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

lsm2010@uw.edu