Language Services Quality Improvement at the Cambridge Health Alliance

 By Ranjani Paradise, PhD

Here at ICH, we work in close partnership with the Cambridge Health Alliance (CHA) on a number of research, quality improvement, and evaluation projects. CHA serves an extremely ethnically and linguistically diverse patient population. For example, last year, one in three of CHA’s outpatients, and one in four of inpatients, spoke a language other than English at home!

Because of this incredible linguistic diversity, CHA has long been working to ensure that limited English proficient (LEP) patients can communicate with their doctors in safe and effective ways. To support communication with LEP patients, the Multicultural Affairs and Patient Services (MAPS) Department offers professional interpreter services in three modalities: face-to-face, telephone, and videoconference. In addition, MAPS offers language testing for multilingual providers who wish to speak directly to their LEP patients.

For one of my ICH projects, I work with MAPS on language services quality improvement. Over the last several months, a major focus of our work has been to reduce the use of patients’ family members and friends as interpreters, as this practice can compromise the quality of communication in a number of ways.

When you think about potential risks related to using family/friends as interpreters, what comes to mind?

Perhaps the most obvious risk is that family members and friends are often not familiar with medical terminology, and may make errors or omissions during interpretation that could compromise patient safety. If an interpretation error or omission results in harm to the patient, this can have severe legal and financial consequences for the hospital. In one well known case, misinterpretation of a single word resulted in a $71 million lawsuit against a hospital after the patient ended up with quadriplegia (paralysis of both the arms and legs). This illustrates the fact that interpretation errors can present truly serious patient safety concerns as well as liability issues.

Another problem with using family members and friends to interpret is that they have a personal connection with the patient. Because of this:

·        Family members and friends may choose to withhold bad news or insert personal opinions into the conversation, which can compromise communication accuracy.

·        The patient, as well as the family member or friend, may be uncomfortable discussing sensitive information, such as sexual or mental health. This can create a situation where important information is not disclosed to the doctor. Imagine having to discuss the sexual history of a parent, and I’m sure you’ll understand why this can be a problem!

Communicating through a family member or friend may prevent a patient from being able to tell you about domestic violence or other abuse. In fact, a physician friend of mine (not at CHA) experienced this firsthand – a patient came to the hospital and she didn’t speak English, but her husband did. The hospital was not able to bring in a professional interpreter right away, so the patient’s husband interpreted. When the professional interpreter was later brought in, my friend had a chance to talk with the patient while the husband was out of the room. The patient stated that her husband had been abusing her and that she did not trust him to interpret for her. Patients should feel safe sharing this kind of information with their doctors, and using a family member or friend to interpret can compromise this.

As part of our quality improvement work, we monitor data each month to track how often family and friends are being used to interpret at CHA sites. We have also surveyed providers to understand reasons behind this practice. We got some terrific information from the survey: many providers were candid in sharing the challenges they face in caring for LEP patients, which really helped us understand their perspectives on this issue. We’re currently working on using the survey findings to identify resources that we can provide to help providers communicate with their LEP patients in the safest and most effective ways possible.

I’m glad to be a part of the team and look forward to supporting MAPS in their efforts to keep improving LEP patient care at CHA!

Ranjani Paradise, PhD is a Research Associate II at the Institute for Community Health.

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Engaging Youth through PhotoVoice: ICH Intern Perspective II

By Alice Chan, ICH Intern

What a wonderful way to start off the New Year with the third session of our Youth Photovoice project, funded through the Saffron Circle, in Malden! After a successful last session, Shalini and I were ready to move forward with the next (and exciting) step of the project – the Photography Workshop! The objective of this session was to train the youth with a basic tutorial in using digital cameras, generously loaned to us by Yolanda Ortiz from Wayside Youth, before giving the youth the cameras to capture trial run photos.

It was important to review the principles and importance of the ethics involved in taking photos and so I led a team building exercise to refresh the youth’s memory on these ethical principles developed at a prior session. Everyone proved to be very knowledgeable about the “dos and don’ts” with their soon-to-be-assigned cameras. Following this brief review came the photography tutorial part of our session. Who better to lead this photography workshop than our fellow Cambridge Health Alliance colleague Dr. Freeman Changamire, MD, ScD, an expert and enthusiast in all things photography? Dr. Changamire led an outstanding demonstration of the cameras’ functions and settings. Thanks to his guidance, I am confident that the youth are well-prepared to spend the next month taking pictures that capture their attention and convey personal meanings in relation to mental health.

Now that the youth have finally received their digital cameras, they have an opportunity to capture their thoughts and ideas on the topic of mental health and wellness via photos. The goal from now until the next session is for the youth to experiment and be creative as they are exploring their community for those fascinating and noteworthy photo opportunities.

As the cliché goes: a picture is worth a thousand words. At the next session, that is exactly what we will be proving (that is, we will be putting, or “analyzing,” the images with words). Stay tuned for more updates!

Alice Chan is an intern at ICH working with Shalini Tendulkar, ScD, ScM on the Youth Photovoice project through the ICH Education Program. Ms. Chan is a sophomore in the Department of Psychology at Tufts University.

For more information on internship opportunities like this one at ICH, please click here!

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

It’s Healthy Weight Awareness Week – Let’s Celebrate Our Bodies in Movement

By Bernice Raveche Garnett, Guest Blogger

ICH welcomes guest blogger, Bernice Raveche Garnett:

It is of no coincidence that the Annual Healthy Weight Awareness Week is smack in the middle of January – following the perennial New Year’s resolutions to lose weight that are usually coupled with fad diets, excessive exercise and self-blame. The mission and goal of Healthy Weight Awareness Week – , as stated by the sponsor, the Healthy Weight Network - is a “time to celebrate healthy diet-free living habits that last a lifetime and prevent eating and weight problems.”

I find this mission statement extremely refreshing – not often do we find the word “celebration” next to “diet-free living.” In our current culture, we often forget to celebrate our bodies! There is mixed evidence for the long-term effectiveness of a variety of different popular diets for sustained weight loss. While interviewing community-nominated leaders of health and physical activity in Cambridge,MA as part of an ICH community-based participatory research project dedicated to understanding persistent racial/ethnic disparities in excess weight among Cambridge youth, many of these “positive deviants” reflected on their personal successes and struggles with creating and maintaining a healthy lifestyle for themselves and their families. One respondent stressed the importance of personal health (as opposed to a focus on weight) as being the most effective and sustainable motivator for healthy weight maintenance and lifestyle change:

“Most people – they [are] doing it for other people - but when you sit down and think ‘I am doing it for me and my health,’ then you are going to keep at it.”

And of course – weight is not the only measure of health. The emphasis on body mass index (BMI) as a barometer of health has diverted much attention from other indicators of health and wellness. There are significant health consequences of excess weight, including increased risk of diabetes, cardiovascular diseases, cancers, and stroke. The relationship between BMI and health is complicated (what isn’t!) and often contested. For example, a recent meta-analysis conducted by researchers from the Centers for Disease Control and Prevention (CDC) on the relationship between BMI and all-cause mortality published in this month’s Journal of the American Medical Association (JAMA) has sparked lots of national media attention. The authors reported that being overweight was actually associated with a 6% decrease in mortality among adults; however in an interview with NPR, Harvard’s Walter Willet criticized the author’s methods.

The above mentions of scientific studies that have contributed to our understanding of the relationship between weight, health and diet is not meant to further complicate the discussion – but rather to provide room for a different discourse. Gaining national momentum and advocacy attention is the Healthy at Every Size (HAES) movement, which “acknowledges that good health can best be realized independent from considerations of size. It supports people—of all sizes—in addressing health directly by adopting healthy behaviors.”

With national focus on ending the obesity epidemic, I often worry that we are further marginalizing overweight individuals and increasing weight bias and stigma, which can further paralyze individuals in making healthier choices. Movements like HAES hope to promote size diversity in order to encourage healthy eating and active living through a focus on health – not weight.
Given the tag line of Healthy Weight Awareness Week – let’s do something drastic this week – celebrate our bodies in movement.

“Happiness is a state of activity” ~ Aristotle

Bernice Raveche Garnett has been a consultant at ICH for 4 years, working on various projects including: a Cambridge healthy weight disparities community-based research project, funded by Harvard Catalyst; the Cambridge Healthy Children Task Force; and Shape Up Somerville initiatives and on-going evaluation and planning efforts. Ms. Garnett holds a master’s degree in public health from Columbia University Mailman School of Public Health, and is currently a doctoral candidate at the Harvard School of Public Health in the department of Social and Behavioral Sciences, graduating in May 2013. Her dissertation focuses on the intersections of multiple forms of discrimination among ethnically diverse adolescents, highlighting the consequences of weight-based discrimination and bullying for the mental and physical health of adolescents.
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The views expressed on the Institute for Community Health blog page are solely those of the blog post author, and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Engaging Youth through PhotoVoice: ICH Intern Perspective I

By Alice Chan, ICH Intern

The second session of our Youth Photovoice project funded through Saffron Circle took place on Sunday, November 18th at the Chinese Culture Connection (CCC). It was great that our session took place in Malden, the home to most of our high school participants. After not seeing the youth for a month, I was excited to see them at the meeting! I’m sure they were also excited to take the next step in our exciting project!

Our second meeting focused on introducing the principles and importance of ethics, something that our youth needed to know about before receiving cameras to photograph their communities and lives. I’m sure our easy-to-read and creative ethics powerpoint slides helped to drive the message home! The slides and our quiz should be adequate resources for the youth to have before snapping a photo of a person. After this session, the youth will receive cameras to start on this exciting project – capturing pictures to represent what “mental health” means for them.

As the youth marked down the upcoming meeting dates on their Project Calendars, I felt optimistic about the project’s future. Along with the youth, I too expect to become better aware of mental health in my community and understand mental health’s presence in the Asian American community. Pictures are fun, simple, and creative works of art that express our emotions, stories, and ideas. Who wouldn’t like to have plenty of photos to share and show the world? I know I would. That being said, let’s run wild with our cameras!

The Saffron Circle Youth Photovoice Project is one of ICH’s many projects featuring novel Qualitative Methods and a Community-Based Participatory Research approach.

Alice Chan is an intern at ICH working with Shalini Tendulkar, ScD, ScM on the Youth Photovoice project through the ICH Education Program. Ms. Chan is a sophomore in the Department of Psychology at Tufts University.

For more information on internship opportunities like this one at ICH, please click here!

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

Dissemination: Strategies for doing it right in community based participatory research

By Shalini A. Tendulkar, Institute for Community Health, Stacey King, Cambridge Public Health Department

For academic researchers, dissemination typically involves the sharing of research findings through peer-reviewed journals. In the world of community-based participatory research or evaluation, dissemination can take on many different forms. Regardless of whether you ultimately disseminate your work here are few strategies to help you along the way…

• Have an open discussion about dissemination with your partners and collectively identify the potential shared value of dissemination.
• Collectively identify dissemination goals with partners early on in the project. Ask what would be most useful to partners. For example, they may want to include information and photos on their website that would be important to their own stakeholders. This may be relatively simple, but extremely valuable. Revisit these discussions at checkpoints throughout the project timeline.
• If you are an academic partner, recognize that community partners are generally not in the “business” of writing articles. Be respectful of this when discussing dissemination with community partners.
• Take time to learn how partners typically communicate with their stakeholders. Include some ways to work within their usual outreach. For example, they may host community meetings or hold events for families. These may be opportunities to co-present or staff an information table. Community-based organizations, like other entities, are always looking for ways to demonstrate their value to the people they serve.
• Be open to considering non-traditional forms of dissemination. Click here to view the Institute for Community Health’s dissemination catalog to help start a conversation with your partners about the various forms of dissemination.
• When developing grants with partners, try to allocate time and money to dissemination efforts if possible. If you have examples of dissemination strategies that have worked well in the past, it’s always useful to include these in a discussion. This will help the partners visualize better what could be effective for them.
• Give all your partners an opportunity to be involved in dissemination efforts and recognize their contributions appropriately either through co-authorship or other types of acknowledgements.
• Be focused in selecting dissemination strategies and set the group up for success. Generating a longer list of ways to disseminate will make everyone feel overwhelmed. Decide what you can do this year, what you can do next year, and so forth. Make sure that the group feels the plan is realistic and has value to everyone. Check in periodically on what is working and adjust the plan accordingly. Everyone wants to feel that they are contributing to a successful effort.
• When considering dissemination it’s important to recognize that some participants may have very tightly controlled communication policies compared with others. It’s important to understand these policies and involve the appropriate individuals in making decisions about dissemination and how communication occurs. Especially when media is involved, you’ll only have one chance to “get it right.” Media has special challenges, and policies vary from agency to agency.

What other strategies have worked for you?

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.

New ICH website launches!

By Brianna Mills, Adriana Bearse, Shalini Tendulkar, Lisa Arsenault, Eileen Dryden, Lise Fried


Hi, and welcome to the new ICH website. It’s been a long time coming, but our site is now more like us: easy to connect with and focused on utility and accessibility!



We’re very proud of the team here at ICH who have spearheaded this update. If you click on the names of the authors of this blog post, you can learn more about them on their brand new profile pages, along with the rest of our staff.

We would also like to thank our Executive Director, Senior Staff, and our staff and partners who have helped out with this project. Special thanks go out to our social media consultant, Doreen Nicastro, Steve Carter and the IT department at the Cambridge Health Alliance, and the designers and developers at Electric Pulp, who made this website a reality!

Here’s a quick tour of the site…

Connecting to the community is at the heart of what we do here at ICH, and we’re highlighting that work on our new site, with pages dedicated to our partners, our community initiatives, and our internship program. We’ve revamped the descriptions of our products and services as well, adding new detail about our approach and expertise. We’ve also expanded our project profiles and catalogued our publications, including abstracts, reports and journal articles.

Finally, check out our blog for project updates, news and personal posts from ICH staff that will give you a sense of who we are and what it’s like to work with us.

This is a big change for us, and we’d love to get your comments below, or hear from you on Twitter, Facebook or via email. Welcome once again, and let us know what you think!

Using the Census to Make Sense of Your Community

    By Lisa Arsenault, PhD, Shalini Tendulkar, ScD, ScM, Nazmim Bhuiya, MPH, Kelly Washburn, MPH, Lise Fried, DSc, MS

The first population census of the United States was conducted back in 1790 when the population was just under 4 million.  The US Census Bureau has come a long way since those early days, yet the images that come to mind are still probably pretty archaic — data enumerators going from door to door with pencils and clip boards and maybe even on horseback in the early years!  Well today the Bureau works like a well-oiled machine, coordinating a monthly data collection of 250,000 households via mailed questionnaires, computer assisted telephone interviews, and in-person interviews.  This data (called the American Community Survey or ACS) is combined to give us very detailed estimates each year of who is living in the US.  In contrast, the decennial census (conducted every 10 years) collects only basic information on gender, race/ethnicity, household composition, and housing tenure.    

Recent news that the US House of Representative voted to cut funding for the ACS (and the Economic Census) may lead you to conclude that the data from such surveys cannot be that informative or useful.  However, nothing can be further from the truth, particularly for those of us working with communities and public health-related programs at the local level!  US Census Bureau Director, Robert M. Groves, does a wonderful job explaining the impact of the proposed defunding in his Director’s Blog.  Here we hope to highlight several examples of how the Institute for Community Health has used data from the American Community Survey to support the work of our community partners and further research into the health of local populations.

One nearly universal topic of interest is poverty.  The ACS is one of the primary sources for poverty data and we work on this topic frequently.  Recently, ICH pulled together a presentation for the Community Affairs Department of Cambridge Health Alliance that included the proportion of individuals living below the poverty line in Cambridge, Chelsea, Everett, Revere, and Somerville, MA.  We paired the data with information that ICH had collected on the weight status of adults in these cities and were able to illustrate a relationship between poverty and obesity at the population level.  The data provided a catalyst for the Community Affairs group to begin discussions related to food justice within their service communities.
Census data is also an integral part of our work as evaluators of public health programs.  The Massachusetts Alliance on Teen Pregnancy’s Youth First Initiative is currently testing community-wide approaches to reducing teen pregnancy in Springfield and Holyoke, MA.

As evaluators of their efforts, ICH has pulled data from the ACS to determine the number and proportion of teens residing in each city by census tract.  This data will be mapped and overlaid with the locations of the community health centers that have partnered with MATP on the project.  This information will provide Youth First with invaluable information on where the at-risk population resides within the community and how well the clinical providers are geographically positioned to serve the target population.   Such information can help a program evaluate and target their efforts, use resources more efficiently, and achieve a greater impact on a community’s health.

Finally, we frequently use census data to more generally describe a community’s population and its changes over time.  ICH supported the data efforts of the “Well Being of Somerville Report 2011” which was released last fall by the Somerville Health Agenda at Cambridge Health Alliance.  Using census data, we were able to describe the current population of Somerville, MA and show how the population’s characteristics have changed over the past decade.  Indicators including age, race/ethnicity, poverty, housing, language, country of origin, income, and educational attainment were all obtained from the US Census and ACS for Somerville.  And importantly, these indicators are all considered ‘determinants of health’ or factors in peoples lives that can affect one’s health in positive and/or negative ways.  Collecting these types of data and examining them alongside other types or sources of data yield great insight into the assets a community possesses as well as the challenges it may face from a public health perspective.  Overall, the this report is currently serving as a tool for local leaders and stakeholders to determine the public health needs of Somerville and inspire future planning efforts in the city.

We hope you’ve been impressed by how integral the data from the US Census Bureau is to what we do to improve health.  Our community partners rely on these data to inform their efforts — whether spurring new conversations, planning and targeting programmatic activities, or generally assessing the characteristics of a community.  There simply is no substitute for the American Community Survey.   And the most amazing part?   The data are there, right now, available online to anyone who is interested in learning about their own community.  Check it out!

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The views expressed on the Institute for Community Health blog page are solely those of the blog post author(s), and do not necessarily reflect the views of ICH, the author’s employer or other organizations with which the author is associated.