Not Lost in Translation: Interpretation and Other Drivers for Health Equity

1. Not Lost in Translation:Interpretation and Other Drivers for Health Equity Bob Gardner Healthcare Interpreters Network November 23, 2009

2. The Challenge • 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.”

3. Key Message • 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

4. Outline • 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

5. Starting Point I: Increasing Diversity of Population • 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

6. Starting Point II: Health Disparities • 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

12. Lower Income: Higher Diabetes Rate 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

14. Defining Health Equity • 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

15. Defining Health Equity: Positive Vision • 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

16. Another Angle on Health Equity

17. Goal: Reduce the Gradient • 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

18. Social Determinants of Health • 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

19. Social Determinants of Health as a Complex Problem • 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

20. Canadians With Chronic Conditions Who Also Report Food Insecurity

21. Think Big, But Get GoingSDoH Into Action • 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

22. Equity Into the Health System: Why • 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

23. Equity Into the Health System: Why II • 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

24. Hospitalization Rates for Diabetes: Ontario and Central LHIN

25. Lower Income: More Physician Visits For Arthritis 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

26. Lower Income: Lower Hip Replacement Rate 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

27. Gender Disparities • 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…..

28. Gender and Clinical Practice • 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

29. Equity Into the Health System: How • goal is to ensure equitable access to high quality healthcare regardless of social position • can do this through a two pronged strategy : • 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 • 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

30. How II: Identify and Act on Pre-Conditions for Health Equity • 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

31. Equity-Focused Planning • 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

32. Equity Planning by Providers • 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

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

34. Part of This Project Was To Identify ‘Quick Wins’ • 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

35. Look Widely For Ideas and Inspiration • 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

36. Building Equity Into Performance and System Management • 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.

37. Getting Specific: Building Language and Interpretation Into Performance Management • 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

38. Connecting the Dots and Driving Change: Building Interpretation Into Performance Management • 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

39. Connecting the Dots and Driving Change II: Equity-Focussed Data • 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

40. Target Investment for Equity Impact • 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

41. Aligning with Existing System Drivers • 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

42. Aligning with Quality Agenda • 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

43. Aligning With Provincial Priorities • 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

44. Building Equity Into Targets • 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.

45. Up Stream Through an Equity Lens: Chronic Conditions • 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

46. Up Stream Through an Equity Lens: Health Promotion • 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

47. Community Engagement Into Planning • 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

48. All About Culture • 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

49. Build on/Link to Community Innovation • 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

50. Build on/Link to Community Innovation II • 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