Reporting on knowledge, attitudes, and behaviours of pharmacists regarding the active offer of French language health services in Ontario: A quantitative survey study

Seale E., Reaume M., Batista R., Eddeen A.B., Roberts R., Rhodes E., McIsaac D.I., Kendall C.E., Sood M.M., Prud’homme D., Tanuseputro P.

Background: When patients and physicians speak the same language, it may improve the quality and safety of care delivered. We sought to determine whether patient–physician language concordance is associated with in-hospital and postdischarge outcomes among home care recipients who were admitted to hospital. Methods: We conducted a population-based study of a retrospective cohort of 189 690 home care recipients who were admitted to hospital in Ontario, Canada, between 2010 and 2018. We defined patient language (obtained from home care assessments) as English (Anglophone), French (Francophone) or other (allophone). We obtained physician language from the College of Physicians and Surgeons of Ontario. We defined hospital admissions as language concordant when patients received more than 50% of their care from physicians who spoke the patients’ primary language. We identified in-hospital (adverse events, length of stay, death) and post-discharge outcomes (emergency department visits, readmissions, death within 30 days of discharge). We used regression analyses to estimate the adjusted rate of mean and the adjusted odds ratio (OR) of each outcome, stratified by patient language, to assess the impact of language-concordant care within each linguistic group. Results: Allophone patients who received language-concordant care had lower risk of adverse events (adjusted OR 0.25, 95% confidence interval [CI] 0.15–0.43) and in-hospital death (adjusted OR 0.44, 95% CI 0.29–0.66), as well as shorter stays in hospital (adjusted rate of mean 0.74, 95% CI 0.66–0.83) than allophone patients who received language-discordant care. Results were similar for Francophone patients, although the magnitude of the effect was smaller than for allophone patients. Language concordance or discordance of the hospital admission was not associated with significant differences in postdischarge outcomes. Interpretation: Patients who received most of their care from physicians who spoke the patients’ primary language had better in-hospital outcomes, suggesting that disparities across linguistic groups could be mitigated by providing patients with language-concordant care.

Timony P.E., Waite N., Houle S., Violette R., Gauthier A.P.

Hays C.A., Taylor S.M., Glass B.D.

Health outcome delivery for rural and remote Australian communities is challenged by the maldistribution of the pharmacy workforce. High staff turnover rates, reduced pharmacist numbers, and reliance on temporary staff have placed great strain on both state health services and rural community pharmacies. However, recent changes to the demographic profile of the rural pharmacist including a lower average age and increased time spent in rural practice highlights a more positive future for the delivery of better health outcomes for rural communities. The aim of this study was to investigate the factors that motivate and challenge pharmacists' choice to practice rurally.Rural pharmacists were invited to participate in semi-structured interviews using purposive non-probability sampling. Twelve pharmacists were interviewed with early-, middle- and late-career pharmacists represented. Participants described their experiences of working and living in rural and remote locations. Three themes emerged: workforce, practice environment and social factors, which were examined to determine the underlying challenges and motivators impacting rural and remote pharmacy practice.Lack of staff presented a workforce challenge, while motivators included potential for expanded scope of practice and working as part of a multidisciplinary team. While social isolation has often been presented as a challenge, an emerging theme highlighted that this may no longer be true, and that notions of "rural and remote communities as socially isolated was a stigma that needed to be stopped".This study highlights that despite the challenges rural pharmacists face, there is a shift happening that could deliver better health outcomes for isolated communities. However, for this to gain momentum, it is important to examine both the challenges and motivators of rural pharmacy practice to provide a platform for the development and implementation of appropriate frameworks and programs to better support the rural pharmacy workforce.

Jutras C., P. Gauthier A., E. Timony P., Côté D., Kpazaï G.

Résumé : Il est possible d’améliorer la santé et les soins de santé de manière efficace par l’entremise de l’amélioration de l’expérience du patient. L’objectif principal de cette étude était de saisir et comprendre l’expérience de patient(e)s francophones chez leur médecin de famille en examinant les effets de la concordance et la discordance linguistique sur cette expérience. La méthode de collecte de données fut inspirée des deux premières étapes de l’approche « Experienced-Based Design » (EBD). Six groupes de discussions ont été organisés dans des communautés fortement francophones du nord de l’Ontario où vingt-neuf participant(e)s ont partagé l’expérience d’une visite chez leur médecin de famille. L’expérience de patient(e)s francophone est caractérisée par de nombreuses émotions, dont plusieurs sont éprouvés en raison de la concordance et la discordance linguistique avec le médecin de famille. La discordance linguistique au service de santé de première ligne suscite une expérience moins favorable en matière de confort, d’accessibilité, de sécurité et de sentiments d’aptitude personnelle. L’offre active de services en français en tenant compte de la préférence linguistique des patients au-delà les apparences du bilinguisme, tout en offrant un environnement de santé de première ligne bilingue (ex. affiches, formulaires) favoriserait une expérience de santé positive pour des Franco-Ontariens.

Diamond L., Izquierdo K., Canfield D., Matsoukas K., Gany F.

Approximately 25 million people in the USA are limited English proficient (LEP). When LEP patients receive care from physicians who are truly language concordant, some evidence show that language disparities are reduced, but others demonstrate worse outcomes. We conducted a systematic review of the literature to compare the impact of language-concordant care for LEP patients with that of other interventions, including professional and ad hoc interpreters. Data was collected through a systematic review of the literature using PubMed, PsycINFO, Web of Science, Cochrane Library, and EMBASE in October 2017. The literature search strategy had three main components, which were immigrant/minority status, language barrier/proficiency, and healthcare provider/patient relationship. The quality of the articles was appraised using the Downs and Black checklist. The 33 studies were grouped by the outcome measure studied, including quality of care (subdivided into primary care, diabetes, pain management, cancer, and inpatient), satisfaction with care/communication, medical understanding, and mental health. Of the 33, 4 (6.9%) were randomized controlled trials and the remaining 29 (87.9%) were cross-sectional studies. Seventy-six percent (25/33) of the studies demonstrated that at least one of the outcomes assessed was better for patients receiving language-concordant care, while 15% (5/33) of studies demonstrated no difference in outcomes, and 9% (3/33) studies demonstrated worse outcomes in patients receiving language-concordant care. The findings of this review indicate that, in the majority of situations, language-concordant care improves outcomes. Although most studies included were of good quality, none provided a standardized assessment of provider language skills. To systematically evaluate the impact of truly language-concordant care on outcomes and draw meaningful conclusions, future studies must include an assessment of clinician language proficiency. Language-concordant care offers an important way for physicians to meet the unique needs of their LEP patients.

Khoong E.C., Le G.M., Hoskote M., Rivadeneira N.A., Hiatt R.A., Sarkar U.

In order to address health disparities, it is important to understand how vulnerable individuals seek information. This study used an adapted version of the Health Information National Trends Survey (HINTS) administered in English, Spanish, and Chinese to describe the behaviors and preferences of a diverse group of vulnerable urban residents.We administered a modified HINTS survey in English, Spanish, and Chinese and used purposive sampling to ensure 50% were non-English speakers evenly divided between Spanish and Chinese speakers, and 50% of English-speakers identified as Black. We used multivariable logistic regression to determine characteristics associated with sources used for health information and preferences for delivery of health information.Among 1027survey respondents (514 English, 256 Spanish, 260 Chinese), 55% had adequate health literacy, and 50% reported household income

de Moissac D., Bowen S.

Introduction: The risks to patient safety and quality of care faced by members of linguistic minority groups have been well-documented. However, little research has focused on the experience of official language minorities in Canada. Methods: This multiple method study (online and paper-based surveys combined with semi-structured individual interviews with patients and interpreters-health navigators) explored the experience of minority Francophones living in 4 Canadian provinces. Results: Patients and interpreters-navigators described experiences where language barriers contributed to poorer patient assessment, misdiagnosis and/or delayed treatment, incomplete understanding of patient condition and prescribed treatment, and impaired confidence in services received. Reliance on Google Translate and ad hoc, untrained interpreters are commonly reported, in spite of evidence highlighting the risks associated with such practice. Conclusion: Increased awareness that the risks of language barriers apply to official language minorities is essential.

King-Shier K., Lau A., Fung S., LeBlanc P., Johal S.

To develop an understanding of south Asian and Chinese people's preferences about where to find health information and how best to receive health information, relative to their white counterparts.South Asian and Chinese ethnic groups represent the largest proportion of Canada's growing visible minorities. There may be challenges to ensuring that south Asian and Chinese people have access to health information in the same way that others do.Qualitative descriptive.Fifty-two participants (12 white, 16 south Asian and 24 Chinese) engaged in six focus groups (two for each ethnocultural group). Focus groups were conducted in English, Punjabi and Cantonese, with the assistance of Punjabi and Cantonese interpreters. Questions were focused on how participants have preferred or would prefer to receive health information (e.g., when, where, what format, from whom), as well as the facilitators and barriers to understanding the health information.Participants agreed that although physicians were their primary source for health information, they also used written materials, media and the Internet to glean information. Participants identified concerns regarding the use of technical jargon by healthcare providers. South Asians and Chinese referred to their English language fluency and the lack of ethnoculturally specific information as additional challenges to understanding information they were offered. Whether and how family members were included in the communication process, also varied by ethnocultural group.As Canada welcomes immigrants from other countries, and its population becomes more diverse, healthcare providers need to have an understanding of the potential diversity in how to approach offering health information.Healthcare providers need to consider what people of different ethnocultural backgrounds need when developing effective health communication strategies.

Mazza G.L., Enders C.K., Ruehlman L.S.

Often when participants have missing scores on one or more of the items comprising a scale, researchers compute prorated scale scores by averaging the available items. Methodologists have cautioned that proration may make strict assumptions about the mean and covariance structures of the items comprising the scale (Schafer & Graham, 2002 ; Graham, 2009 ; Enders, 2010 ). We investigated proration empirically and found that it resulted in bias even under a missing completely at random (MCAR) mechanism. To encourage researchers to forgo proration, we describe a full information maximum likelihood (FIML) approach to item-level missing data handling that mitigates the loss in power due to missing scale scores and utilizes the available item-level data without altering the substantive analysis. Specifically, we propose treating the scale score as missing whenever one or more of the items are missing and incorporating items as auxiliary variables. Our simulations suggest that item-level missing data handling drastically increases power relative to scale-level missing data handling. These results have important practical implications, especially when recruiting more participants is prohibitively difficult or expensive. Finally, we illustrate the proposed method with data from an online chronic pain management program.

Savard J., Casimiro L., Benoît J., Bouchard P.

Comment peut-on mesurer l’impact des actions entreprises pour améliorer l’offre active de services sociaux et de santé en français dans les communautés francophones en situation minoritaire? Un questionnaire mesurant premièrement les comportements individuels de l’offre active et deuxièmement la perception du soutien organisationnel à faire de l’offre active a été créé. La validité de contenu de la Mesure de l’offre active de services en françaisen contexte minoritaire a été établie à l’aide d’une recension d’écrits, de consultations menées auprès d’expertes et d’experts et d’un sondage Delphi pancanadien. Sa fidélité a été examinée à partir de données recueillies auprès de récents diplômés en santé et en service social. L’outil démontre une bonne consistance interne et des études auprès d’un plus large échantillon sont nécessaires pour augmenter la confiance envers sa stabilité temporelle. Il s’agit des premiers pas d’une démarche visant à mesurer l’évolution des comportements d’offre active à la suite d’activités de formation ou de changements organisationnels en faveur de services en français. Une telle mesure est aussi susceptible d’être utile dans les recherches visant à saisir les déterminants de ces comportements d’offre active.

Drolet M., Savard J., Benoît J., Arcand I., Savard S., Lagacé J., Lauzon S., Dubouloz C.

We explore in this qualitative research the challenges faced by bilingual health and social services professionals in a Canadian bilingual setting, as well as the strategies used to overcome them. Eight focus groups were conducted with a total of 43 bilingual Francophone professionals who offered services in French in 21 health and social service organizations in eastern Ontario, Canada. We highlight linguistic issues affecting a minority Francophone clientele, the shortage of services in French, and organizational issues within these agencies. The solutions that the professionals adopt for better serving the clients and overcoming these challenges focus on adapting services from linguistic angles. In the long term, such an enhanced approach can affect staff well-being. Ensuring access to services for linguistic minority populations and the active offer of same should not rest solely on the shoulders of such professionals, but rather on organizational strategies.

Pong R.W.

Shortages and maldistibution of physicians in northern Ontario, Canada, have been a long-standing issue. This study seeks to document, in a chronological manner, the introduction of programmes intended to help solve the problem by the provincial government over a 35-year period and to examine several aspects of policy implementation, using these programmes as a case study. A programme analysis approach was adopted to examine each of a broad range of programmes to determine its year of introduction, strategic category, complexity, time frame, and expected outcome. A chronology of programme initiation was constructed, on the basis of which an analysis was done to examine changes in strategies used by the provincial government from 1969 to 2004. Many programmes were introduced during the study period, which could be grouped into nine strategic categories. The range of policy instruments used became broader in later years. But conspicuous by their absence were programmes of a directive nature. Programmes introduced in more recent years tended to be more complex and were more likely to have a longer time perspective and pay more attention to physician retention. The study also discusses the choice of policy instruments and use of multiple strategies. The findings suggest that an examination of a policy is incomplete if implementation has not been taken into consideration. The study has revealed a process of trial-and-error experimentation and an accumulation of past experience. The study sheds light on the intricate relationships between policy, policy implementation and use of policy instruments and programmes.

Ngo-Metzger Q., Sorkin D.H., Phillips R.S., Greenfield S., Massagli M.P., Clarridge B., Kaplan S.H.

Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients. We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes. Cross-sectional survey, response rate 74%. A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities. Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding. Patients with language-discordant providers reported receiving less health education (β = 0.17, p < 0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β = 0.28, p < 0.05), and were more likely to give low ratings to their providers (odds ratio [OR] = 1.61; CI = 0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers. Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

Shrive F.M., Stuart H., Quan H., Ghali W.A.

Missing data present a challenge to many research projects. The problem is often pronounced in studies utilizing self-report scales, and literature addressing different strategies for dealing with missing data in such circumstances is scarce. The objective of this study was to compare six different imputation techniques for dealing with missing data in the Zung Self-reported Depression scale (SDS). 1580 participants from a surgical outcomes study completed the SDS. The SDS is a 20 question scale that respondents complete by circling a value of 1 to 4 for each question. The sum of the responses is calculated and respondents are classified as exhibiting depressive symptoms when their total score is over 40. Missing values were simulated by randomly selecting questions whose values were then deleted (a missing completely at random simulation). Additionally, a missing at random and missing not at random simulation were completed. Six imputation methods were then considered; 1) multiple imputation, 2) single regression, 3) individual mean, 4) overall mean, 5) participant's preceding response, and 6) random selection of a value from 1 to 4. For each method, the imputed mean SDS score and standard deviation were compared to the population statistics. The Spearman correlation coefficient, percent misclassified and the Kappa statistic were also calculated. When 10% of values are missing, all the imputation methods except random selection produce Kappa statistics greater than 0.80 indicating 'near perfect' agreement. MI produces the most valid imputed values with a high Kappa statistic (0.89), although both single regression and individual mean imputation also produced favorable results. As the percent of missing information increased to 30%, or when unbalanced missing data were introduced, MI maintained a high Kappa statistic. The individual mean and single regression method produced Kappas in the 'substantial agreement' range (0.76 and 0.74 respectively). Multiple imputation is the most accurate method for dealing with missing data in most of the missind data scenarios we assessed for the SDS. Imputing the individual's mean is also an appropriate and simple method for dealing with missing data that may be more interpretable to the majority of medical readers. Researchers should consider conducting methodological assessments such as this one when confronted with missing data. The optimal method should balance validity, ease of interpretability for readers, and analysis expertise of the research team.

JACOBS E., CHEN A.H., KARLINER L.S., AGGER-GUPTA N., MUTHA S.

Many U.S. residents who speak little English may face language barriers when seeking health care. This article describes what is currently known about language barriers in health care and outlines a research agenda based on mismatches between the current state of knowledge of language barriers and what health care stakeholders need to know. Three broad areas needing more research are discussed: the ways in which language barriers affect health and health care, the efficacy of linguistic access service interventions, and the costs of language barriers and efforts to overcome them. In each of these areas, we outline specific research questions and recommendations.