Language barriers putting CALD patients at higher risk of medicine harm, PSA report finds.
Language barriers are putting culturally and linguistically diverse (CALD) Australians at heightened risk of medicine-related harm, a new PSA report has found.
A refugee teenager handed another patient’s antidepressant prescription, doubling his dose while believing it was acne medicine. A woman relying on more than 20 non-prescription products developed rhinitis medicamentosa from decongestant overuse. And a refugee discharged with a complex regimen for hepatitis C and HIV wasn’t taking any of his medicines because no one in his household could read the instructions.
These are just some of the real-world medicine misadventure examples identified in PSA’s newest medicine safety report, Medicine Safety: Culturally and Linguistically Diverse Community Care, which found that Australians from CALD backgrounds face significantly higher risks when it comes to safely accessing and using their medicines.
Launching the report at PSA26 this morning, PSA National President Professor Mark Naunton MPS put the scale of the problem in blunt terms.
‘It’s not just about accessing medicines – it’s how they’re used, and you can only use them safely if they’re understood,’ he said. ‘It’s rarely just a drug issue. It’s often a communication and systems issue.’
CALD communities experiencing high medicine use and polypharmacy
Australia’s population is changing. In 2021, more than 7 million people (27.6% of the population) were born overseas, with 22.8% of people speaking a language other than English at home.
Those numbers also translate into medicine use. In 2022, around 29% of all Pharmaceutical Benefits Scheme (PBS) medicine recipients were born overseas, with 13% speaking a language other than English at home, and 3% reporting limited English proficiency.
Among PBS recipients with limited English proficiency, nearly half (45%) were dispensed six or more different medicines in 2022.
While we often associate increased medicine use with older populations, the reverse has been observed in some CALD communities. Among people born in Asia, Africa and the Middle East, around 70% of PBS medicine recipients were of working age (18–64 years), with less than 20% aged 65 or over – meaning younger CALD populations may have different medicine information needs.
Divya Lal, PSA NSW/ACT State Manager and a community pharmacist of almost 20 years, told delegates at the Medicine Safety panel that pharmacists are often the one consistent point of contact these patients have with the health system.
‘We’re accessible. We’re the central point – whether they go to a GP, a specialist, an optometrist or a physio, at the end of the day they’re going to come to the pharmacy regardless,’ she said.
High-risk medicine use more common
The report flags particular concern around high-risk medicines. Among people born in Europe and those with limited English proficiency, 13% were dispensed antithrombotic agents. Opioids were dispensed to 19% of European-born individuals, 15% of those born in Africa or the Middle East, and 11% of people with limited English proficiency.
While both classes of medicines are associated with serious adverse effects – including bleeding, falls, sedation and overdose – access to multilingual, medicine-specific information is identified as a key gap.
Evelyn Pe, a bilingual health worker and Burmese interpreter, said even simple dosing instructions can be dangerously misread.
‘You say “twice a day” for the medication and pharmacists think everyone understands. But some people hear ‘two times’ and take it 2 hours apart. That’s very dangerous.’
Disadvantage compounds the risk
A compounding layer to medicine misadventure risks in CALD communities is socioeconomic disadvantage. Medicine use is higher in these communities, with two in five (42%) of PBS medicine recipients with limited English proficiency living in areas classified as the most disadvantaged – significantly higher than the 29% observed for the overall Australian population.
Preventative care is also less accessible, with people in disadvantaged areas more likely to rely on urgent or hospital-based care. These factors are evident in health outcomes, with almost half (41%) of people with limited English proficiency reporting fair or poor health.
Adherence is another concern: studies referenced in the report found that Arabic-speaking, Vietnamese, Indian and Chinese migrant populations with diabetes or hypertension have reported missed doses, delayed treatment initiation and discontinuation of prescribed medicines.
Ms Pe said it’s often fear, not just language, that keeps many patients from asking questions.
‘Some people believe that if they ask something wrong, they’ll be deported back to their country. That kind of fear stops them asking,’ she said.
Cultural stigma around mental illness adds another layer, she said.
‘In my culture, we don’t really have the [concept] of mental health. People believe it is a punishment from God,’ Ms Pe said.
Curtis Ruhnau MPS, a community pharmacist of more than 40 years and President of the Pharmacists’ Support Service, warned against over-relying on family members as interpreters – a common workaround when professional interpreters aren’t used.
‘A family member will, of course, filter any information we give through their own belief system before passing it on. Even using a trusted family member is a fraught thing.’
Home Medicines Reviews underutilised
While many people in CALD communities would benefit from a Home Medicines Reviews (HMR), the report found they are potentially underutilised, with community consultations revealing limited awareness of HMRs among participants.
The report recommends targeted strategies to increase HMR uptake, including culturally tailored referral pathways.
Dr Deborah Hillman-White, a GP working entirely in refugee health from her practice, Medeco Inala, told the panel she wants pharmacists brought into the process far earlier before problems reach crisis point.
‘You’ve got Abdul here on 18 different medicines. Is this needed? How about we do an HMR?’ she said.
PSA’s five recommendations
The report sets out five recommendations, to be implemented as a matter of priority, to ensure equity of access and improved support for CALD people:
- Embed culturally responsive communication and interpreter use as standard care
- Strengthen pharmacist-led medicine review services
- Improve data collection and monitoring
- Expand access to culturally appropriate medicines information
- Integrate cultural safety into pharmacist education and practice standards
Pharmacists also have a broader role in health system navigation – facilitating referrals, connecting patients to interpreter services and contributing to preventive care through vaccination and health screening.
Community consultation participants specifically valued pharmacists as accessible and approachable, with people willing to travel further to access a pharmacy where staff spoke their first language.
Upon reading the report, Mr Ruhnau said it was a confronting but valuable exercise, even after decades in the profession.
‘I realised how many things I’ve got wrong over the last 40-odd years. We don’t have to keep making those mistakes one at a time. We can learn from this together, so we can build better, together,’ he said.
Ms Pe’s advice to fellow pharmacists was simply to slow down.
Just take 2 or 3 extra minutes to explain the medication – what it’s for, whether it needs to be taken with food. That little bit of extra time changes everything.’
