Not Lost in Translation: Interpretation and other drivers for health equity

Bob Gardner Healthcare Interpretation Network November 23, 2009 © The Wellesley Institute www.wellesleyinstitute.com

• from a resident participating in Wellesley community-based research in St James Town “Language is a big barrier to us whenever we use any services. When our doctor is on leave then we are unable to visit a different one due to language problem. So we may have to go to a walk-in clinic or emergency. There were no interpreter services. I do not know if they arrange them in hospitals. I couldn’t follow what the doctor said.” 2

• free and equitable access to high quality interpretation is: • crucial to breaking down barriers to good health care for disadvantaged and marginalized populations • an indispensable pre-condition for achieving equal opportunities for good healthcare for all-- especially in an increasingly diverse society • vital to other key components of an effective health system – from enhancing access to primary care, to preventing and managing chronic conditions and ensuring good quality, patient- centred care • building high quality interpretation services is a crucial element of an overall progressive health equity strategy 3

• starting points: • increasing diversity of population • pervasive health disparities • health equity strategy • bigger picture: health equity and social determinants • acting on health equity within the health system • building equity into all planning and delivery – highlighting some frameworks and resources for equity-focused planning • targeting some % of programs and resources for equity impact • where interpretation and language fit as key enablers of health equity • relating interpretation to other key drivers and enablers to move an equity agenda forward 4

• 41% of population in Toronto Central LHIN are immigrants (28% in Ont) • 8% of population in Toronto Central and 10% in Central arrived in last five years • more that half Central's population have a mother tongue other than English • digging down locally: 66% of residents in St James Town have a mother tongue that is neither English nor French. • 42% speak neither English nor French at home • 5% of Toronto Central’s population have no knowledge of English or French • digging down by population: more than 17% of seniors in Central do not understand English well or at all 5

• health disparities in Ontario – and in LHINs across the province -- are pervasive • there is a clear gradient in health in which people with lower income, education or other indicators of social inequality and exclusion tend to have poorer health • plus major differences between women and men • the gap between the health status of the best off and most disadvantaged can be huge – and damaging • in addition, there are systemic disparities in access to and quality of care within the healthcare system • those are the problems we are all trying to solve with health equity strategy and action 6

Diabetes Incidence, TC LHIN 2004/05 16 14 13.3 12 New Cases/1,000 10 8 5.8 6 4 2 0 Low Income High Income Two fold difference in Diabetes Incidence among lowest and highest neighbourhoods. Age Standardized Rates. Data Source: Ontario Diabetes Database, 2004/05 www.ices.on.ca/intool 12

• health disparities or inequities are differences in health outcomes that are avoidable, unfair and systematically related to social inequality and disadvantage • this concept: • is clear, understandable & actionable • identifies the problem that policies will try to solve • is also tied to widely accepted notions of fairness and social justice • the goal of health equity strategy is to reduce or eliminate socially and institutionally structured health inequalities and differential outcomes 14

• A positive and forward-looking definition = equal opportunities for good health • Health equity is a broad concept that also prioritizes diversity: • reflecting the increasing diversity of Ontario society and the fact that racism and ethno-cultural differences are important determinants of health disparities • recognizing that services that reflect and speak to the diversity of cultures -- cultural competence – are essential to an equitable system • Impact of achieving health equity would • extend far beyond enhancing individual and collective well being • would also contribute to overall social cohesion, shared values of fairness and equality, economic productivity, and community strength and resilience 15

• To reduce the scale and severity of disparities • Not only improving the health and health opportunities of the most vulnerable and disadvantaged • But benefiting people along the gradient: • the kinds of integrated comprehensive primary care needed by those with the most pressing and complex needs – will benefit all • reducing language and cultural barriers will benefit many newcomers and those who have difficulty receiving services in English, not just those who face the harshest health disparities 17

clear research consensus that roots of health disparities lie in broader social and economic inequality and exclusion real problem is differential access to these determinants – many analysts are focusing more specifically on social determinants of health inequalities 18

•Determinants interact and intersect with each other •In constantly changing and dynamic system •In fact, through multiple interacting and inter- dependent economic, social and health systems •Determinants have a reinforcing and cumulative effect on individual and population health 19

• everything can’t be tackled at once: • need to split strategy into actionable components and phase them in • but coordinate through a cohesive overall framework • timing is everything: • need to recognize that fundamental policy action on equity takes time – need patience and long view • pick some ‘quick wins’ -- issues and levers that will show progress and build momentum for action on equity • pick issues and direct resources to areas that will have the greatest equity impact • either in terns of meeting the health needs of most disadvantaged populations • or addressing most important barriers to health equity • need to start somewhere – and we’re in healthcare system – and you’re in one of most crucial equity areas 21

• even though roots of health disparities lie in far wider social and economic inequality • this doesn’t mean that how the health system is organized and how services and care are delivered are not crucial to tackling health disparities • many countries have been developing comprehensive multi-sectoral strategies to reduce health disparities • in all of them, transforming the health system is an indispensable element, including: • reducing barriers to equitable access to high quality care • targeted interventions to improve the health of the poorest fastest 22

• it is in the health system that the most disadvantaged end up sicker and needing care • equitable healthcare can help to mediate the harshest impact of the wider social determinants of health on health disadvantaged populations and communities • in addition, there are systemic disparities in access and quality of healthcare that need to be redressed • more vulnerable populations tend to have poorer access to health services, even though they may have more complex needs and require more care • unless we address inequitable access and quality, healthcare could make overall disparities even worse • at the least, the goal is to ensure equitable access to care for all who need it, regardless of their social position 23

Lower Income: More Physician Visits For Arthritis % With Physicia n Visits for Arthritis, Age 45-64, TC LHIN 2001-03 25 20 20 14 15 13 11 10 5 0 Low Income High Income Males Females Proportion of Residents with physician visits for Arthritis is higher in Lower Income neighbourhoods, especially females. Neighbourhood Income Quintiles Toronto Community Health Profiles Partnership, www.torontohealthprofiles.ca 25

Hip Replacement Rate, TC LHIN, 2004/05 144 150 #/100,000 100 68 50 0 Lowest Income Highest Income Despite poorer health and greater need/potential to benefit from diagnosis and treatment in lower income groups, the hip replacement rate is over twice as high in the highest income neighbourhoods. Age Standardized Rates. Total Hip Replacements per 100,000 Population by Neighbourhood Income Quintiles. .Source: Institute for Clinical Evaluative Sciences (ICES) November 2006 26

• broad social and healthcare provider consensus that discrimination between women and men is no longer acceptable • but research has shown that women are less likely than men to receive: • standard heart medication • dialysis treatment • admission to intensive care units • certain surgical procedures – cardiac catherization, kidney transplants, knee arthroplasty (replacement) • surgeons and referring physicians respond in surveys that sex of patient has no effect on their clinical decisions • so….. 27

to see if there were differences by gender in clinical practice • standardized male and female patients went to family physicians and orthopaedic surgeons • presented with the same scripted clinical scenario found striking differences: • orthopaedic surgeons were 22X more likely to recommend male for total knee arthroplasty than female • family physicians were 2X more likely for male Source: Borkhoff et al, CMAJ, March 11, 2008 28

• goal is to ensure equitable access to high quality healthcare regardless of social position • can do this through a two pronged strategy : 1. building health equity into all health planning and delivery • doesn’t mean all programs are all about equity • but all take equity into account in planning their services and outreach 2. targeting some resources or programs specifically to addressing disadvantaged populations or key access barriers • looking for investments and interventions that will have the highest impact on reducing health disparities or enhancing the opportunities for good health of the most vulnerable 29

• language is one of most crucial barriers to access to care • like most barriers it can be addressed through good policy and services → • need high-quality trained interpretation services available to all who need them -- where and when they need them • need flexible continuum of responsive and consumer- centred interpretation services • how to ensure interpretation services are available and accessible = crucial challenge for equitable and efficient system • high on Toronto Central LHIN agenda and on province’s 30

• addressing health disparities in service delivery and planning requires a solid understanding of: • key barriers to equitable access to high quality care • the specific needs of health-disadvantaged populations • gaps in available services for these populations • this requires good information • and effective and practical equity-focused planning tools 31

• a promising direction is to have providers undertake specific equity planning exercises designed to: • identify access barriers, disadvantaged populations, service gaps and opportunities in their catchement areas and spheres • develop programs and services to address those gaps and better meet healthcare needs of disadvantaged communities • these provider plans have the potential to: • raise awareness of equity within the organizations • more effectively build equity into planning, resource allocation and routine delivery • pull their many existing initiatives together into a coherent overall equity strategy • build connections amongst providers for addressing common equity issues • hospitals in Toronto Central and Central LHINs developed equity plans broadly meeting those objectives 32

http://www.torontoevaluation.ca/tclhin/index.html 33

• a very consistent theme was need to improve interpretation services and address language as a critical barrier → major project to develop more systematic coordinated approach to interpretation in downtown hospitals • this project initially arose out of Healthcare Interpreters Network • not just Toronto Central: one of identified equity challenges for North York General hospital in Central LHIN was language: • useful to hook up to Central on this – so many of these issues are at least GTA-wide • HIN could play a key role in this linking up 34

• e.g. for the language project • some jurisdictions – Oslo, Sydney -- are seen to be leaders in municipal-wide coordinated interpretation services • centralized services all providers can draw on • sometimes cross-sectoral – not just health • will see some other examples shortly of community- based initiatives that provide services in various languages as part of their core approach → • need to link community and institutional services into a coherent system or web of services • need to learn from each other and share resources 35

• all hospitals, agencies and CHCs sign Service Accountability Agreements with LHINs that govern flow of funds and provision of services • can build in specific equity expectations – will vary by community and provider -- but could include: • undertaking appropriate equity-focused planning • providing sufficient services in languages of community and appropriate interpretation • identifying areas where access to services is inequitable and developing plans to address barriers and gaps • ensuring service utilization matches appropriately with demography and needs of their catchment profile • developing specific services or outreach to particular disadvantaged populations – newcomers who don’t speak English well, homeless, isolated seniors, etc. 36

• need to define clear equity-focussed expectations: • all providers will deliver sufficient high-quality interpretation services to meet the needs of the people, communities and catchment areas they serve • then build requirements to meet these expectations – and targets and indicators to measure progress -- into performance management systems: • not just Service Accountability Agreements between LHINs and providers • accreditation requirements and processes • professional Colleges and other regulatory mechanisms 37

• for providers to meet these requirements, they will need to: • know the language needs of the communities they serve • this is far more than just the languages of those who come to them for services • also need to know who is not coming in because of language and other barriers = unmet need • and it doesn't mean just basic demographic data on languages spoken • it means what language people are most comfortable receiving care in • so demand/drive for accessible interpretation → built into performance mgmt → providers assessing community needs far better 38

• driving change through performance management will require better data on language and other needs of community • need far better social determinants type data across the health system • need to also collect data on service delivery • in addition to language needs • clients’ socio-economic and cultural background → contributes to building up better picture of community needs • impact of interpretation services – comparing re-admission rates, satisfaction, post-hospital recovery, infection, etc. → builds case for investing in interpretation • need to ensure interpretation practitioners and experts are at planning tables where equity-focused indicators and data collection systems are being worked out 39

• target services to specific areas or populations: • those facing the harshest disparities – to raise the worst off fastest • or most in need of specific services • or the worst barriers to equitable access to high-quality services • this requires sophisticated analyses of the bases of disparities: • i.e. is the main problem language barriers, lack of coordination among providers, sheer lack of services in particular neighbourhoods, etc. • which requires good local research and detailed information – speaks to great potential of community-based research to provide rich local needs assessments and evaluation data • involvement of local communities and stakeholders in planning and priority setting is critical to understanding the real local problems 40

• key things that worry EDs and CEOs: • reducing risk and enhancing safety • delivering high-quality care efficiently • meeting provincial priorities – wait times, mental health or diabetes, ALCs • access to interpretation underlies all of these system drivers: • poor communication between provider and patient due to language or cultural barriers can contribute to misdiagnoses and inappropriate prescriptions • inability to read or understand instructions can lead to medication errors → safety and cost implications • promising indications that good interpretation helps keep people out of hospital and gets them out sooner • aligning to such drivers and incentives = crucial to build support for interpretation strategy 41

• the Ontario Health Quality Council has identified a number of key features of a well-performing health system • equity and patient-centred high quality care are crucial features • communications and provider-patient relationship are crucial to quality of care • in an increasingly diverse society this means: • high quality care = culturally competent care • access to interpretation where, when and how needed is an integral part of quality, as well as equity 42

• chronic conditions – especially diabetes -- mental health, reducing ER wait times, etc. are all provincial priorities • equity is essential to meeting these priorities • e.g.. diabetes is particularly sensitive to social conditions and context • prevention and management programs cannot be successful unless they take account of social conditions and constraints – meaning SDoH in general • more specifically, support for self-management for diabetes and other chronic conditions has to be delivered in languages of communities to be effective • educational and other material has to be translated • simply so that medical issues are understood • but also because so much of enabling people to manage their own health is about culture and support – far more effective in language people are comfortable with 43

• there will be clear targets for provincial priorities such as diabetes and mental health → build equity into targets: • need to identify populations/areas where diabetes incidence is highest, and many of them are language or ethno-cultural communities → equity target = reduce differences in incidence, complications and rates of hospitalization between groups within a LHIN • similarly, systemic inequities in depression and other mental health problems → equity target = reduce those differences by language, ethno-cultural background and other determinants • many providers assess their services through consumer satisfaction surveys and similar methods • providers look for high and improving satisfaction → equity target = reduce any differences in satisfaction by language spoken, gender, income, ethno-cultural background, etc. 44

• very clear gradient in incidence – and impact – of chronic conditions • some populations and communities need greater support to prevent and manage chronic conditions → need to build these specific needs into CDPM planning and resource allocation • and that includes addressing language barriers and ensuing that all programs are culturally competent • a very interesting primer has been developed by Health Nexus, Ontario Chronic Disease Prevention Alliance and other partners to help incorporate social determinants into chronic care management and support http://www.ocdpa.on.ca/docs/Primer%20to%20Action%20SDOH% 20Final.pdf 45

• more emphasis on health promotion is vital to long- term sustainability of system and individual health • consistent data on variations of risk factors along the social gradient • anti-smoking, exercise and other health promotion programmes need to explicitly foreground the particular social, cultural and economic factors that shape risky behaviour in poorer communities– not just the usual focus on individual behaviour and lifestyle • need to customize and concentrate health promotion programs to social conditions and constraints of particular communities • and that includes addressing language barriers and ensuing that all programs are culturally competent • if this isn’t done → can unintentionally widen disparities as better off take up programs more 46

• assessing the potential equity impact of initiatives on particular populations requires solid understanding of that population's health situation, needs and context • this can benefit from ongoing community engagement with the population and/or specific community-based research or needs assessment • analyzing how to design services to meet specific barriers or population needs will also benefit from engaging the affected population • similarly, monitoring and assessing the impact of service initiatives also needs: • research and input from the affected population on impact • health outcome data stratified by population and determinants 47

• interpretation is never just about words, but culture • skilled high-quality interpretation is one part of ensuring culturally competent care • all part of inter-related changes needed to ensure inclusive health services and healthcare system • cultural sensitivity and competence – just as equity overall – need to be built into core fabric of daily service provision • so cultural competence and interpretation must be central to wider equity and diversity-focussed organizational and system transformation • and need to build on the many local community-based initiatives and front-line innovations who are doing just that 48

• peer ambassadors – local initiatives out of Toronto CHCs: • members of specific neighbourhoods or ethno- cultural communities are trained and supported • play roles such as helping others in their community navigate through health system or deliver health promotion programs • ambassadors often work within the language of the community/consumer • need to be well trained and supported 49

• potential in other provincial priorities – e.g. cancer screening: • cancer systems are good at treating people equitably once they get into programs • but not so good at screening – systemic disparities • generally its the more marginalized who are not screened – and those facing access barriers such as language → potential here also of peer/community ambassador types to enhance outreach and support to marginalized • MOHLTC is considering incorporating such a program into cancer screening initiative 50

• MiVIA (my Way) • personal electronic health record originally developed for mostly Hispanic seasonal farm workers in California – and then extended to other vulnerable populations • supports continuity and efficiency – highlighting the potential of eHealth for even the most marginalized • the web-based portal and records are in Spanish as well → helping to reduce language barriers • a vital element of success has been ‘promotores’ -- community/peer health promoters – who recruit people into the program, train them on the tools and support them in their own health management • all services are free 51

• Edmonton Multi-Cultural Health Brokers Cooperative • provides navigation, counselling and other support to people, who because of language or cultural barriers have trouble making their way through the health system • arose from a grass-roots recognition that these barriers were increasingly important but not being addressed • jointly developed by the local regional health authority, public health and other stakeholders • many of the brokers were internationally trained providers -- doing this work allowed them to use their skills and become familiar with the provincial system as they waited for recognition of their qualifications 52

• health brokers example highlights importance of advocates for equitable interpretation to support other progressive reform demands • streamlining assessment and integration for internationally trained providers could correct important injustice • would also help to enhance the capacity of the system to deliver professional care in more languages • language barriers often intersect with other lines of inequality: • for example, many people who do not have access to OHIP and who face terrible disparities as a result also face language barriers • HIN and other advocates for addressing language barriers can join with advocates working to ensure that lack of OHIP does not prevent people from getting vital care 53

• huge number of community and front-line initiatives already addressing equity – across this LHIN and province • + equity focused planning – through provider equity plans, HEIA or other tools -- will yield useful information on existing system barriers and the needs of disadvantaged populations, and on promising and successful programme interventions • we need to be able to: • collate and analyze all the useful intelligence gained from provider equity- focused planning • capture and share information on local initiatives, and build on local front-line insights • share the resulting knowledge across the LHIN – and beyond • assess most promising initiatives or directions • scale up promising initiatives across the province where appropriate 54

• ensuring equitable access to high-quality interpretation will help contribute to creating an equitable healthcare system by: • addressing barriers -- language and culture are among most important barriers to equitable access and quality of care • using available levers – how interpretation can be built into health providers’ incentives, expectations and requirement • aligning with system drivers – linking interpretation to system priorities like safety, quality, managing ER, ALC and other bottlenecks, risk management, mental health, chronic conditions • supporting opportunities for innovation • making connections – where building interpretation services intersects with – and underpins – an overall equity strategy 55

• back to bigger picture • following is a roadmap for comprehensive integrated policy action on determinants of health and health inequality 56

1. look widely for ideas and inspiration from jurisdictions with comprehensive health equity policies, and adapt flexibly to Canadian, provincial and local needs and opportunities; 2. address the fundamental social determinants of health inequality – macro policy is crucial, reducing overall social and economic inequality and enhancing social mobility are the pre-conditions for reducing health disparities over the long- term; 3. develop a coherent overall strategy, but split it into actionable and manageable components that can be moved on; 4. act across silos – inter-sectoral and cross-government collaboration and coordination are vital; 5. set and monitor targets and incentives – cascading through all levels of government and programme action; 57

6 rigorously evaluate the outcomes and potential of programme initiatives and investments – to build on successes and scale up what is working; 7 act on equity within the health system: • making equity a core objective and driver of health system reform – every bit as important as quality and sustainability; • eliminating unfair and inefficient barriers to access to the care people need; • targeting interventions and enhanced services to the most health disadvantaged populations; 8 invest in those levers and spheres that have the most impact on health disparities such as: • enhanced primary care for the most under-served or disadvantaged populations; • integrated health, child development, language, settlement, employment, and other community-based social services; 58

9 act locally – through well-focussed regional, local or neighbourhood cross- sectoral collaborations and integrated initiatives; 10 invest up-stream through an equity lens – in health promotion, chronic care prevention and management, and tackling the roots of health disparities; 11 build on the enormous amount of local imagination and innovation going on among service providers and communities across the country; 12 pull all this innovation, experience and learning together into a continually evolving repertoire of effective programme and policy instruments, and into a coherent and coordinated overall strategy for health equity. 59

• these speaking notes and further resources on policy directions to enhance health equity, health reform and the social determinants of health are available on our site at http://wellesleyinstitute.com • my email is bob@wellesleyinstitute.com • I would be interested in any comments on the ideas in this presentation and any information or analysis on initiatives or experience that address health equity 60

The Wellesley Institute advances urban health through rigorous research, pragmatic policy solutions, social innovation, and community action. 61

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Not Lost in Translation: Interpretation and other drivers for health equity

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Not Lost in Translation: Interpretation and other drivers for health equity — Presentation Transcript