Multilingual Access to Breast Cancer Early Detection

Institution: Alameda County Health Care Foundation
Investigator(s): Susan Stewart, Ph.D. - Linda Engelstad, M.D. -
Award Cycle: 2006 (Cycle 12) Grant #: 12AB-1701 Award: $10,000
Award Type: CRC Pilot Award
Research Priorities
Community Impact of Breast Cancer>Health Policy and Health Services: better serving women's needs

Initial Award Abstract (2006)
The proposal described below was awarded a $10,000 planning grant to enable the applicants to strengthen the scientific and community elements of their project, as detailed in the scientific review evaluation document, and incorporate these elements into a new application for the 2007 funding cycle.

Introduction to the research topics:
Public medical facilities are universally challenged today by the critical task of providing equal access to health care for increasing numbers of ethnically diverse women who are not proficient in either English or Spanish, speaking a variety of much less common languages. Many women come from areas where breast cancer is not considered a major health risk and where mammography is not readily available. Studies have shown that once in the United States, women may experience an increased risk of developing breast cancer and need access to regular screening and diagnostic tests for early detection. In order to make California’s “Every Woman Counts” program a reality, medical systems need to make changes that promote equal access to breast health services, regardless of a woman’s language.

The question(s) or central hypotheses of the research:
The questions addressed by this proposal are:
  1. What are the key linguistic, cultural and institutional barriers to breast cancer screening and diagnostic services among low-income women with limited English proficiency (LEP)?

  2. Will an intervention developed to address specific barriers among LEP women be feasible in public healthcare settings?

  3. Can we develop a multilingual access program (MAP) comprised of key steps that institutions need to address in order to provide equal language-access to breast health services?

The general methodology:
To answer these questions, we will interview LEP women through interpreters in four targeted languages (Cambodian, Cantonese, Mien and Tigrigna) in order to identify barriers that LEP women face if they have a breast problem or want to be screened for breast cancer. We will also interview interpreters and providers in a major inner city public medical center to better understand the system and to identify potential system barriers and their solutions. To further explore issues raised in interviews with LEP women, interpreters and physicians, we will conduct two focus groups: one with nurses and one with clinic staff and bilingual Community Health Outreach Workers. Participants will be recruited via professional and community networks. Using this information, we will develop a unique intervention, which may use interpreters and Community Health Outreach Workers, to promote breast health for women experiencing language barriers. To evaluate the feasibility of the new system, we will invite a number of women from within the medical setting and from the community to try out the new language-access intervention and we will learn from their experiences to make further improvements.

Innovative elements of the project:
While many studies have investigated barriers to breast cancer services for specific ethnic and language groups, the problem increasingly encountered by public healthcare facilities is how to simultaneously deliver high quality and cost-effective healthcare to a multilingual, multicultural population. This proposal is innovative in addressing language barriers that affect increasing numbers of low-income, underinsured and uninsured women, including many recent immigrants, who use public hospitals and clinics as their primary source of medical care. Instead of focusing attention on the most commonly encountered languages, we will improve or develop new steps to breast health for women who speak less common languages. The focus on identifying modifiable linguistic, cultural and institutional barriers is also innovative.

Community involvement:
Women who seek medical care at the Alameda County Medical Center speak more than 26 distinct non-English, non-Spanish languages. Many women can only communicate their medical needs through bilingual friends, relatives and interpreters, and, in recent years, a number of women have made their unmet breast services needs known to the Pathfinders Program staff. Members of the community have been, and will continue to be, actively involved in the planning and implementation of all phases of this project through participation of the Community Advisory Committee that meets regularly with the Community and Scientific Co-Principal Investigators. During this project, we will continue to strengthen our partnership with the community for future collaboration.

Final Report (2007)
The purpose of the 2006-2007 Planning Grant was to strengthen our proposal for a Pilot Study that addresses the challenge faced by public healthcare facilities to provide improved access to health care for increasing numbers of ethnically diverse women with limited English proficiency (LEP). During the Planning Grant, the Community and Scientific team utilized the reviewers’ critique, expert consultation and Community Advisory Committee involvement to further improve the study design.

The aims of the original pilot study were to:
  1. Identify the key linguistic, cultural and institutional barriers to breast cancer screening, diagnostic and treatment services among under- and uninsured women with limited English proficiency?

  2. Design and test the feasibility of an intervention that addresses identified cultural, linguistic and institutional barriers to breast cancer services among women with limited English proficiency in a public healthcare setting?

  3. Develop a multilingual access program comprised of key steps that institutions need to address in order to provide equal access to breast health services for women with limited English proficiency?

The Scientific and the Community Partner met bi-monthly, in person or by conference call, and initially focuses on a review of the former proposal and the reviewers’ comments in order to develop a plan for addressing and for strengthening the partnership and the overall study design. The Community Partner collaborated fully in all aspects of the proposal development. Several key areas, however, were identified for the focus of the planning grant.

One key area identified was the appropriateness of the scientific model that had been selected as the basis of the proposed study. During the Planning Grant, the Scientific Partner sought expert scientific consultation in order to select a model as the basis for this study and to develop an understanding of how to integrate this model into the study design. Drs. Susan Stewart and Nancy Burke sought consultation from Dr. Lawrence Green because of his expertise in this area and his proximity at the UCSF Cancer Center. Following his review of the prior Pilot Study proposal, Dr. Green recommended several articles which supported the choice of the Pathways model as an appropriate model for this study because it incorporates both community and institutional variables. He made suggestions on how the variables, identified in the model, could be better integrated more into the study design data collection tools and outcome measurements. Drs. Stewart and Burke then set about on the task of incorporating Dr. Green’s suggestions to support the choice of the model and to strengthen its utility in the proposal design.

Another key area identified was the Community input and, in particular, the role of the Community Advisory Committee (CAC). To address this issue, we went back to basics and reviewed the composition of our CAC. The CAC met and decided to broaden its membership to include other key community stakeholders. In particular, the CAC decided to add three former breast patients and cancer survivors, who were members of the ethnic communities being targeted in the Pilot Study, along with their interpreters, who were leaders of local community organizations. At an earlier separate meeting, we included two new members from community clinics and CBO’s in Alameda County that experience similar issues in providing breast services. The ideas developed at CAC meetings were incorporated into the revised proposal. In addition to the formal meetings of the CAC, members of the CAC met with the Scientific and Community Partners to advise them and reviewed drafts and appendices on an as needed basis.

The Partners believe that we made a sincere and diligent effort to revise the proposal to address criticism that we had received in the past and we were very hopeful that we would have an opportunity to carry out this Pilot Study, which was unique in it’s potential to impact breast health care for multi-lingual and multicultural women at the “point of service.”