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BACKGROUND: Little is published about the factors that facilitate and hinder the intervention implementation process. OBJECTIVE: The aim of this study was to examine factors that facilitated and hindered the implementation of a culturally appropriate colorectal cancer screening intervention targeting Vietnamese Americans in a Federally Qualified Health Center located in the Puget Sound area of Washington. METHODS: Three focus group discussions (2 during the implementation phase and 1 during the maintenance phase) with the medical assistants (N = 13) who were the intervention implementation agents were conducted at the Federally Qualified Health Center. Three research team members independently analyzed the data using content analysis and then compared for agreement. We reread and recoded the transcripts until consensus was reached. The themes were clustered by similar codes and categorized into 4 groups, each including facilitators and hindrances of implementation: identification of implementation agents, implementation environment, intervention recipients, and the colorectal cancer screening intervention. RESULTS: Facilitators included medical assistants' high motivation with a positive attitude toward the intervention, team approach, and simplicity of the intervention, whereas hindrances included lack of time, forgetfulness, staff turnover, and language barriers. CONCLUSION: The findings emphasized the importance of supporting implementation agents to ensure effective intervention program implementation. IMPLICATIONS FOR PRACTICE: Oncology nurses need to particularly take into consideration the evidence-based findings when planning any intervention programs.

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Bystander CPR doubles survival from cardiac arrest but limited English proficient (LEP) individuals face barriers calling 911 and performing CPR. Previous training increases the chance that an individual will perform CPR, yet access to classes in non-English speaking populations is limited. We used a cultural adaptation approach to develop a graphic novella for Chinese LEP immigrants about how to call 911 and perform bystander CPR. Collaboration with members of this community occurred through all stages of novella development. One hundred and thirty-two LEP Chinese adults read the novella and answered a survey measuring behavioral intentions. All respondents stated they would call 911 after witnessing a person's collapse, but those previously trained in CPR were more likely to say that they would perform CPR. All participants indicated that they would recommend this novella to others. Developing culturally-responsive evidence-based interventions is necessary to reduce disproportionate death and disability from cardiac arrest in LEP communities.

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BACKGROUND: "Context" is a mediating construct that significantly influences the initiation and maintenance of program implementation, but it has seldom been studied in process evaluation. This case study describes the contextual factors that encourage or impede the implementation processes of a research-tested program at a Federally Qualified Community Health Center. METHOD: We conducted 14 key informant interviews with providers, nurses, medical assistants, and clinic staff in leadership and management positions during the 24 months of active implementation. Interview data were analyzed using Atlas.ti software. A written log documenting exposure, adherence, and coverage of the implementation was used to describe implementation fidelity. RESULTS: Findings indicated that program implementation needs to align with the organization's mission and values. Sensemaking caused individuals to understand the importance of the new process and increased their motivation to follow assigned procedures. Revisions of the implementation process allowed the program to fit better with the clinic's existing workflow. However, permitting flexibility in the delivery of an intervention may result in inconsistent implementation fidelity. In this study, threats to implementation included unanticipated changes in the clinic environment, such as budget cuts to resources and staff turnover as a consequence of the current economic downturn. CONCLUSIONS: Momentum leading to sustainable implementation requires a continuous team effort and a stable environment; consequently, a successful implementation requires a structure that supports problem solving, communication, and evaluation.

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OBJECTIVES: We estimated the impact on cancer disparities in US states that have chosen or not chosen to expand Medicaid since passage of the Patient Protection and Affordable Care Act. METHODS: Data came from the 2013 Uniform Data System for colorectal and cervical cancer screening rates among patients of federally qualified health centers (FQHCs); the 2012 Behavioral Risk Factor Surveillance System for colorectal, cervical, and breast cancer screening rates; and the US Cancer Statistics (2007-2011) for colorectal, cervical, and breast cancer mortality-to-incidence ratios (MIRs). Dyads of Medicaid expansion decisions with cancer screening rates and MIRs were mapped using ArcMap. RESULTS: States that had not expanded Medicaid as of September 2014 had lower cancer screening rates, especially among FQHC patients. Overall, cancer MIRs were not significantly different by Medicaid expansion status. However, Southeastern states without Medicaid expansion tended to have higher cancer MIRs and lower screening rates. CONCLUSIONS: Disparities in cancer screening that already disfavor states with high cancer rates may widen in states that have not chosen to expand Medicaid unless significant efforts are mounted to ensure their residents obtain preventive health care.

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OBJECTIVE: Mammography is the most effective method to detect breast cancer in its earliest stages, reducing the risk of breast cancer death. We investigated the relationship between accessibility of mammography services at Federally Qualified Health Centers (FQHCs) and mortality-to-incidence ratio (MIR) of breast cancer in each county in the United States. METHODS: County-level breast cancer mortality and incidence rates in 2006-2010 were used to estimate MIRs. We compared breast cancer MIRs based on the density and availability of FQHC delivery sites with or without mammography services both in the county and in the neighboring counties. RESULTS: The relationship between breast cancer MIRs and access to mammography services at FQHCs differed by race and county of residence. Breast cancer MIRs were lower in counties with mammography facilities or FQHC delivery sites than in counties without a mammography facility or FQHC delivery site. This trend was stronger in urban counties (p=0.01) and among whites (p=0.008). Counties with a high density of mammography facilities had lower breast cancer MIRs than other counties, specifically in urban counties (p=0.01) and among whites (p=0.01). Breast cancer MIR for blacks was the lowest in counties having mammography facilities; and was highest in counties without a mammography facility within the county or the neighboring counties (p=0.03). CONCLUSIONS: Mammography services provided at FQHCs may have a positive impact on breast cancer MIRs. Expansion of services provided at the FQHCs and placement of FQHCs in additional underserved areas might help to reduce cancer disparities in the United States.

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Federally qualified health centers (FQHCs) offer primary and preventive healthcare, including cancer screening, for the nation's most vulnerable population. The purpose of this study was to explore the relationship between access to FQHCs and cancer mortality-to-incidence ratios (MIRs). One-way analysis of variance was conducted to compare the mean MIRs for breast, cervical, prostate, and colorectal cancers for each U.S. county for 2006-2010 by access to FQHCs (direct access, in-county FQHC; indirect access, adjacent-county FQHC; no access, no FQHC either in the county or in adjacent counties). ArcMap 10.1 software was used to map cancer MIRs and FQHC access levels. The mean MIRs for breast, cervical, and prostate cancer differed significantly across FQHC access levels (p < 0.05). In urban and healthcare professional shortage areas, mean MIRs decreased as FQHC access increased. A trend of lower breast and prostate cancer MIRs in direct access to FQHCs was found for all racial groups, but this trend was significant for whites only. States with a large proportion of rural and medically underserved areas had high mean MIRs, with correspondingly more direct FQHC access. Expanding FQHCs to more underserved areas and concentrations of disparity populations may have an important role in reducing cancer morbidity and mortality, as well as racial-ethnic disparities, in the United States.

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Having 911 telecommunicators deliver CPR instructions increases cardiac arrest survival, but limited English proficiency (LEP) decreases the likelihood callers will perform CPR and increases time to first compression. The objective of our study was to assess which 9-1-1 CPR delivery modes could decrease time to first compression and improve CPR quality for LEP callers. 139 LEP Spanish and Chinese speakers were randomized into three arms: receiving CPR instructions from a 9-1-1 telecommunicator (1) with telephone interpretation, (2) using alternative, simple ways to rephrase, or (3) who strictly adhered to protocol language. Time interval from call onset to first compression, and CPR quality were the main outcomes. The CPR quality was poor across study arms. Connecting to interpreter services added almost 2 min to the time. CPR training in LEP communities, and regular CPR training for phone interpreters may be necessary to improve LEP bystander CPR quality.

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BACKGROUND: To accelerate the translation of research findings into practice for underserved populations, we investigated the adaptation of an evidence-based intervention (EBI), designed to increase colorectal cancer (CRC) screening in one limited English-proficient (LEP) population (Chinese), for another LEP group (Vietnamese) with overlapping cultural and health beliefs. METHODS: Guided by Diffusion of Innovations Theory, we adapted the EBI to achieve greater reach. Core elements of the adapted intervention included: small media (a DVD and pamphlet) translated into Vietnamese from Chinese; medical assistants distributing the small media instead of a health educator; and presentations on CRC screening to the medical assistants. A quasi-experimental study examined CRC screening adherence among eligible Vietnamese patients at the intervention and control clinics, before and after the 24-month intervention. The proportion of the adherence was assessed using generalized linear mixed models that account for clustering under primary care providers and also within-patient correlation between baseline and follow up. RESULTS: Our study included two cross-sectional samples: 1,016 at baseline (604 in the intervention clinic and 412 in the control clinic) and 1,260 post-intervention (746 in the intervention and 514 in the control clinic), including appreciable overlaps between the two time points. Pre-post change in CRC screening over time, expressed as an odds ratio (OR) of CRC screening adherence by time, showed a marginally-significant greater increase in CRC screening adherence at the intervention clinic compared to the control clinic (the ratio of the two ORs=1.42; 95% CI 0.95, 2.15). In the sample of patients who were non-adherent to CRC screening at baseline, compared to the control clinic, the intervention clinic had marginally-significant greater increase in FOBT (adjusted OR=1.77; 95% CI 0.98, 3.18) and a statistically-significantly greater increase in CRC screening adherence (adjusted OR=1.70; 95% CI 1.05, 2.75). CONCLUSIONS: Theoretically guided adaptations of EBIs may accelerate the translation of research into practice. Adaptation has the potential to mitigate health disparities for hard-to-reach populations in a timely manner.

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INTRODUCTION: Dispatcher-assisted CPR (DA-CPR) can increase rates of bystander CPR, survival, and quality of life following cardiac arrest. Dispatcher protocols designed to improve rapid recognition of arrest and coach CPR may increase survival by (1) reducing preventable time delays to start of chest compressions and (2) improving the quality of bystander CPR. METHODS: We conducted a randomized controlled trial comparing a simplified DA CPR script to a conventional DA CPR script in a manikin cardiac arrest simulation with lay participants. The primary outcomes measured were the time interval from call receipt to the first chest compression and the core metrics of chest compression (depth, rate, release, and compression fraction). CPR was measured using a recording manikin for the first 3 min of participant CPR. RESULTS: Of the 75 participants, 39 were randomized to the simplified instructions and 36 were randomized to the conventional instructions. The interval from call receipt to first compression was 99 s using the simplified script and 124 s using the conventional script for a difference of 24s (p<0.01). Although hand position was judged to be correct more often in the conventional instruction group (88% versus 63%, p<0.01), compression depth was an average 7 mm deeper among those receiving the simplified CPR script (32 mm versus 25 mm, p<0.05). No statistically significant differences were detected between the two instruction groups for compression rate, complete release, number of hands-off periods, or compression fraction. DISCUSSION: Simplified DA-CPR instructions to lay callers in simulated cardiac arrest settings resulted in significant reductions in time to first compression and improvements in compression depth. These results suggest an important opportunity to improve DA CPR instructions to reduce delays and improve CPR quality.

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Limited English speaking communities face communication challenges during emergencies. Our objective was to investigate Chinese limited English proficiency individuals' perceptions of and inclination to interact with emergency communication systems. A telephone survey was conducted in Mandarin or Cantonese with 250 ethnic Chinese individuals who spoke little or no English. Respondents who spoke no English were less likely to name 9-1-1 as their first source of help for a medical emergency than those who spoke some English (p < 0.01). Those reporting higher levels of confidence in handling the situation were more likely to name 9-1-1 as their first source of help, as were those who listed 9-1-1 as their most trusted source of help (p < 0.01). For this group, the results indicate that calling 9-1-1 may require a sense of self-efficacy. Not calling 9-1-1 in a medical emergency can have serious health consequences, thus interventions are needed to increase confidence in accessing 9-1-1.

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OBJECTIVE: The objective of this study was to investigate the effect of language barriers during medical 9-1-1 calls, on the time to dispatch and level of medical aid (Basic or Advanced Life Support). METHODS: All 9-1-1 medical calls to two large call centers during one week for each of the months of August, October, December 2010 and February 2011, were reviewed for a notation of language barrier (LB). Non-language barrier calls were identified from the same time period such that there were an equal proportion of LB and non-LB calls by dispatch code and dispatcher. A total of 272 language barrier calls were identified. The computer-assisted dispatch (CAD) reports for the LB and non-LB calls were abstracted by research staff using a standard form, including: Start time of call, time to dispatch of BLS, time to dispatch of ALS, dispatch code, interpretation service use, on-scene upgrade to ALS, and on-scene downgrade to BLS. 9-1-1 recordings were abstracted for LB calls only to obtain information about use of interpreter services. Difference between LB and English speakers in time to assignment of BLS and ALS was examined using linear mixed effects models with log time as the outcome; language barrier, call center and dispatch code as fixed effects and dispatcher as a random effect. RESULTS: The effect of language barrier on time to BLS assignment was, on average, 33% longer (p < 0.001) and time to ALS assignment 43% longer (P = 0.008). A majority of the effect was due to the effect of interpreter use, which increased time to BLS by 82% and 125% for ALS, when compared to non-language barrier calls. Data from the 9-1-1 recordings showed an average of 49 seconds between connecting to the service operator and connecting to the language interpreter. Language barrier calls were more likely to be up- and down-graded, only statistically significantly so for on-scene downgrades. CONCLUSION: Language barriers increase time to dispatch and the accuracy of the level of aid dispatched during medical emergency calls. Decreasing the time to connecting to an actual interpreter when using an interpretation service could minimize existing delays.

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BACKGROUND: Failure to engage in emergency preparedness, response, and recovery contributes to the differential outcome experienced by limited English proficiency (LEP) populations. Little is known about how psychosocial factors influence LEP individuals' perception of emergency and their process of understanding, collecting, and synthesizing information. The purpose of this exploratory study is to understand how LEP conceptualize an emergency situation to determine when help is needed. METHODS: The authors conducted 4 focus groups with 36 adult Chinese LEP speakers living in Seattle. All discussions were audio-taped, translated, and transcribed. Coded text passages were entered into Atlas.ti for data management and model generation. RESULTS: Perception of an emergency situation affects LEP individual's ability to manage the crisis. Self-efficacy may be an important psychological variable that positively shapes an individual's response to an emergency situation by improving their confidence to handle the crisis and ability to connect to resources. Response to emergency resulting from this series of information gathering, synthesis, and utilization may not always result in a positive outcome. DISCUSSION: Self-efficacy in risk communication messages should be included to engage LEPs in emergency preparedness. Effective communication can increase LEPs' awareness of emergency situations and connecting LEP individuals with existing community resources may enhance LEPs' level of self-efficacy in emergencies.

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Health literacy is critical to effective communication between individuals and their health care providers. However there is little consistency in conceptualization and measure of health literacy. The objective of this review is to examine existing health literacy models and measures to assess their application to limited English proficient population in the context of information and communication technology. Communication platforms change with the development of new technology and existing health literacy models and measures are insufficient to capture the complex interaction that occurred in these communication platforms. A new health literacy model composed of four domains: sources, context, process, and outcome were introduced.

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Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.

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In the United Sates, populations with limited English proficiency (LEP) report barriers to seeking emergency care and experience significant health disparities, including being less likely to survive cardiac arrest than whites. Rapid utilization of 9-1-1 to access emergency services and early bystander cardiopulmonary resuscitation (CPR) is crucial for successful resuscitation of out-of-hospital cardiac arrest patients. Little is understood about Asian LEP communities' preparedness for emergencies. In this exploratory survey, we sought to assess intentions to call 9-1-1 in an emergency and knowledge of CPR in the Cambodian LEP community. We conducted an in-person interview with 667 Cambodian adults to assess their intentions to call 9-1-1 and their awareness of and training in bystander CPR. While the majority of participants stated that they would call 9-1-1 in an emergency, almost one-third of the sample would call a friend or family member. Awareness of CPR was very high but training in CPR was lower, especially for women. A higher level of English proficiency and greater proportion of time in the US was a strong predictor of CPR training and intention to call 9-1-1 in an emergency. This suggests that greater efforts need to be made to reach the most linguistically-isolated communities (those with little or no English) with emergency information in Khmer.

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Photovoice, a qualitative methodology using photography by study participants, is an ideal tool for collecting information on awareness of cardiovascular health from the perspective of persons of different cultural backgrounds and English-speaking abilities who are often subject to health disparities. Participants of Chinese, Vietnamese, and Korean ethnicity were provided disposable cameras to photograph their perceptions of scenes promoting or acting as barriers to cardiovascular health. After the pictures were developed, they returned for a discussion in their native languages to contextualize the stories told in their photographs. Group facilitators spoke the respective native languages and transcribed sessions into English. Twenty-three adults participated (7 to 9 persons per ethnicity), ranging in age from 50 to 88 (mean 71.6) years; 48% were women. The photographs stimulated conversations of knowledge, beliefs, and concerns regarding heart disease and stroke. Issues surrounding food and exercise were most dominant across ethnic groups, focusing on fat and salt intake and the need to remain active. Cultural beliefs and issues of emotional health, including stress and loneliness related to living in a new country, were also depicted. Photovoice provided insight into perceptions of cardiovascular health that is vital for developing health promotion and education interventions in limited-English-speaking communities.

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Effective communication during a medical emergency is crucial for an appropriate emergency medical services (EMS) response. This exploratory qualitative study explored intentions to use 9-1-1 in a Chinese speaking community and the barriers and facilitators to accessing EMS. Focus groups with Chinese adults who self-reported limited English proficiency were conducted. An inductive iterative approach was used to categorize and connect themes identified in the discussions. Language difficulties, negative perceptions of EMS, perceived costs of using emergency services, and no previous experience with 9-1-1 were commonly described as barriers to calling EMS during emergencies. Positive past experiences with EMS and encountering an emergency situation perceived as too great to manage alone are common facilitators for calling 9-1-1. Further exploration is necessary to assess barriers to calling 9-1-1 unique to specific communities, test findings, and tailor interventions to improve EMS communication.

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Cardiopulmonary resuscitation (CPR) is an effective intervention for prehospital cardiac arrest. Despite all available training opportunities for CPR, disparities exist in participation in CPR training, CPR knowledge, and receipt of bystander CPR for certain ethnic groups. We conducted five focus groups with Chinese immigrants who self-reported limited English proficiency (LEP). A bilingual facilitator conducted all the sessions. All discussions were taped, recorded, translated, and transcribed. Transcripts were analyzed by content analysis guided by the theory of diffusion. The majority of participants did not know of CPR and did not know where to get trained. Complexity of CPR procedure, advantages of calling 9-1-1, lack of confidence, and possible liability discourage LEP individuals to learn CPR. LEP individuals welcome simplified Hands-Only CPR and are willing to perform CPR with instruction from 9-1-1 operators. Expanding the current training to include Hands-Only CPR and dispatcher-assisted CPR may motivate Chinese LEP individuals to get trained for CPR.

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Cardiovascular disease (CVD) is the leading cause of death among Asian Americans, the majority of whom are foreign-born. However, CVD and risk factor data is sparse for specific Asian immigrant populations. To assess knowledge and understanding of CVD and risk factors within Chinese, Korean and Vietnamese immigrant populations, we conducted eight focus groups of 77 participants between 36 and 84 years old. Participants correctly identified signs and symptoms for heart attacks while knowledge about stroke was incomplete. While poor diet, lack of exercise, older age, and high cholesterol were frequently discussed as risk factors, mechanisms perceived as contributing to heart disease were influenced primarily by non-Western paradigms. Non-Western remedies were discussed in detail among Chinese and Vietnamese participants. All participants desired more information, and identified barriers to effective communication with healthcare providers. A deeper understanding of beliefs and barriers faced by Asian immigrants can help guide health promotion efforts.

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BACKGROUND: Colorectal cancer (CRC) screening rates among Asian Americans are 30-50% lower than among Whites. Using practice management and electronic medical records data from a community health center, we examined the association of CRC screening with continuity of care and comorbidity. These variables have not previously been studied in Asian American and limited-English proficient populations. METHODS: After obtaining IRB approval, we extracted data in 2009 on age-eligible Vietnamese patients who had one or more clinic visits in the prior 24 months. Our analysis examined associations between CRC screening (per current US Preventive Services Task Force guidelines) and clinic site, demographics, insurance status, continuity of care, comorbidities, and provider characteristics. RESULTS: We identified a total of 1,016 eligible patients (604 at Clinic 1 and 412 at Clinic 2). Adherence to CRC screening was lower for patients who were male; lacked insurance; had only one medical visit in the past 12 months; and had no assigned primary care provider. Our multivariable models showed higher screening rates among patients who were female; had public health insurance; and had more than one medical visit in the past 12 months, regardless of high or low continuity of care. CONCLUSIONS: We found no association between higher continuity of care and CRC screening. Additional primary care systems research is needed to guide cancer screening interventions for limited-English proficient patients.

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