it’s not what you say, but how you say it. terri richardson, m.d. african american center of...
TRANSCRIPT
It’s not what you say, but how you say it.It’s not what you say, but how you say it.
Terri Richardson, M.D.Terri Richardson, M.D.African American Center of Excellence
Kaiser Permanente ColoradoMarch 12, 2013
Linguistic Congruence for Linguistic Congruence for African Americans..African Americans..
8th National Conference on Quality Health Care for Culturally Diverse Populations
Linguistic Congruence ProjectLinguistic Congruence Project
•Introduction Kaiser Permanente Health Disparities
•Background General Project Concept
•Project Design Hypothesis Linguistic Palette Focus groups
•Results
•Next steps
•Introduction Kaiser Permanente Health Disparities
•Background General Project Concept
•Project Design Hypothesis Linguistic Palette Focus groups
•Results
•Next steps
IntroductionIntroduction
Kaiser Permanente(KP), founded in 1945, is a comprehensive, integrated managed care organization (federally qualified HMO).
•KP provides health care services for its members using doctors and facilities located within a specific geographic region. •Has state of the art electronic health records that are used in the clinical setting as well as for population disease management.•The electronic medical record insures that self identified race, ethnicity, and language preference is embedded in the medical record.
Kaiser Permanente(KP), founded in 1945, is a comprehensive, integrated managed care organization (federally qualified HMO).
•KP provides health care services for its members using doctors and facilities located within a specific geographic region. •Has state of the art electronic health records that are used in the clinical setting as well as for population disease management.•The electronic medical record insures that self identified race, ethnicity, and language preference is embedded in the medical record.
IntroductionIntroduction
Health Disparities have existed for decades. Elimination of disparities will take a multitude of approaches, both large and small. Improving or enhancing cultural appropriateness is one measure that has been utilized.
Goode, et al note that cultural and linguistic competence are critical components of quality and effective care in relation to health outcomes and well-being.
Health Disparities have existed for decades. Elimination of disparities will take a multitude of approaches, both large and small. Improving or enhancing cultural appropriateness is one measure that has been utilized.
Goode, et al note that cultural and linguistic competence are critical components of quality and effective care in relation to health outcomes and well-being.
Our hope is to achieve cultural “competency” in every aspect of the health environment for
the present and future generations.
IntroductionIntroduction
• (AACE) formed in 2007 to address health disparities
• Learning laboratory
Linguistic Congruence ProjectLinguistic Congruence Project
Background• Idea was formed as AACE examined the cultural
aspects of HTN IVR outreach.• Review of the literature revealed no evidence.
– Lots of literature on linguistic profiling in the housing arena.
• Decided to take a positive spin on the uniqueness of the African American voice.
• Created the NOVELNOVEL approach
Informal Community Focus Group ResultsInformal Community Focus Group ResultsPalette-men, womenPalette-men, women
• Participants did not view as stereotyping.• Participants validated the importance of
linguistic congruence for African Americans.• Participants applauded efforts to customize or
tailor outreach.• Participants felt included, “inclusiveness is
important”.
Linguistic Palette Concept TestingLinguistic Palette Concept Testing
44
46
48
50
52
54
56
%unscreened
White
Black
Latino
Colorectal Cancer (CRC) Screening FocusColorectal Cancer (CRC) Screening Focus
In 2008, KPCO initiated a region-wide IVR CRC screening outreach. Completion rates were lower in KPCO’s African American members.
From the LiteratureFrom the Literature
African Americans:Factors that contribute to screening differential:
• Lower educational/SES• Reduced access to
screening• Language or
acculturation barriers• Fear• Medical mistrust• Lack of knowledge about
screening
CRC Screening Background InformationCRC Screening Background Information
• Diagnosed at later stages
• Lower survival rate
• Greater likelihood of dying when diagnosed
CRC Screening BackgroundCRC Screening Background
Purnell, et al suggest that traditional cultural orientation, group susceptibility to CRC screening, and medical mistrust should be considered when developing behavioral interventions to increase screening among African Americans.
Purnell, et al suggest that traditional cultural orientation, group susceptibility to CRC screening, and medical mistrust should be considered when developing behavioral interventions to increase screening among African Americans.
KPCO CRC Linguistic Congruence PilotKPCO CRC Linguistic Congruence Pilot
Hypothesis
Using a congruent voice for colorectal screening automated outreach calls will engender trust and ultimately improve screening outcomes.
Purpose
- Develop an appropriate linguistically congruent IVR CRC outreach call.
- Conduct a qualitative evaluation to validate the approach and facilitate development.
Hypothesis
Using a congruent voice for colorectal screening automated outreach calls will engender trust and ultimately improve screening outcomes.
Purpose
- Develop an appropriate linguistically congruent IVR CRC outreach call.
- Conduct a qualitative evaluation to validate the approach and facilitate development.
KPCO CRC Linguistic Congruence PilotKPCO CRC Linguistic Congruence Pilot
Project Design
• Creating the “evidence base”
• Phase 1: Member survey and focus groups
Understand how qualities of the voice effect trust, understanding, motivation, or other factors that influence screening rates
Assess voice preference
Determine Phase 2 feasibility, design, implementation, & measurement
Project Design
• Creating the “evidence base”
• Phase 1: Member survey and focus groups
Understand how qualities of the voice effect trust, understanding, motivation, or other factors that influence screening rates
Assess voice preference
Determine Phase 2 feasibility, design, implementation, & measurement
KPCO CRC Linguistic Congruence PilotKPCO CRC Linguistic Congruence Pilot
Focus groups•Target: 5 groups (4AA + 1 mixed race)•Standard facilitator guide•AA female facilitator and note taker from the community (non-KP).
Demographic Questionnaire•Determine important characteristics and typical participation in preventive screening.
Focus groups•Target: 5 groups (4AA + 1 mixed race)•Standard facilitator guide•AA female facilitator and note taker from the community (non-KP).
Demographic Questionnaire•Determine important characteristics and typical participation in preventive screening.
KPCO CRC Linguistic Congruence PilotKPCO CRC Linguistic Congruence Pilot
• A standard script from the existing CRC automated calls (approximately 1 minute in length) was utilized by all voice talents.
• Voices were all female since standard practice voice is female:
1 standard Caucasian1 lightly accented Latina3 African Americans with varying degrees of ethnic flavor.
• A standard script from the existing CRC automated calls (approximately 1 minute in length) was utilized by all voice talents.
• Voices were all female since standard practice voice is female:
1 standard Caucasian1 lightly accented Latina3 African Americans with varying degrees of ethnic flavor.
CRC Linguistic Palette CRC Linguistic Palette
Linguistic PaletteLinguistic Palette
Demonstration
Write down your top 1 and 2.
Demonstration
Write down your top 1 and 2.
1 2 3 4 51 2 3 4 5
KPCO CRC Linguistic Congruence PilotKPCO CRC Linguistic Congruence Pilot
Focus Groups•6 total, ranged in size from 4-7 participants•33 TOTAL KPCO members•All African American•Male and female, females > males•Ages 50-76•Denver, Aurora
82% listed phone as best way to reach
Focus Groups•6 total, ranged in size from 4-7 participants•33 TOTAL KPCO members•All African American•Male and female, females > males•Ages 50-76•Denver, Aurora
82% listed phone as best way to reach
Focus Group ResultsFocus Group Results
What did the members say?
What did the members say?
It’s not what you say, but how you say itIt’s not what you say, but how you say it
*Same, standard script *
•Commented on rhythm, tone
• Some participants perceived:
•More personalized message
•More information given
•“Emphasized the positive”
*Same, standard script *
•Commented on rhythm, tone
• Some participants perceived:
•More personalized message
•More information given
•“Emphasized the positive”
Disliked Voices 1 and 2Disliked Voices 1 and 2
“Would have made me hang up on them.”“Sounds like a telemarketer.”“Too scripted.”“Overly rehearsed.”“Sounding like a machine.”“Zero sincerity.”
Other concepts: sounded too young, unpleasant tone, not understandable, not motivating to action.
“Would have made me hang up on them.”“Sounds like a telemarketer.”“Too scripted.”“Overly rehearsed.”“Sounding like a machine.”“Zero sincerity.”
Other concepts: sounded too young, unpleasant tone, not understandable, not motivating to action.
Liked African American VoicesLiked African American Voices
“ It sounds like a familiar voice.”
“It would make me think about calling my doctor to get more information.”
“..Personable tone. Sounded like my mother.”
“Sounded mature.”
“I liked the tone in her voice, she was specific, like she had empathy for me.”
“Talked to me, not at me.”
“ It sounds like a familiar voice.”
“It would make me think about calling my doctor to get more information.”
“..Personable tone. Sounded like my mother.”
“Sounded mature.”
“I liked the tone in her voice, she was specific, like she had empathy for me.”
“Talked to me, not at me.”
Voices 3 and 4Voices 3 and 4
Voice Did MatterVoice Did Matter
AA voices 3 & 4 were most appealing and strongly preferred by the FG participants.
Voices 3 & 4 would most motivate them to continue to listen to the automated message.
Voices 3 & 4 were considered most trustworthy(recognized as AA). Most trusted V4 and especially V3.
Voice 3 was identified as most motivating to move participants to action( screening)
AA voices 3 & 4 were most appealing and strongly preferred by the FG participants.
Voices 3 & 4 would most motivate them to continue to listen to the automated message.
Voices 3 & 4 were considered most trustworthy(recognized as AA). Most trusted V4 and especially V3.
Voice 3 was identified as most motivating to move participants to action( screening)
Voice 3 in ParticularVoice 3 in Particular
V3 in particular was singled out for praise. It was described as “sounding African American,” sounding like she cared, sounding like she was creditable, and being calm, clear, and informative.
The fact that V3 was clearly recognizable as an African American voice “automatically puts you at ease.” It was effective to “hear the African American voice.”
V3 in particular was singled out for praise. It was described as “sounding African American,” sounding like she cared, sounding like she was creditable, and being calm, clear, and informative.
The fact that V3 was clearly recognizable as an African American voice “automatically puts you at ease.” It was effective to “hear the African American voice.”
FG Participant Views on Automated Calls:FG Participant Views on Automated Calls:
• In general disliked
• Pointers when using automated calls to AAs:
-Use recognizable AA voices-Provide immediate clarity of purpose-Highlight the importance of the issue to AAs-Avoid sounding scripted-Voice qualities: personable, warm, trustworthy, positive in tone, don’t “talk down” to or create fear.
• In general disliked
• Pointers when using automated calls to AAs:
-Use recognizable AA voices-Provide immediate clarity of purpose-Highlight the importance of the issue to AAs-Avoid sounding scripted-Voice qualities: personable, warm, trustworthy, positive in tone, don’t “talk down” to or create fear.
Other Important InformationOther Important Information
• Linguistic congruence may just be unique to African Americans.
• Participants liked a mature voice.
• The CRC script will not be tailored:
-Standard voice already recorded-Costs-Time
• Linguistic congruence may just be unique to African Americans.
• Participants liked a mature voice.
• The CRC script will not be tailored:
-Standard voice already recorded-Costs-Time
Next Steps: Phase 2 DesignNext Steps: Phase 2 DesignCRC IVR Outreach Protocol
Segment population by RELP Data
AA(non-Hispanic)
Intervention (AA) IVR
Hispanic/ Latino
White/ Caucasion
(non-Hispanic)
Asian or Pacific Islander
(non-Hispanic)
American Indian/ Alaskan
Native(non-Hispanic)
No RELP, Unknown,
Other, Decline, Null
Multi(non-Hispanc)
RandomizeRandomize Randomize
Standard IVR
Conngruent Voice
•Quantitative assessment• Willingness to accept and complete
the call• Completion of screening by FIT or
colonoscopy
•Qualitative assessment• Satisfaction with the outreach
process• Trust
•Quantitative assessment• Willingness to accept and complete
the call• Completion of screening by FIT or
colonoscopy
•Qualitative assessment• Satisfaction with the outreach
process• Trust
Phase 2 Outcome AssessmentPhase 2 Outcome Assessment
•As automated calls/IVR are increasingly utilized we need to insure that cultural aspects continue to be incorporated in this arena as well.
•The impact on health outcomes is still to be determined.
•Qualitative outcomes are valuable.
Albert Einstein: “Not everything that can be counted counts and not everything that counts can be counted.”
•As automated calls/IVR are increasingly utilized we need to insure that cultural aspects continue to be incorporated in this arena as well.
•The impact on health outcomes is still to be determined.
•Qualitative outcomes are valuable.
Albert Einstein: “Not everything that can be counted counts and not everything that counts can be counted.”
AACE Final MorselsAACE Final Morsels
African American Center of ExcellenceAfrican American Center of Excellence
Contact InformationContact Information
Terri Richardson, MD
Physician Lead, AACE
303-360-1714
Contact InformationContact Information
Terri Richardson, MD
Physician Lead, AACE
303-360-1714