July 25, 2024

By: Toni Shears

Patients with a Spanish language preference can ask for medication fact sheets and health information in the language of their choice at pharmacies and health centers, and they should get them. That’s the law. But will that information be clear and conveyed in a culturally relevant context? 

Maybe not, Beatriz Manzor Mitrzyk, Assistant Professor of Clinical Pharmacy, has found. With Ana I. Lopez-Medina and Karen B. Farris, they conducted a study assessing the effectiveness of the pamphlets and handouts commonly given to patients with depression and those who are prescribed antidepressants. 

The authors found that most study participants reported that on first pass the information in the handouts was easy to understand and useful, but after re-reading and being asked open-ended questions, they identified words that were confusing and concerning to them. A small but important share (10%) expressed concern or misunderstood phrases they felt reinforced stigmas associated with depression and antidepressants. The study was published in Health Education Research in March 2024.

Patient handouts for antidepressants include information meant to reduce such stigmas, says Dr. Manzor Mitrzyk, PharmD ‘92. These educational materials are intended to reassure patients that their condition is common, biologically based, and treatable. The English version may say, in effect, that “taking an antidepressant does not mean you are crazy,” she says. The study findings highlight a need to address the quality of translations and revise existing health information materials with greater attention to cultural and linguistic differences. 

This is a good example of when this information is translated literally from English to Spanish, nuances get lost, she said. “While we did not ask participants specifically, the disconnect between the perceived and intended meaning could be related to Spanish language grammar and self stigma.  With the Spanish language, word order is less fixed and adjectives can come before or after a noun. A reader may miss or misunderstand the “no” in front of the point being made. With stigma, persons might hear words that confirm the stigma much more clearly than words that counter it. That highlights the importance of culturally adapting health information materials and testing them with their intended audience.”

A case in point: information about the side effects of antidepressants might mention a change in sleeping patterns. The direct translation of “patron de sueño” means “pattern of dreams” in Spanish. Instead, Spanish speakers would say “falta de sueño” or “lost sleep.” 

Study participants initially said the handouts were useful and easy to understand, but follow-up questioning revealed gaps in their understanding. “When they re-read the information a little slower and we asked open-ended questions, we found they encountered words they didn’t understand,” says Dr. Manzor Mitrzyk.

When sharing health information with patients, best practices include confirming their understanding. For example, a caregiver can ask, “I just shared a lot of information and I want to be sure I did my job well. Can you tell me how you’ll take this medication once you’re at home? ”or “What are three things that you want to remember about this visit? These questions are not intended to quiz someone, but to reinforce understanding and identify possible gaps or misunderstandings and then help fill them in. 

 

Hearing a Need

Dr. Manzor Mitrzyk trained as a clinical pharmacist, then found her way back to research with a postdoctoral fellowship at the College in 2016. She studied pharmacogenomics in mental health disorders and medication adherence in special populations. Now an assistant professor, she uses a community-engaged research approach to investigate medication-related health disparities with a focus on depression in Latine populations. 

The daughter of Cuban immigrants, Dr. Manzor Mitrzyk recalls translating health information for her grandmother as a child. As part of her current role, she serves as a clinical pharmacist at Community Health and Social Services (CHASS), a federally qualified health center in Detroit. She also has served as a clinical pharmacist at the Michigan Medicine Ypsilanti Family Medicine clinic, where about a fourth of the population is Spanish-speaking. In these roles, she saw many cases where translation and cultural adaptation were essential. 

She has vivid memories of a patient she counseled who was hospitalized twice with recurring uncontrolled seizures. His medical team thought he was not taking the seizure medications as prescribed; he attributed the seizures to high blood sugar. Dr. Manzor Mitrzyk discovered that he and his caregivers, all Spanish speakers and readers, were misreading the medication instructions on the prescription labels, which were written in English. They thought they remembered the instructions given to him during the hospital discharge; but instead gave him half of the prescribed doses of his two anti-seizure medications. 

Patient experiences like this inspired her to do studies to assess patient understanding of health materials and to continue to investigate ways to improve access to Spanish language health education information that is easy to understand and culturally specific. 

The idea to study the comprehension of translated materials solidified after receiving a grant from the Eisenberg and Family Depression Center to conduct focus groups with Latine adults with depression. “We asked participants about their beliefs about antidepressant medications from the perspective of being Latino and, if relevant, they preferred to speak Spanish. We also asked about concerns they had when their doctor prescribed an antidepressant. Many participants reported they had never received a prescription medication label in Spanish. For those who had, the instructions and medication facts sheets provided by the pharmacy were still confusing to them. Many participants said they spoke some English. Even so, they didn’t understand all the words, and that scared them,” Dr. Manzor Mitrzyk recalled. The findings from these focus groups informed the previously described study.

“We felt these findings were important to share. It is alarming that we have known for decades that the number and complexity of words, the font size and formatting of written health information can make the difference between understanding and misunderstanding it. The examples used in the study were found in the majority of handouts we had collected during it. We could only analyze some sections of some of the handouts, so our research team and steering committee preselected sections considered to be the most confusing for patients.”

In the case of the medication fact sheets collected in 2022, “the copyright dates ranged from 2006-2019,” she points out. “I hope that these findings bring renewed attention to this issue. Following recommended best practices for written health information, which includes easy to understand information that is culturally adapted, has broad potential to improve an individual’s medication adherence. Furthermore, it is an important opportunity for community pharmacies to foster rapport with the Spanish-speaking community,” she notes.

 

A Gap That Fosters Health Inequities

A basic tenet of organizational health literacy is that healthcare systems supply “culturally responsive, language concordant” health information. When they don’t, health disparities arise or are exacerbated. 

When patients receive prescriptions with instructions they don’t completely understand, medications may be taken incorrectly, as in the case of Dr. Manzor Mitrzyk’s patient with seizures. When patients receive health information that is confusing or decreases their confidence in the treatment or healthcare professional, they may choose not to take that treatment or take it differently than prescribed, and their condition could worsen. These circumstances and outcomes could create or reinforce mistrust of the healthcare system and healthcare providers.

Understanding medication information is especially important for Latine individuals with mental health conditions, Dr. Manzor Mitrzyk says. For example, Latine individuals with depression may attribute their symptoms to a loss or traumatic event they experienced in the past. They may not understand how medication can help them feel better. Explaining the neurochemistry behind the causes and treatment of depression symptoms using appropriate terminology, collaboratively developing treatment goals, and offering different treatment options can help individuals make better informed decisions. 

“As an analogy, I might explain that a drug like Ozempic can help with weight loss because it acts on the neurochemicals that signal hunger. People know how tough it is to control blood sugar when you crave sugar and eat big portions, and they make the connection with how the drug will help with that. Likewise, an antidepressant treats the neurochemicals that are making sadness and other related symptoms persist and helps lessen them enough so they can begin to work through it,” she says. For some individuals, understanding this and being prepared for possible side effects is the support they need to start depression treatment. 

“The Latine and immigrant populations may have different views of health and how illnesses are treated from non-Latine or non-immigrants because of their beliefs, prior experiences, or lack of interactions with the US healthcare system,” Dr. Manzor Mitrzyk adds. “Even so, everyone wants good health. People from different places might go about taking care of themselves in a way that is more aligned with how they learned before they came to the US or how their parents taught them.”

 

A Deeper, Wider Look at the Problem within Community Pharmacy Services

Federal laws and policies require that health information be provided in the patient’s preferred language. Health systems and community pharmacies have software that can provide prescription medication labels, and written health and medication information in the most common languages spoken in the US. 

Dr. Manzor Mitrzyk is expanding her research to better understand the systemic and structural factors that might be responsible for the inconsistent provision of language-concordant and culturally specific written medication information.

“One reason might be a lack of awareness of the need for the information in Spanish,” she says. “We know that when there is a higher population of Spanish speakers and there are Spanish-speaking pharmacy staff, patients are more likely to get their medication labels and medication information sheets in Spanish. Community pharmacies should provide signage to indicate availability and a way to ask for language services, including access to a medical interpreter.

“One reason I think it may be a systemic issue is that the majority population or privileged group consists of people who speak English. Those in the minority group or people who do not speak or read English well aren’t able to get medication instructions or health information in their preferred language consistently and do not have access to resources like interpreters that are required by federal and state laws. There are loopholes in these laws and other barriers that could make language services an option and not a requirement. This language disparity happens in various pharmacies, in various locations, and inconsistently between and within pharmacies. This is a health disparity that is felt at an individual patient level. Findings from our focus groups suggest participants felt they were treated differently because they did not speak English and thought the reason they were not offered a label in Spanish was because they were perceived as not being American,” she says.

Results from another study found inconsistencies in the availability of language services from community pharmacies located within geographical areas with high and low proportions of Spanish speakers. Federal laws and policies around language services at community pharmacies appear to be implemented differently within community pharmacies and between pharmacies within the same retail chain.” She plans to explore these issues and the effectiveness of language and culturally specific written health information in future studies.

“The seriousness of the organizational health literacy-based issues identified in this and previous studies require that government and healthcare organizations make necessary and timely revisions to address them,” Dr. Manzor Mitrzyk concludes.