It’s not what you say, but how you say it. Terri Richardson, M.D.

1. Linguistic Congruence for African Americans.. It’s not what you say, but how you say it. Terri Richardson, M.D. African American Center of Excellence Kaiser Permanente Colorado March 12, 2013 8th National Conference on Quality Health Care for Culturally Diverse Populations

2. Linguistic Congruence Project • Introduction • Kaiser Permanente • Health Disparities • Background • General • Project Concept • Project Design Hypothesis Linguistic Palette Focus groups • Results • Next steps

3. Introduction • 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.

4. Introduction 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.

5. Introduction • (AACE) formed in 2007 to address health disparities • Learning laboratory Our hope is to achieve cultural “competency” in every aspect of the health environment for the present and future generations.

6. Linguistic 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 NOVEL approach

7. Linguistic Palette Concept Testing Informal Community Focus Group ResultsPalette-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”.

8. Colorectal Cancer (CRC) Screening Focus In 2008, KPCO initiated a region-wide IVRCRC screening outreach. Completion rates were lower in KPCO’s African American members.

9. CRC Screening Background Information From 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 • Diagnosed at later stages • Lower survival rate • Greater likelihood of dying when diagnosed

10. 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.

11. KPCO 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.

12. KPCO 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

13. KPCO 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.

14. KPCO CRC Linguistic Congruence Pilot CRC Linguistic Palette • 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 Caucasian • 1 lightly accented Latina • 3 African Americans with varying degrees of ethnic • flavor.

15. Linguistic Palette Demonstration Write down your top 1 and 2. 1 2 3 4 5

16. KPCO 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

17. Focus Group Results • What did the members say?

18. It’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”

19. Disliked 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.

20. Liked African American Voices Voices 3 and 4 “ 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.”

21. Voice 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)

22. Voice 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.”

23. 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.

24. Other 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

25. Next Steps: Phase 2 Design

26. Phase 2 Outcome Assessment • Quantitative assessment • Willingness to accept and complete the call • Completion of screening by FIT or colonoscopy • Qualitative assessment • Satisfaction with the outreach process • Trust

27. AACE Final Morsels • 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.”

28. African American Center of Excellence Contact Information Terri Richardson, MD Physician Lead, AACE Terri.Richardson@kp.org 303-360-1714