Its not what you say, but how you say it.

Terri Richardson, M.D.African American Center of ExcellenceKaiser Permanente ColoradoMarch 12, 2013

Linguistic Congruence for African Americans..8th National Conference on Quality Health Care for Culturally Diverse Populations

Linguistic Congruence Project

Introduction Kaiser Permanente Health Disparities

Background General Project Concept

Project Design Hypothesis Linguistic Palette Focus groups

Results

Next steps

IntroductionKaiser 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.

IntroductionHealth 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.Introduction

Linguistic Congruence ProjectBackgroundIdea 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 NOVEL approach

Informal Community Focus Group ResultsPalette-men, womenParticipants 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 Testing

Colorectal Cancer (CRC) Screening FocusIn 2008, KPCO initiated a region-wide IVR CRC screening outreach. Completion rates were lower in KPCOs African American members.

From the LiteratureAfrican Americans:Factors that contribute to screening differential:Lower educational/SESReduced access to screeningLanguage or acculturation barriersFearMedical mistrustLack of knowledge about screening CRC Screening Background Information

CRC 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.

KPCO CRC Linguistic Congruence PilotHypothesis

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 PilotProject 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 PilotFocus groupsTarget: 5 groups (4AA + 1 mixed race)Standard facilitator guideAA female facilitator and note taker from the community (non-KP).

Demographic QuestionnaireDetermine important characteristics and typical participation in preventive screening.

KPCO 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.

CRC Linguistic Palette

Linguistic PaletteDemonstration

Write down your top 1 and 2.1 2 3 4 5

KPCO CRC Linguistic Congruence PilotFocus Groups6 total, ranged in size from 4-7 participants33 TOTAL KPCO membersAll African AmericanMale and female, females > malesAges 50-76Denver, Aurora

82% listed phone as best way to reach

Focus Group Results

What did the members say?

Its not what you say, but how you say it*Same, standard script *Commented on rhythm, tone Some participants perceived:More personalized messageMore information givenEmphasized the positive

Disliked Voices 1 and 2Would 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 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.Voices 3 and 4

Voice Did MatterAA 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 ParticularV3 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: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, dont talk down to or create fear.

Other Important InformationLinguistic 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 Design

CRC IVR Outreach Protocol

Hispanic/ Latino

No RELP, Unknown, Other, Decline, Null

Multi(non-Hispanc)

Segment population by RELP Data

Randomize

Randomize

Randomize

Intervention (AA) IVR

AA(non-Hispanic)

White/ Caucasion(non-Hispanic)

Asian or Pacific Islander (non-Hispanic)

American Indian/ Alaskan Native(non-Hispanic)

Standard IVR

Conngruent Voice

Quantitative assessmentWillingness to accept and complete the callCompletion of screening by FIT or colonoscopyQualitative assessmentSatisfaction with the outreach processTrust

Phase 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.AACE Final Morsels

African American Center of ExcellenceContact InformationTerri Richardson, MDPhysician Lead, AACETerri.Richardson@kp.org303-360-1714

*KPCOThis presentation will examine a project that is designed to develop a linguistically congruent automated phone outreach to enhance health outcomes in African Americans.

*KPCO has over 500,000 members*Thank you for the opportunity.**Culturally appropriateKP has about 5% AA members, over 500, 000 membersAfrican American center of excellence started in 2007 to address health disparitiesThe seedAnecdotal experience**Pilot informal focus group to assess recognition ability and assess any potential negative consequences of using an ethnic voicePalette had 6 voices 4 men, 2 women 3 black, 2 white 1latino maleUsed HTN script from KPCO HTN video*KK physician champion. Prevention department initiated the education CRC IVR and mailed kits for fecal immunochemical testing( FIT kits)Wanted to focus our initially QI project/pilot. Decided CRC.[despite equal opportunity to screen and without the barrier of lack of insurance coverage,stats from Dr. Kempe][8 African Americans are consistently diagnosed at later stages of disease and have a lower survival rate and a greater likelihood of dying when diagnosed.9 Some studies suggest that relatively lower educational/socioeconomic status, reduced access to screening, language or acculturation barriers, fear, medical mistrust, and lack of knowledge about screening contribute to the screening differential.10.11. ]*

Wanted to focus our initially QI project/pilot. Decided CRC.[despite equal opportunity to screen and without the barrier of lack of insurance coverage,stats from Dr. Kempe][8 African Americans are consistently diagnosed at later stages of disease and have a lower survival rate and a greater likelihood of dying when diagnosed.9 Some studies suggest that relatively lower educational/socioeconomic status, reduced access to screening, language or acculturation barriers, fear, medical mistrust, and lack of knowledge about screening contribute to the screening differential.10.11. ]

Used HTN script from KPCO HTN video****Confirm self identified race and ethnicityMale and female participationZip code- living in representative areasExposure to KP norms, outreach- # years KP memberBirthplace and grew up- dialectical influence, cultural influenceSES- education, employment, marital statusSelf reported health statusCompletion of preventive screeningsCompletion of CRC screeningBest ways to contact

**Play palette voicesThis is the tool used.*$30 gift card was the standard for participation**

***Recognized as African American****Next steps moving to phase 2, clinical application of linguistic congruence.Two factors related to these voices race and age. In addition to examining impact on AA CRC screening outcomes, also thought it would be instructive to assess how other groups responded to the AA voice.**Lets not lose sight that qualitative outcomes are valuable as well.A E quote always relevant when dealing with human populations.Reference availableSummary*