A Complex Intervention to Improve Intercultural Communication and Aboriginal Patient Outcomes: Which Components Worked?

Abstract


Introduction
Effective communication between Aboriginal language-speaking patients and healthcare providers requires cultural respect and appropriate interpreter use.Use of professional interpreters can improve patient outcomes [1,2] but in Australia's Northern Territory (NT), where dozens of languages are commonly spoken [3], uptake of interpreters is low for people who primarily speak an Aboriginal language [4 ].Poor communication compounds existing health disparities.Adverse outcomes for Aboriginal patients including death have been attributed to communication failures [5][6][7].One outcome considered a consequence of impaired communication is the high rate of self-discharge from NT hospitals, with resulting health costs to individuals, negative impacts on staff morale, and high health system costs [8][9][10].
Previously we found that healthcare providers at the largest tertiary NT hospital lack skills in identifying language need or working with interpreters, face a convoluted bookings process and may experience frustration due to interpreter unavailability [4].
In response, Top End Health Services which manages Royal Darwin Hospital, supported the employment of an Aboriginal Interpreter Coordinator for a 12-month pilot period.The study team supplemented this with additional activities to provide a 'bundle' of interventions: training sessions for healthcare providers about working effectively with Aboriginal interpreters, and clinical championing of interpreter use, whereby volunteer medical o cers promoted interpreter use in the hospital.The concept of 'care bundles' is common in hospital practice to improve quality of care.[11] We conducted a quasi-experimental pilot study using interrupted time-series analysis to determine effects of the intervention on interpreter bookings made (primary outcome measure), bookings completed and self-discharge rates by Aboriginal people (secondary outcomes), during a 24-month baseline period (April 2016 -March 2018) and a 12month intervention period (April 2018 -March 2019), and found that study activities were associated with immediate and up-trending increases in Aboriginal interpreter bookings, and a downtrend in selfdischarges.[12] The aims of this paper are to explore the likely reasons for the improved interpreter uptake identi ed during the study period; speci cally to determine which components of the intervention should best be invested in by the health service, and other health services into the future, to sustain change.Further, we wished to explore the likelihood of a causal association between study activities and the decrease in selfdischarge rates which occurred during the study intervention period.

Design
This is an evaluation of a complex intervention [13] using the Template for Intervention Description and Replication (TIDieR) as a framework [14].Each intervention component is described in the template according to what it comprised, who implemented it, how, where, when and how much, whether modi cations were made during the study and reach of each component (how well it was implemented).
Main ndings are published elsewhere.[12] In brief, the primary outcome, which measured healthcare provider behaviour, was the proportion of Aboriginal patients needing an interpreter for whom an interpreter booking was made in the intervention period ( A 'cultural safety' lens underpinned delivery and evaluation.Cultural safety requires organizations and individuals to critique existing power structures and review the policies, procedures, and practices which maintain health inequity [16].A monitoring framework has been proposed by the Australian Institute of Health and Welfare to guide assessments of 'Cultural safety in healthcare for Indigenous Australians' [18].The study responded to this framework by addressing how health care services are provided (whether Aboriginal interpreters are used) and Indigenous patients' experience of health care (re ected in selfdischarge rate).Additionally, implementation and delivery included Aboriginal leadership.Note, the term 'Indigenous' refers collectively to Aboriginal and Torres Strait Islander peoples.Our study focused on Aboriginal patients, who form the large majority of Indigenous patients at the study setting.

Setting
Royal Darwin Hospital is a 360-bed tertiary centre in the NT.Around 100 Aboriginal languages and dialects are spoken in the NT [3].Prior estimates indicate approximately 60% of Aboriginal people at Royal Darwin Hospital [4] and in the NT [19] speak an Aboriginal language as their rst language.Community consultation indicates that the majority would bene t from an interpreter in healthcare interactions [20].We conservatively estimated that 50% of Aboriginal patient separations would bene t from an interpreter.Royal Darwin Hospital uses the offsite Aboriginal Interpreter Service which services a number of government agencies.Interpreters are available for face-to-face, telephone or audio-visual interpreting.The service also provides one 'rostered interpreter' to the hospital on weekdays for four hours.

Data
All Aboriginal interpreter bookings data for 1 April 2016-31 March 2019 were provided by the NT Aboriginal Interpreter Service including ward, language and whether completed or cancelled.Royal Darwin Hospital separations data (discharged or transferred, left against medical advice/discharge at own risk, died, unknown, other or change of care type) were used as a count of admissions.Data were obtained for all Indigenous people for the same timeframe..In this paper we use 'self-discharge' synonymously with 'left against medical advice/discharge at own risk'.. Torres Strait Islanders, admissions for dialysis, same-day procedures, private hospital, outpatient cardiology, borders and care provided in psychiatry units (where interpreter use is already high) [4] were excluded.

Evaluation and analyses
The TIDieR framework was populated for each study intervention component: employment of an Aboriginal Interpreter Coordinator, 'Working with Interpreter' training, and championing of interpreter use.
Timing of activities was compared to the interrupted time-series analysis plots of interpreter bookings and self-discharge rates.[12] Other activities underway at the hospital independent of this study that may have impacted study outcomes were ascertained and documented through discussions with other clinicians and researchers and members of the health services executive.Health service data custodians and analysts were consulted to determine whether capture of hospital separations data had changed during the period 2016-2019.Quantitative analysis was undertaken using Stata version 15.1.[21] Simple linear regression was used to examine the relationship between numbers of interpreter bookings made per month and self-discharge rates.

Original study ndings
As previously reported, interpreter booking requests increased -especially telephone or AV interpretingand admissions ending in self-discharge decreased in the intervention compared with baseline periods (Table 1).[12] Self-discharge as a proportion of all discharges (using predicted values from the regression model) fell from 12.0% in April 2018 to 10.1% in March 2019.The most common language requests were for Yolŋgu Matha, Murrinh-Patha and Kunwinjku.

Evaluation of intervention components using the TIDieR framework
The study intervention period commencement date was chosen to coincide with the date of commencement of the Aboriginal Interpreter Coordinator.The Coordinator had training and experience as an Aboriginal Health Practitioner and Aboriginal Liaison O cer and was familiar with the health service (Table 2).While the role was conceived as being a coordinator role to improve e ciency and ease of bookings, it was in fact realised somewhat differently, focussing more on Aboriginal staff support, particularly provision of mentoring for interpreters on assignment to the hospital.It became apparent that the complexity of the hospital -the physical structure and processes and procedures -can be daunting to Aboriginal interpreter staff, such that a support role helping them to navigate the complex environment was greatly valued.'Working with Interpreter' training was provided for emergency and surgical division doctors in September and October 2018, and for all new interns during orientation in January 2019 shortly before the intervention phase of the study ended.While the sessions were well-received (unpublished), no 'spikes' or uptrends in Aboriginal interpreter use was seen following these sessions [13].Rather the increase in interpreter uptake (and decrease in self-discharge rate) coincided with commencement of the Aboriginal Interpreter Coordinator and continued to steadily improve thereafter.
Clinical championing of interpreter use comprised hospital junior medical o cers who ensured appropriate use of interpreters in their clinical practice and advocated use to colleagues.In addition to these volunteers, a number of hospital clinicians across levels of seniority have been longstanding champions for interpreter use and cultural safety.For this study, champions met regularly with the study team to discuss ways to promote Aboriginal interpreter use.This component was incorporated since championing by peers or organisational leaders is considered an important strategy to achieve sustainable clinician behaviour change [22].However the champions in this study were not in leadership positions.As junior medical o cers, they rotated through different rosters including night shifts.They had power to change their own practice and potentially in uence colleagues, but since only three champions were engaged, their ability to impact a large health service was considered to be relatively low (Table 2).

Other activities during 2016-2019
Independent this study, an initiative in the hospital cardiac care unit from January 2018 comprised production and distribution of Aboriginal language lanyard cards matching community names with languages to help determine what language the patient might speak, and providing a guide to booking an interpreter including phone and email contacts [23].This initiative might have contributed to improved interpreter uptake.It commenced during the study baseline period but may have gained momentum during the intervention phase.
Other initiatives aiming to decrease self-discharge and improve cultural safety had been occurring, guided by TEHS' Organisational Culture Charter, the Northern Territory Aboriginal Cultural Security Framework [24] and the Australian National Safety and Health Service Standards [25].The hospital foyer was renovated to position the Aboriginal Support Unit at the entrance, display Aboriginal artworks and acknowledge traditional owners (works completed December 2017).Additionally, in 2016 self-discharge data were included as a key indicator in monthly performance reports to motivate reductions in selfdischarge rates.These activities may be contributing to growing momentum in provision of more culturally safe care (including increased interpreter use for Aboriginal language speakers) that improves patient experience and thereby decreases self-discharge.However, the activities pre-dated the study intervention period and therefore are unlikely to have had a large role in contributing to the speci c changes shown in the interrupted time-series analysis.

Relationship between self discharge and interpreter bookings
During the whole 3-year study period (baseline and intervention phases), a statistically signi cant inverse association occurred between interpreter bookings and likelihood of self-discharge among Aboriginal inpatients (Fig. 1); regression coe cient − 55.2 (95% CI -99.5 to -10.9).

Discussion
a hospital-based multi-component intervention to improve Aboriginal interpreter uptake, a signi cant increase in the proportion of Aboriginal patients gaining access to an interpreter occurred, and self-discharge rates among Aboriginal people fell.In this analysis, we have determined that employment of an Aboriginal Interpreter Coordinator was likely the most important activity contributing to these ndings, given the change in intercept in the time-series analysis noted on commencement of the role, and lack of noticeable 'spikes' coinciding with the timing of the 'Working with Interpreter' training sessions.The impact of the three junior clinical champions we considered likely to be smaller.However, in teasing apart the potential components, we acknowledge that there may have been synergism from the 'bundled' interventions; multi-component strategies are acknowledged as being potentially more successful in changing health systems and clinician behaviour than single-strategy approaches [11,26].
Previous research has identi ed that interventions seeking to 'restructure and reinforce new practice norms and associate them with peer and reference group behaviours' may be successful in achieving behaviour change [26].In this study, the activities were intended to make it easier for clinicians to recognise the need for Aboriginal interpreters, book an interpreter, and interact with the interpreter and patient more effectively -and to 'normalise' this behaviour.Approaching this through training and championing, as well as providing the mechanism to enable new behaviours (through a Coordinator) led to success in achieving the study's goals of increased interpreter uptake and improved patient outcome, measured as a decrease in self-discharge.
The association between interpreter bookings and self-discharge rates was explored in more detail.The logic is that better-informed patients who have access to an interpreter have better comprehension of the need to receive hospital care, and better experience of care, leading to a lesser likelihood of selfdischarge.Not only did interpreter uptake and self-discharge show signi cant changes in gradient during the 12-month study implementation phase compared with the baseline period as already described [12]; these outcomes also showed a linear (inverse) relationship with each other throughout the 3-year baseline and intervention period (Fig. 1).This provides internal validity in attributing the fall in selfdischarge rates to the rise in interpreter bookings.This is to our knowledge the rst time this association has been shown, and corroborates previous suggestions of a likely association between better communication and lower self-discharge rates [8][9][10].While this lends weight to there being a causal relationship between these measures, data linked by patient identi er would provide much stronger evidence for a direct association between access to an interpreter and reduction in self-discharge; this needs to be explored in future research.
Non-study activities may have contributed to the changes seen.The hospital has been striving to decrease self-discharge, currently targeting 7% (3% lower than was attained by the end of this study).New measures to improve cultural safety for Aboriginal people have been implemented.However, the study intervention dates showed a particular association with the change in outcomes.
A limitation of this study is the di cultly genuinely measuring 'reach' of each intervention component.
Qualitative data exploring why clinicians do or don't use interpreters may have helped determine the relative importance of different study components.Related in-depth qualitative work is underway focusing on remaining barriers [27] and further system-strengthening activities are planned to scale up these study ndings and to implement the Australian National Standards on Quality and Safety in Health care, which include 'communicating for safety' [25].We have used TIDieR as an evaluation tool whereas it was developed as a descriptive tool for intervention components [14].We suggest it has a useful role in this regard due to the clarity and simplicity of the structure.We also recognise that the success attributed to an Aboriginal Interpreter Coordinator role may have depended to a large extent on the particular skillset of that individual, who was con dent in engaging with clinicians and other relevant personnel.Replicating success in the future may require careful selection in appointing to such a role.

Conclusions
Use of interpreters for people who primarily speak an Aboriginal language is one critically important component of culturally safe communication in healthcare.Improvements in interpreter uptake, with associated change in health behaviours and outcomes, can be achieved through systems changes incorporating Aboriginal leadership.Further strategies to escalate the proportion of Aboriginal patients getting access to high-quality communication in this setting are required to improve health outcomes.To achieve the much greater-magnitude change now required, substantial investment in combined strategies for upscaling Aboriginal interpreter use addressing supply, demand, e ciency and effectiveness, are needed.

Declarations
Ethics approval and consent to participate Approval was provided by the Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-2017-3007 and HREC-2018-3245).Individual participants were not recruited and consent to participate was not required.
Consent for publication NA to study implementation; CR runs the interpreter service and helped implement interpreter provision; AC co-designed the study and provided academic leadership.

1
April 2018-31 March 2019) compared with the baseline period (1 April 2016-31 March 2018).Secondary outcomes were: proportion of Aboriginal interpreter bookings completed in the intervention compared with baseline period and proportion of Aboriginal admissions ending in self-discharge during the two periods.The study was conducted as part of a collaborative initiative called the 'Communicate Study' between Menzies School of Health Research, Royal Darwin Hospital and the NT Aboriginal Interpreter Service.

Ethics
Approval was provided by the Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-2017-3007 and HREC-2018-3245).

Figures
Figures

Figure 1 Self
Figure 1

Table 1
Royal Darwin Hospital separations (Aboriginal people) and interpreter booking requests during the baseline and intervention periods The proportion of Aboriginal patients estimated to bene t from an interpreter was set at 50% of hospital separations for Aboriginal people, where Aboriginal people were those coded as 'Aboriginal' or 'Aboriginal and Torres Strait Islander'.'Torres Strait Islander and not Aboriginal' were excluded.
*The proportion of Aboriginal patients estimated to bene t from an interpreter was set at 50% of hospital separations for Aboriginal people, where Aboriginal people were those coded as 'Aboriginal' or 'Aboriginal and Torres Strait Islander'.'Torres Strait Islander and not Aboriginal' were excluded.**hospital location for telephone and audio-visual interpreting not provided ***hospital location for telephone and audio-visual interpreting not provided

Table 2
Description of study intervention activities according to the Template for Intervention Description and Replication (TIDieR) checklist of hospital separations of Aboriginal people at Royal Darwin Hospital are for Aboriginal language speakers who would bene t from the use of an interpreter, but few get access.Ineffective communication about health matters including diagnosis, treatment and prognosis is associated with poor health outcomes, while interpreter use can improve outcomes.Systems changes are needed to support greater uptake of interpreters.High quality inter-cultural communication is one component of culturally safe care.