If you can read this sentence, you may question the need to rethink the labels on medicine. But 53 per cent of Singaporeans aged 65 and above, who are not literate in English, will likely disagree with you.
Medicine labels - the sticker labels printed and affixed by hospitals, polyclinics, GP clinics and community pharmacies in Singapore on prescription medicine packets and bottles before they are dispensed - contain written information on the medicine alongside patient and healthcare institution or pharmacy details.
The Health Products Act mandates the provision of such labels while dispensing prescription medicines, and that they should be in English. Although there is no restriction on adding another language, most medicine labels are provided only in English.
A 2015 study conducted by Duke-NUS Medical School's Centre for Ageing Research and Education (Care) which examined 1,167 prescription medicine labels found that 81 per cent used only English. In 2020, a smaller study conducted on 113 labels found that 95 per cent were only in English.
While patients of any age who are not literate in English are likely to be challenged by such medicine labels, the issue is rather acute for older patients, as they are the largest users of prescription medicines for chronic diseases.
Take Mr Lee, 75, who has hypertension, diabetes mellitus and kidney disease, and cannot read English well. He often asks the pharmacy staff to translate and write the dosage and dosing frequency information in Chinese on the labels.
Medicine labels also contain precautionary information, which may be too complex to read and understand. Mr Lee relies on the pharmacy staff to explain it to him verbally in Mandarin and the onus is on him to retain and recall this information.
Difficulty in understanding medicine labels does have real consequences. In a 2020 study of 1,167 older adults, such difficulty led to uncertainty in the frequency of taking the medication among one in two older adults, which in turn was associated with medication non-adherence.
Evidently, there is a gap in the health system that needs to be filled. Older adults should be given access to written medicine information that they can read and understand. One strategy that is suitable for Singapore's multilingual society is to include another preferred official language, such as Chinese, Malay or Tamil, to medicine labels, in addition to English.
We posit four reasons why this system-level change is necessary.
1. Enable our growing senior population to understand their medicines better
Nationally-representative surveys conducted by Care show that the proportion of older Singaporeans reporting more than three chronic diseases has almost doubled between 2009 and 2017. Consequently, an increasing number of older adults are using long-term medicines daily.
The surveys also reveal that one in six older Singaporeans has polypharmacy - that is, taking five or more prescription medicines daily. Not understanding the multiple labels fully puts older adults at a greater risk of adverse drug reactions and makes taking medicine more challenging.
Pharmacy services should constantly evolve to serve the changing needs of the people. Our 2017 study has shown empirically that bilingual labels improve older people's understanding of medicine labels, compared with English-only labels. They reduce uncertainty and help older adults with their medication routines.
2. Empower older adults to manage medicines more independently
Family caregivers or domestic helpers play a key role in managing medicines for older adults. Caregivers are often relied upon to explain medicines in a preferred language or write the translated instructions on the labels, especially for older adults who are not literate in English.
However, family caregivers who are busy with work may not always be able to attend to medicine-related questions of those under their care. There is also a greater number of older adults living alone now - 10.8 per cent last year compared with 8.6 per cent in 2010.
Our ongoing study, Prescription Medication Label Improvement for Singaporean Elderly (Promise), reflects the strong preference of older adults and family caregivers for bilingual labels. For instance, Madam Ria, aged 68, said: "People will be able to really understand what the medicine is for if (the label was) written in their own mother tongue."
In our recent survey of 280 older adults that was part of the Promise study, nine in 10 agreed that bilingual labels should be provided for older adults. With bilingual labels, these patients will be empowered to better understand and take care of their medical needs independently.
3. Support pharmacy's role in patient education and counselling
Older adults seek the help of pharmacy staff to translate and write the medication information, such as dosing instructions and food instructions, on the label. The staff also explain to them verbally the precautions and possible side effects from the medication in the patients' preferred language. Given the limited "real estate" on labels, it would be impractical to pen all this translated information in the space available.
The time for medication counselling is short, and while ad hoc improvisations to labels are useful, they take up the time that could have been used for counselling the patients, such as discussions about medicine interaction and lifestyle modifications.
Currently, initiatives are in place to help patients with low literacy levels understand their medicines. Some public hospitals and clinics use medicine packets with pictograms depicting the different times of day the medicines should be taken.
These pictograms come with dosing frequency and food instructions in Singapore's four official languages. However, these initiatives are not embedded in routine counselling practice.
Implementing the use of bilingual medicine labels is an efficient way to address the language needs of older adults. Having standardised translations will also reduce human errors or inconsistencies associated with translations and handwritten instructions of drug information.
4. Offer a non-digital solution for older adults
A 2019 InfoComm Media Development Authority survey showed that only 58 per cent of older adults, aged 60 years and above, used the Internet. Filtering relevant information on medicine online can be tedious. These older Singaporeans continue to rely on physical medicine labels.
Despite the benefits of bilingual labels, implementing them may not be straightforward. There will likely be financial, logistical and administrative challenges.
For instance, an initial investment in developing accurate and standardised medicine information in the official languages will be required, and the existing hardware and software for printing bilingual labels will have to be replaced and adapted.
The label and font size also require careful consideration; poorly designed labels will impede legibility. One way is to use larger medicine packets or labels, or even fold-out labels, to accommodate the additional text. Printing an additional label, in the preferred language, as is done in some polyclinics (though only on demand) is another option.
As work is currently being done under the National Pharmacy Strategy, which is a plan to address pain points and challenges in pharmaceutical care delivery in Singapore, this is an opportune time to push for bilingual labels.
Rethinking how medications are labelled can go a long way to helping older Singaporeans learn more about their medications, keep track of their medical conditions and have more independence in managing their health.
Dr Rahul Malhotra is head of research at the Centre for Ageing Research and Education (Care) and an assistant professor at the Health Services and Systems Research programme, Duke-NUS Medical School. Tan Yi Wen is a senior research assistant and Sumithra Suppiah is a senior research associate at Care.