Dual Purposing of Interpreters to Increase Colorectal Cancer Screening in Vietnamese-Speaking Patients: Results
from a Pilot Study
Morales LS1, Dinoso-Ghods B2, Anderson-Sparks B3, Grafton J1, Jackson C4, Hoang L1
Author Affiliations: 1University of Washington, 2Kaiser Permanente Northern California, 3Group Health Cooperative, 4Harborview Medical Center
This work was supported by a Group Health Foundation Innovations Fund Grant
(co-PIs: Morales and Dinoso-Ghods)
Study Goal
To develop and pilot test a low cost intervention to increase colorectal cancer screening rates among patients with limited English proficiency by training interpreters with provide patients with CRC screening information.
Innovation
• Train interpreters to inform patients about CRC screening much as community health workers (“promotoras de salud”)
• Interpreters are similar to CWHs in many respects:– Knowledgeable about the community
– Linguistically and culturally concordant
• Interpreters are part of the current workforce– Reimbursement issues
• Efficient: allows providers to focus on other work while interpreter provides screening information
Background
• Nationally, 57 million speak languages other than English at home and 25 million have limited English proficiency (LEP)
• 5% of adults in US live in linguistically isolated households where no one > 5 years speaks English
• 1.2 million in Washington State speak a language other than English at home and 488,856 have LEP
Growth in Numbers of Individuals that Speak Languages Other than English at Home
WA Language Proficiency, 2013
Non-English
Speakers
Number LEP Percent LEP
Spanish 543,073 225,375 42%
Other Indo-European
Languages 259,800 69,886 27%
Asian and Pacific Islander
Languages 362,445 168,174 46%
Other Languages 70,610 25,420 36%
Total 1,235,928 488,856 40%
Source: American Community Survey, US Census Bureau
GH Language Services, 2011
• 49,075 encounters; increasing by ~20% per year past 4-5 years
• 9,300 members requiring interpreters
• Cost: $2.79 million
• Top five language: Spanish, Vietnamese, Korean, Cantonese, Russian
• Top five facilities: Capital Hill, Bellevue, Tacoma, Rainier Valley, Burien
Language Disparities in Care
Compared with non-LEP patients are:• More often defer needed medical care (Flores et al.,
2000)• Leave against medical advice (AMA) (Flores et al.,
1998)• Less likely to have a PCP or USC (Alpert et al., 1993)• More likely to have missed follow-up appointments
(Kirkman-Liff et al., 1991)• More likely to be non-adherent (Manson et al., 1988)• More likely to report fair or poor health (Kirkman-Liff
et al., 1991)
Disparities in CRC
Intervention Overview
• Develop partnership with interpreter agency
• Work with health plan leadership to develop script for interpreters; then obtain approval from clinical leadership
• Identify and recruit intervention clinic sites
• Develop training program and materials for interpreters
• Recruit participants
Intervention Manual (TOC)
• Project Overview
• Cancer Epidemiology
• Colorectal Cancer
• Appointment Process
• Prevention Message
• FIT procedure
• Other CRC Screening Methods: Flexible Sigmoidoscopy, Colonoscopy
Simplified and Translated Materials
English Vietnamese
Clinical Sites
• Burien Medical Center (intervention)
– 2,176 non-English encounters per year
– 588 Vietnamese language encounters per year
• Rainier Medical Center (controls)
– 2,481 non-English language encounters per year
– 993 Vietnamese language encounters per year
Study Participants
• Vietnamese-speaking patients receiving the intervention (cases)
• Vietnamese-speaking patients receiving usual care (control arm 1)
• Vietnamese English-speaking patients receiving usual care (control arm 2)
Participant Eligibility Criteria
• Age 50 years or older
• Scheduled with a Vietnamese interpreter
• Identified as needing CRC screening by clinical exception report
CRC Screening Workflow
Participant Characteristics
Cases (n=24)
Vietnamese-SpeakingControls (n=19)
VietnameseControls (n=20)
Age 50-64 17 16 18
65+ 7 3 2
Gender Male 10 4 10
Female 14 15 10
Charlson Score 0 15 14 14
1+ 9 5 6
6-Month Screening ResultsCases(n=24)
Vietnamese-Speaking Controls(n=19)
Vietnamese Controls(n=20)
FIT 21 10 7
Sigmoidoscopy 0 1 0
Colonoscopy 3 2 0
Any Screening 23 11 7
% Any Screening Rate 96% 58% 35%
Patient Survey (RR=80%; n=19)Variable Category Count
Years at GH <1 3
1-5 9
5+ 6
DK 1
Visits in past year
None 3
1-2 9
3+ 7
Variable Category Count
Birthplace Vietnam 19
Years in US >20 9
10-20 6
<10 4
LEP Yes 18
No 1
Education 0-6 years 6
7-12 years 12
13+ years 1
How satisfied were you with the interpreter on your visit to Burien
Clinic?
• Very Satisfied -19
• Somewhat Satisfied
• Somewhat dissatisfied
• Very Dissatisfied
On a scale from 0 to 10, how would you rate the interpreter you had at
Burien clinic?
|
15
|
4
How satisfied where you with the information provided to you about CRC screening by the interpreter?
• Very satisfied – 18
• Somewhat satisfied – 1
• Not satisfied – 0
Did the interpreter talk with you about using FIT?
• Yes – 18
• No – 1
Did the interpreter talk with you about sigmoidoscopy?
• Yes – 13
• No – 3
• DK – 1
Did the interpreter talk with you about colonoscopy?
• Yes – 14
• No – 3
• DK – 2
Did you have any questions about CRC screening after hearing what the interpreter had to say?
• Yes – 4
• No – 15
Did the interpreter give you enough time to ask all your questions?
• Yes – 4
• No – 0
How satisfied were you with the interpreter’s answers to your questions?
• Very Satisfied – 3 • Somewhat Satisfied – 1• Not Satisfied – 0
How much time did the interpreter spend talking with you about CRC
screening?
• <5 minutes – 3
• 6 to 10 minutes – 7
• 11 to 15 minutes – 5
• >15 minutes – 3
How confident were in the information the interpreter provided to you about
CRC screening?
• Very confident – 19
• Somewhat confident – 0
• Not confident – 0
Conclusions
• This intervention appears to be highly effective in increasing CRC screening among Vietnamese-speaking patients
• The intervention was well received by patients, providers and interpreters
• The intervention has the potential to be disseminated and adapted for other screening services and for other language groups
Discussion
• Trained interpreters working in health care systems may be able to serve multiple purposes, including promoting cancer screening.
• In this time of limited resources and a growing number of patients with LEP, interpreters may be an underutilized resource.
• Interpreter training programs may be adapted for other preventative healthcare procedures beyond colorectal cancer screenings.
Questions
Leo S. Morales, MD, PhD, FACP
Chief Diversity Officer
Professor of Medicine
Director, Center for Health Equity, Diversity and Inclusion
Co-Director, Latino Center for Health
UW School of Medicine