Volume 39, Issue 1 , Pages 16-22, March 2008
Development of Dual Language Information Cards as a Tool for Communication Between Radiation Therapists and Cantonese-Speaking Patients Undergoing Radiation Treatments for Head-and-Neck Cancer
Article Outline
- Abstract
- Résumé
- Introduction
- Materials and Methods
- Evaluation Results
- Discussion
- Conclusion
- Acknowledgments
- References
- Biography
- Copyright
Abstract
The establishment of an effective relationship between patient and provider is dependent upon effective communication. However, this can be difficult to achieve with patients who do not speak English as their first language. Language barriers are associated with adverse effects on quality of care, treatment outcomes, and patient and provider satisfaction. These patients are more likely to experience acute side effects and more likely to use emergency room services for problems that are treatable in primary care settings. Interpreter services and dual language providers are often used to overcome these barriers, but they are often limited by their cost and availability. The radiation therapy environment provides further challenges to overcoming these barriers by virtue of the outpatient setting and high volume of appointments. As part of their efforts to improve patient care, the British Columbia Cancer Agency (BCCA)–Vancouver Centre radiation therapy department introduced dual language cards as a tool to facilitate communication between Cantonese-speaking patients and radiation therapists. This paper outlines the method of devising and evaluating a dual language tool.
Résumé
L'établissement d'une relation efficace entre le patient et le fournisseur dépend d'une communication efficace. Par contre, ceci peut être difficile à accomplir avec des patients qui n'ont pas l'anglais comme langue maternelle. Les barrières linguistiques sont associées aux effets indésirables sur la qualité des soins, les résultats de traitement et la satisfaction du patient et du fournisseur. Ces patients sont plus aptes à éprouver des effets secondaires aigus et sont plus porter à utiliser des soins d'urgences hospitaliers pour des problèmes qui sont traitables en soins primaires. Des services d'interprète et des fournisseurs bilingues sont utilisés fréquemment pour surmonter ces barrières; mais ils sont souvent limités par leurs coûts et disponibilités. L'environnement de la radiothérapie fournit d'autres défis pour combattre ces barrières dans le cadre des patients externes et de la demande élevée de rendez-vous. Afin d'améliorer les soins aux patients, le département de la radiothérapie du centre de Vancouver de l'Agence du cancer de la Colombie-Britannique a introduit des cartes bilingues pour faciliter la communication entre les patients qui parlent le cantonnais et les technologues en radiooncologie. Cet article décrit la méthode de concevoir et d'évaluer un outil à deux langues.
Introduction
Cancer is a major health problem in Canada. Approximately 38% of Canadian women and 44% of Canadian men will develop some form of cancer in their lifetimes [1]. The treatment of cancer involves three modalities: surgery, chemotherapy, and radiation therapy. These treatments can be used, either alone or in combination, to improve prognosis and to increase chances of survival. Of these three modalities, radiation therapy is the most widely used; approximately half of the those diagnosed with cancer will require radiation treatment at some point [2].
The process of receiving radiation treatment is complex. The number of health care professionals that the patient encounters during the radiation therapy process includes, but is not limited to, the following: the referring physician, the radiation oncologist, technologists for various diagnostic procedures, residents, medical students, nurses, nutritionists, and radiation therapists. Cancer treatment may involve several modalities, especially for head-and-neck cancers; therefore, each of the previously mentioned health care providers can be a potential source of information. However, the presence of language barriers inhibits open communication and negatively affects the provision of timely information. Ultimately, language barriers hinder health care professionals from providing—and patients from receiving—the highest quality of care.
A review of the literature related to communication between health care providers and non–English-speaking patients revealed the need for interpreter and translator services. However, although interpreters facilitate communication, they cannot guarantee understanding. As Maltby states, “the use of interpreters is not a panacea for communication difficulties [4].” There are also issues around availability, access, and confidentiality. Even when professional interpreter services are available, they are not always used. Health care providers often overestimate a patient's ability to speak English and do not arrange for interpreters [3]. Furthermore, complicated booking systems discourage health care providers from using interpreter services [4]. Gerrish found that although nurses often indicated that they would arrange for professional interpreters, this was not observed in practice, and was attributed to the difficulty of arranging interpreter services without advance notice [8]. When patients do not understand, they fail to show for appointments, misuse medications, and are less likely to comply with treatment instructions. As a result, patients are more likely to experience minor side effects and additional complications, and are more likely to use emergency room services for problems that are treatable in primary care settings [5].
When a language barrier exists, it increases the cost of health care for everyone. Missed appointments, increased use of diagnostic tests, reallocation of staff time, unplanned or extended admissions, and overall diminished health status all contribute to this cost [6], [7], [8]. Several studies have also demonstrated the negative effects of language barriers on quality of care, patient and provider satisfaction, and patient health outcomes [6], [7], [8], [9], [10]. For instance, increased stress and lower job satisfaction have been associated with the presence of communication barriers between health care providers and non–English-speaking patients [6], [11]. Health care providers who are not familiar with the patient's cultural background often feel ineffective and sometimes frustrated when they are unable to communicate their message to the patient. Because language barriers hinder health care providers from providing, and patients from receiving, quality care, there is a need for health care providers to be more aware of the language and cultural practices with which they are often confronted. Furthermore, there is a need to devise initiatives that can improve encounters between patients and health care providers.
According to the 2001 Census, allophones—individuals reporting to have a nonofficial language as their mother tongue— accounted for 38.4% of the population of Vancouver, British Columbia (BC). When further analyzed, 15.2% of the population (ie, 1 in 6 individuals) reported Chinese as a mother tongue, followed by Punjabi and Tagalog [12]. In addition, 81% of Chinese speakers surveyed in Canada reported using only or mostly Chinese at home, indicating that these individuals may have limited proficiency in English.
Because of the large population of Chinese people in Vancouver and the prevalence of nasopharyngeal tumors in this population, the Vancouver Cancer Centre (VCC) radiation therapy department treats a significant number of Cantonese-speaking patients. Approximately 71% of interpreter requests at the VCC are for Cantonese speakers [13]. Patients with head-and-neck cancers have very specific needs beyond those of most others diagnosed with cancer [14], including (but not limited to) nutritional, oral, dental, dermatological, and psychological needs. The management of patients undergoing radiation therapy for head-and-neck tumors is complex; it requires extensive assessment of patient conditions and the use of supportive and self-care measures to minimize the impact of radiation reactions to the skin and oral mucosa as well as the oral cavity. In addition, the emotional needs of these patients must be acknowledged. This in turn requires effective communication between the care provider and the patient.
Given that the majority of the Chinese population surveyed in Canada reported speaking only or mostly Cantonese at home, it is possible to forecast that many Chinese patients receiving radiation therapy may have limited proficiency in English. Furthermore, the number of bilingual, Chinese-speaking radiation therapists who are directly involved in treating this cohort of head-and-neck cancer patients may also be limited. As a result, the communication between the non–English-speaking patient and radiation therapists is often limited, and can ultimately affect adequacy of care and the overall outcome of treatment for this cohort of patients.
Effective communication ensures that the message is clear, appropriately conveyed, received by the other party, and, most importantly, understood and accepted. Barriers to communication have negative impacts on quality of care, treatment outcomes, and both patient and provider satisfaction [6], [7], [8], [9], [10]. Noncompliant behavior increases as a result of language barriers [5], [6], [9], [11]. Although there is an abundance of research on language barriers in health care, few efforts have focused on circumstances in the outpatient setting. Furthermore, there is little published information on innovative approaches to enhance communication between health care providers and non–English-speaking patients. Given the patient demographics at the VCC and high incidence of Cantonese interpreter requests [13], a study was initiated at the British Columbia Cancer Agency (BCCA)–Vancouver Centre radiation therapy department using translated information cards as an aid to communication between radiation therapists and Cantonese-speaking patients receiving treatment to the head-and-neck region.
Materials and Methods
Developing the Information Cards
Hilton and Skrutkowski suggest that the ideal approach in developing (research) instruments is from the perspective of the culture under investigation using a bicultural/bilingual approach [19]. This method requires collaboration between individuals from both cultures to develop instruments that provide equally valid concepts and definitions. The dual language cards used at the VCC were devised using this approach.
The initial step involved radiation therapists recording commonly asked questions or frequently encountered issues when communicating with head-and-neck cancer patients. This generated a list of common problems that were then distilled into major symptoms and complaints. In the next step, each symptom or concern was rewritten so that it could be expressed by a single phrase or statement. This step was performed by two co-investigators of the study. Both individuals were radiation therapists, one was of Chinese descent and fluent in Cantonese, and the other was English-speaking only. This revised list of symptoms or complaints was then returned to the treatment units where therapists tallied the number of times each phrase or statement was, or could be used to communicate with head-and-neck cancer patients. The purpose of this step was to further refine and validate the list of phrases. This process was ongoing for about 2 weeks.
Once the list of phrases was finalized, the phrases were incorporated into slides using Microsoft PowerPoint (Microsoft Corporation, Redmond, WA) and paired with associated clip art. Each slide could then be printed to create a flashcard. In total, 31 cards were generated and divided into 3 categories. The first category comprised a single card that contained common questions and complaints expressed by head-and-neck cancer patients. The second category consisted of questions that the therapists would use to clarify the concerns expressed by the patient. This would be followed by a set of responses from which the patient could choose a reply. The third category contained instructions or statements the therapist would use to provide information to the patient. This could include simple self-care measures or could relate to operational concerns such as appointment time changes.
The card from the first category was 19.5 cm wide and 21 cm long, and contained 14 common questions and complaints that could be used by non–English-speaking patients to alert the therapist easily to a problem or concern (Figure 1). This card displayed the Chinese phrase first, followed by an equivalent statement in English.
Figure 1
Category 1: List of Common Complaints.
Examples of category 2 dual language cards are provided in Figure 2, Figure 3, Figure 4. Based on the problem identified, the category 2 cards would then allow the radiation therapist to assess the severity of the issue or to evaluate what kinds of self-care measures (if any) had been initiated by the patient. These cards also included common responses that the patient could choose from to describe the situation.
Figure 2
Example of Category 2 Dual Language Card.
Figure 3
Example of Category 2 Dual Language Card.
Figure 4
Example of Category 2 Dual Language Card.
The third and final category of cards contained instructions for self-care measures or statements related to operational statements. Figure 5, Figure 6, Figure 7, Figure 8, Figure 9 give examples of category 3 dual language cards. Category 2 and 3 cards measured 17.5 cm wide and 13.5 cm long.
Figure 5
Example of Category 3 Dual Language Instructions and Statements Card.
Figure 6
Example of Category 3 Dual Language Instructions and Statements Card.
Figure 7
Example of Category 3 Dual Language Instructions and Statements Card.
Figure 8
Example of Category 3 Dual Language Instructions and Statements Card.
Figure 9
Example of Category 3 Dual language Instructions and Statements Card.
The order in which the Chinese or English phrases were written was determined by the likely initiator of the phrase. If the phrase referred to a complaint by the patient, the Chinese version would be written first. If the phrase referred to a question or statement by the radiation therapist, the English version would be written first. This was purposely designed to facilitate ease of use. The questions were written from the layperson's perspective to ensure that the statements and questions were understandable and did not use technical language. Furthermore, all cards contained an illustration to facilitate understanding of the statements on the card and also to facilitate quick recognition of the card's context. These cards were revised approximately 1 month later based on feedback from the radiation therapists. Two additional cards were added for less frequent, but equally important concerns; these were “I need to use the washroom” and “I need to take your weight.”
To maximize the use of available resources and minimize the cost of producing the translated cards, several volunteers were involved in creating the final product. One volunteer translated all the English questions and statements using a keyboard with Chinese character capability and was able to type out the Chinese characters. Microsoft PowerPoint was chosen as the program of choice because of its accessibility by both the investigators and the volunteer, as well as the availability of the Chinese Microsoft Windows program that can allow both Chinese and English characters to be viewed on-screen and typed.
Other volunteers included Cantonese-speaking patients from the head-and-neck treatment units. Before the cards were introduced for use, three Chinese patients with head-and-neck cancer were approached to review the cards. These patients were selected to represent different age groups. Their health status and availability for providing feedback also played a role in being selected to review the cards. One of the patient volunteers was married to a Mandarin interpreter. This resulted in a fourth reviewer who could speak to the suitability of the cards for Mandarin-speaking patients. All four volunteers were very supportive of the project. Minor edits to the cards were recommended and were subsequently incorporated. Once these individuals reviewed the cards, copies of the cards were made available on treatment units with head-and-neck cancer patients.
Slides generated with Microsoft PowerPoint were printed to create the cards. A standard, black-and-white laser printer was used. The dual language cards were printed on different colors of paper. This was done intentionally to help facilitate identification of the appropriate cards. To ensure durability, cards were then laminated and bound with a single ring before being introduced for general use.
Therapists working in treatment units with head-and-neck cancer patients were then instructed on how to use the dual language cards. They were also instructed to have the cards available to the patient for each appointment. Because all head-and-neck cancer patients must use an immobilization device, these cards were also introduced to the Cantonese-speaking patients at their mould room appointments. These patients would then be aware of the cards' existence and their availability if a Cantonese-speaking radiation therapist or interpreter was unavailable during the treatment.
Evaluating the Information Cards
A patient satisfaction survey was used to evaluate the efficacy of the information cards. Two evaluations were performed. The first was a preimplementation needs assessment based on satisfaction surveys that are delivered as a part of the department's ongoing quality improvement process. These surveys have been used extensively in the radiation therapy program throughout BC since 1999 [18]. The surveys contained 13 items measuring various aspects of patient satisfaction using a Likert response scale. Historically, these surveys were available in the English language only. In 2004, the surveys were translated into Chinese and were delivered to all patients with Cantonese or Mandarin as a first language. Data from the two cohorts were analyzed from April 2004 to August 2005 to detect any differences in responses to questions relating to information needs.
A second modified version of the survey was developed to evaluate the cards themselves. This was a 15-item survey measuring aspects of satisfaction related to information and the management of side effects. This survey was delivered to patients receiving radiation therapy to the head and neck for 6 months after implementation of the study. Two cohorts were established: English-speaking patients who did not need to use the cards; and Cantonese- or Mandarin-speaking patients who did need to use the cards. Ethics approval from the BCCA/University of British Columbia (UBS) Research Ethics Board was obtained to conduct the evaluations. On both evaluations, Student t-tests were performed to detect any statistically significant differences between the two groups.
Evaluation Results
Preimplementation Results
Satisfaction surveys were analyzed from April 2004 to August 2005, before implementation of the cards in September 2005. A total of 67 Chinese surveys and 1470 English surveys were evaluated. Satisfaction was lower in all areas for the Chinese population, and significantly so (P>.05) in areas relating to having enough information about the illness, treatments, and side effects. No significant differences in scores were noted in areas relating to having concerns addressed or being treated courteously, nor to waiting times, waiting areas, and overall satisfaction, although these scores were generally lower on the Chinese surveys.
Postimplementation Results
In all, 9 Chinese-speaking and 40 English-speaking patients were surveyed on the postimplementation survey. Only one statistically significant item was detected, with the Chinese-speaking cohort having less satisfaction with information about appointment times compared with the English-speaking group (P=.025). In general, the scores for the Chinese-speaking patients were lower than for the English-speaking group.
Discussion
The preimplementation needs analysis identified that Chinese-speaking patients had lower satisfaction scores in several areas compared with English-speaking patients. This was not reflected in the smaller postimplementation study, in which the scores for the Chinese population were generally more comparable to those for the English-speaking population. Despite the small sample sizes in the postimplementation survey, the results were encouraging and supported the use of the dual language cards as a communication tool.
Although the VCC employs the services of professional interpreters, multiple appointments of short duration make it impractical to book an interpreter for every treatment; therefore, professional interpreters are arranged only on a weekly basis for the day of a patient's review by the radiation oncologist. During the rest of the week, when an interpreter is not booked for the review clinic, radiation therapists rely on family members and a few Cantonese-speaking radiation therapists or radiation therapy students to facilitate communication. Very often these ad hoc interpreters are unavailable because of their commitment in other work areas. Furthermore, even when family members are present, their English proficiency may be limited.
Although interpreters (professional or ad hoc) may be available and present to liaise between the patient and the therapist, patients may not want to disclose personal information in front of a stranger [15], [16], [17]. By the same token, when family members are asked to translate what kinds of issues are of concern to the patient, such family members may add their own commentaries as representations of what the patient is saying, as opposed to what is truly being said by the patient [16], [17]. Given these difficulties, the dual language flashcards created at the VCC were designed to facilitate direct communication between non–English-speaking patients with non–Cantonese-speaking therapists.
The purpose of these dual language flash cards is not to replace professional medical interpreters or Cantonese-speaking radiation therapists, but to provide a creative means to facilitate communication between non–English-speaking Chinese patients when interpreters are unavailable. Ultimately, the goal of the tool was to respond to a bilingual communication deficiency in the department. Furthermore, it was used as a method of overcoming resource constraints and to minimize any barriers that may hinder quality of patient care this cohort of patients may be experiencing. This includes recommending an appropriate intervention in a timely fashion to reduce any unnecessary delays or to simply communicate a change in appointment.
Bridging the communication gap between non–English-speaking patients and health care providers can be achieved by developing tools in other languages [19]. In October 2005, the dual language flashcards were introduced to patients during their mould room appointment and were placed on treatment units as a communication tool. The final product was made possible because of a collaborative team approach among patients, volunteers, and radiation therapists. Currently, the dual language cards are present on the treatment units and available for use when necessary. As a result of this initiative, we recommend developing such communication tools in other languages and including other tumour sites to facilitate communication for other non–English-speaking patients who are treated in a predominantly English-speaking environment.
Conclusion
Translated information cards were created and used as a method of communication to address a commonly encountered language barrier between Cantonese-speaking patients and non–Cantonese-speaking radiation therapists at the VCC radiation therapy department. The creation of this dual language tool was the result of collaboration among patients, volunteers, and radiation therapists. The creative use of existing resources resulted in a cost-effective method to help address a very costly problem in the delivery of health care. This cost is significant not only in terms of financial resources but also in regard to its impact on the quality of life of patients and the satisfaction of both patients and radiation therapists. This project also provided an opportunity to involve patients in an initiative that could make a positive difference in the care of subsequent patients who may be affected by cultural differences within the radiation therapy environment.
Acknowledgments
This project was made possible due to the grant support of the British Columbia Medical Services - Vancouver Foundation. The authors would like to thank Ming Fong and Fiona Mitchell for their assistance with this project, and Wayne Soo for his invaluable computer skills in using Chinese Microsoft PowerPoint and typing Chinese characters.
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About the Authors
Jenny Soo embarked on her journey to become a radiation therapist shortly after completing her Bachelor of Science degree in Biochemistry and Kinesiology. Since being certified as a radiation therapist in 2003, she has been working at the British Columbia Cancer Agency—Vancouver Cancer Centre. In 2006, she completed her Masters in Education in Diversity and Curriculum Design at Simon Fraser University. Her research interests are in palliative care and patient education.
Stephanie Aldridge received her Diploma in Radiation Therapy in Vancouver in 1996. A large part of her career has been spent working at the Vancouver Cancer Centre; however, she has also worked in Victoria, BC, Saskatoon, Saskatchewan, and Wellington, New Zealand. She received her Bachelor of Science degree from Anglia Polytechnic University in 2004. She is now a radiation therapy instructor at British Columbia Institute of Technology and has recently completed a Masters in Education in Educational Leadership at Simon Fraser University. Her research interests are in education, communication and culture.
PII: S1939-8654(08)00004-0
doi:10.1016/j.jmir.2008.01.003
© 2008 Elsevier Inc. All rights reserved.
Volume 39, Issue 1 , Pages 16-22, March 2008
