Leo Morales, MD, PhD, MPH, Professor and Chief Diversity Officer, University of Washington School of Medicine

1. 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)

2. 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.

3. 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

4. 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

5. Growth in Numbers of Individuals that Speak Languages
Other than English at Home

6. 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

7. 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

8. 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)

9. Disparities in CRC

10. 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

11. Intervention Manual (TOC)
• Project Overview
• Cancer Epidemiology
• Colorectal Cancer
• Appointment Process
• Prevention Message
• FIT procedure
• Other CRC Screening Methods: Flexible
Sigmoidoscopy, Colonoscopy

12. Simplified and Translated Materials
English Vietnamese

13. 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

14. 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)

15. Participant Eligibility Criteria
• Age 50 years or older
• Scheduled with a Vietnamese interpreter
• Identified as needing CRC screening by clinical
exception report

16. CRC Screening Workflow

17. Participant Characteristics
Cases
(n=24)
Vietnamese-
Speaking
Controls
(n=19)
Vietnamese
Controls
(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

18. 6-Month Screening Results
Cases
(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%

19. 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

20. How satisfied were you with the
interpreter on your visit to Burien
Clinic?
• Very Satisfied -19
• Somewhat Satisfied
• Somewhat dissatisfied
• Very Dissatisfied

21. On a scale from 0 to 10, how would
you rate the interpreter you had at
Burien clinic?
|
15
|
4

22. 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

23. Did the interpreter talk with you
about using FIT?
• Yes – 18
• No – 1

24. Did the interpreter talk with you
about sigmoidoscopy?
• Yes – 13
• No – 3
• DK – 1

25. Did the interpreter talk with you
about colonoscopy?
• Yes – 14
• No – 3
• DK – 2

26. 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

27. 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

28. How confident were in the information
the interpreter provided to you about
CRC screening?
• Very confident – 19
• Somewhat confident – 0
• Not confident – 0

29. 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

30. 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.

31. 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