and Compton, Haack, and Phillips (2010). In the study of Banta et al. (2009), Latino respondents were found to be less likely to adhere to prescribed medications in comparison with other ethnicities. Besides, the factors that affected the level of adherence were non-U.S. citizenship, low level of education, lack of insurance, lack of regular medical care, and younger age. Interestingly, binge drinking was not found to be a barrier to medication adherence.

            The qualitative study by Compton, Haack, and Phillips (2010), focused solely on Latino respondents and was based on the pharmacy in Des Moines, Iowa. It found that cultural influences and the language issue were not significant in preventing the Spanish-speaking respondents from medication adherence. This was explained by the fact that the pharmacy and medical staff who prescribed the medication were bilingual. So the respondents did not face difficulties in dealing with the prescribed medications and talking with the staff. Instead, chronic illnesses were found to be the factor that affected the adherence. Other factors named by the study subjects were “communication issues (i.e., content matter, such as when the prescription was ready), logistics, and limited hours of pharmacy operation as the primary barriers in picking up their medications” (Compton et al., 2010).

Solutions

Just as one of the factors to medication adherence is the language barrier, patients who do not speak English or with limited English proficiency will benefit from translations of medication instructions and detailed explanations of how to use them. Following the experience of the European countries, the United States is recommended to make available the medication information on multiple languages. This can increase medication adherence and will help prevent medical errors (Regenstein et al., 2013).

            Further, based on the study implications from Glenn et al. (2008), the services of interpreters should be made readily available in hospital, given the large percentage of families in the United States with limited English proficiency. Interpreters should be hired as regular, full-time staff or may be reimbursed by the third-party affiliates. Additionally, volunteer help is welcomed. This will make the basis for prevention of medication non-adherence through removal of cultural, communication barriers, barriers to empathic understanding on the part of clinicians and to distrust on the part of the non-English speaking patients. This will help provide the patients with detailed and comprehensible explanations for how to adhere to medication.

            Patients who live in rural and remote areas should be provided with the opportunity to get in touch with the medical professionals. Also, they should be educated by nurses and physicians as to how to take the prescribed drug and how to avoid non-adherence (Salt & Frazier, 2011).

            Involvement of non-English speaking patients in decision-making process as to the prescription of the medication and its application is a predictor of successful adherence. Physicians should be educated as to boost their cultural competence along with increasing health literacy for the patients. Bridging the gap in communication is possible through increasing providers’ cultural awareness of the non-English speaking patients they work with (Renfew et al., 2013).

 

Summary

This paper has provided an overview of multiple barriers to medication adherence faced by non-English speaking patients in the United States. Having carefully analyzed the up-to-date scholarly sources on the issue, key barriers to medication adherence include linguistic and cultural barriers. People with low level of English proficiency (immigrants) have been found less adherent to the prescribed medication, whereas Caucasian patients adhered the best. However, it is important to differentiate between different groups’ of immigrants and the impact of the language factor: Latino patients who are illiterate are more likely to adhere due to the powerful impact of other cultural factors (family and social support). With Asians, everything is different; their non-adherence is proportionate to their level of the English language knowledge.  Moreover, the social factor (family binds) acts as a restrictive force to adherence.

             Cultural barriers have been found to be very important, along with psychosocial factors, fears, distrust, prejudice towards the Western medicine, and of providers’ interest into the perception and approach of the person who is to be prescribed a medication. It has been found that interpreting services in hospitals would help remove the barriers. It has also been found that clusters of factors should be considered when looking into what impacts the adherence. These may include depression, poor health status, need to take numerous drugs, and low income. They are typical for all patients and can often be found in non-English speaking patients. Finally, it depends upon the nature of the illnesses and on the providers’ knowledge of their non-English patients to determine which factors are more impactful. Overall, both parts of the process need to improve their perception of personal accountability for both prescription of and adherence to medication. This should be followed by the practical measures described above.

 

References

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Beusterien, K. M., Davis, E. A., Flood, R., Howard, K., & Jordan, J. (2008).HIV patient insight conditions.Drugs & Aging, 27(3), 239-254.DC: U.S. Government Printing Office.

Doggrell, S. A. (2010). Adherence to medicines in the older-aged with chronic conditions.Drugs & Aging, 27(3), 239-254.

Drousel-Wood, M., Muntner, P., Islam, T., Morisky, D., & Webber, L. (2009). Barriers to and determinants of medication adherence in hypertension management: Perspective of the cohort study of medication adherence among older adults (CoSMO). Medical Clinics of North America, 95(3), 753-769.

Flores, G., Torres, S., Holmes, L. J., Salas-Lopez, D., Youdelman, M. K., &Tomany-Korman, S. C. (2008). Access to hospital interpreter services for limited English proficient patients in New Jersey: A statewide evaluation. Journal of Health Care for the Poor and Underserved, 19(2), 391-415.

Gilmer, T. P., Ojeda, V. D., Barrio, C., Fuentes, D., Garcia, P., Lanoutte, N. M., & Lee, K. C. (2009).Adherence to antipsychotics among Latinos and Asians with schizophrenia and limited English proficiency.Psychiatric Services, 60(2), 175-182.

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Jonathan, N. (2012). Adherence to medications among Vietnamese Americans 65 years of age and older.California State University Master’s Thesis.Retrieved from ProQuest database.

Krousel-Wood, M.,&Frohlich, E. (2010). Hypertension and depression: Co-existing barriers to medication adherence. Journal of Clinical Hypertension, 1(7), 481-486.

Regenstein, M., Andres, E., Nelson, D., David, S., Lopert, R., & Katz, R. (2012).Medication information for patients with limited English proficiency: Lessons from the European Union. The Journal of Law, Medicine, and Ethics, 40(4), 1025-1033.

Renfrew, M. R., Taing, E., Cohen, M. J., Betancourt, J. R., Pasinski, R., & Green, A. R. (2013).Barriers to care for Cambodian patients with diabetes: results from a qualitative study. Journal of Health Care for the Poor and Underserved, 24(2), 633-655.

Steadman, L., Thompson, S., &Rutter, D. R. (2012). Adherence to anti-hypertensive medication: Proposing and testing a conceptual model. British Journal of Health Psychology, 17(1), 202-219.

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Tripp-Reimer, T., Choi, E., Kelley, L. S., &Enslein, J. C. (2001). Cultural barriers to care: Inverting the problem. Diabetes Spectrum, 14(1), 13-22.