Increasing Utilization of Preventative Care in Asian American Women in MA

Why are screening rates lower? We report on community-based research to explore factors influencing breast and cervical cancer screening behaviors among Asian American women in Massachusetts Despite high rates of health insurance, screening rates are lower than other ethnicities and we sought to learn why We conducted focus groups with Chinese, Vietnamese, and South Asian American women in MA

Preventive Care Preventive services are an effective way to screen for disease and reduce the burden of disease through early detection  Example is mammography for breast cancer screening The Patient Protection and Affordable Care Act (ACA) mandate Universal health insurance coverage Health plans offer mammograms and Pap tests free of charge

Barriers to Utilization of Preventive Care Primary care physicians (PCP) perceive barriers to screening Patients: lack of knowledge, motivation, fear, and embarrassment Physicians: lack of belief in test efficacy Practices: time constraints System: lack of or inadequate insurance and co-payments

Asian Americans in Massachusetts Preventive care Asian Americans in MA have lowest rates of participation in preventive activities and breast and cervical cancer screenings Lowest for low income and recent immigrants, also for certain ethnic groups: Vietnamese American Yet Asian Americans in MA are well-covered by insurance Only 3.1% Asian American are without insurance compared to 3.4% for Caucasian, 6.8% for African-American, and 10.6% for Hispanic (2012)

Problem Statement We aim to explore why there is this disconnect between Asian American women having health insurance but not receiving screening for breast and cervical cancer at commensurate rates Since access to care and being covered by insurance are not barriers to preventive health services for Asian American women in MA, what are the barriers? If we can identify barriers, we can start to address how to increase cancer screening Research Guided by the principles of community-based participatory research (CBPR) Funded by Tisch College Community Research Center at Tufts (TCRC)

Key Research Questions What are the barriers (e.g., lack of knowledge, motivation, fear, embarrassment) for Asian American women to utilize preventive health behaviors and screenings, particularly screening for breast and cervical cancer? How do Asian American women make health decisions and what are the factors that influence their decision making? What is the level of health literacy for breast and cervical health? Do barriers differ across the specific ethnicities that comprise Asian American women, particularly Chinese, Vietnamese, and South Asian women? What people, programs, activities, or interventions can facilitate increased awareness and utilization of preventive services?

Research Project PI: Lisa Gualtieri, PhD, ScM, Tufts University School of Medicine Co-Investigator: Chien-Chi Huang, Asian Women for Health Community partner: Tam H. Nguyen, PhD, MSN/MPH, RN, Boston College School of Nursing Community partner: Gouri Banerjee, PhD, Saheli Boston RA: Mardi Coleman, MS Mentor: Karen Freund, MD, MPH And many community volunteers

Methods Project is formative and exploratory in nature Used qualitative methods – focus groups – to understand cultural and non-cultural barriers that influence Asian American women’s utilization of preventive services Planned 6 focus groups accounting for language and ethnicity, 2 each with: Chinese American women Vietnamese American women South Asian American women

Accomplished Received exemption through Tufts Medical Center and Tufts University Health Sciences Institutional Review Board (IRB) Developed and refined Focus Group Facilitation Guide How to plan and run focus groups and roles of facilitator and scribe Welcome and closing scripts, questions, timing, and prompts Ran focus group facilitator trainings including role plays Developed recruitment script and recruitment materials Developed and delivered IRB-approved CITI training to community partners Ran and analyzed results from 4 focus groups Discussed findings with Doug Brugge and Karen Freund Drafting paper to Journal of Immigrant and Minority Health

Focus Group Facilitation Guide The worst fear of facilitators is that no one will talk A phrase to use if someone isn’t speaking: “Do you agree with what others have said? Perhaps you could add your own perspective to help us help other women.” The second worst fear is that one person will dominate A phrase to use if someone is too talkative: “It is great to hear about your experiences but I want to make sure we hear from others before we move to the next question.” The third fear is that people will give cursory answers A phrase to use if someone doesn’t go into detail: “What you said is very helpful and it would be great to understand why you think that.” Another problem is “group think”, when one person says something and everyone nods Summarize what you heard and ask if there are other views. Everyone talking at once is another problem that can be culturally appropriate but not helpful in a focus group Try phrases like, “Let’s make sure I captured what you said” or “help me by saying this one at a time so I don’t miss anything.” With phrases like these you are putting the onus on yourself, rather than seeming critical of them. A final problem is misinformation Our role is not to educate here, but we can provide a brochure at the end with accurate information.

Recruitment Social media Flyers Community events Word of mouth

Barriers contributing to lack of adherence to screening guidelines Literature identifies barriers such as culturally insensitive/incompetent providers, which we found too Factors we identified included Lack of knowledge about risks and benefits Lack of knowledge about how screenings are conducted and whether they are painful Concerns about impact of screening on virginity Confusion about recommended ages for screening including misconceptions about the relationship between sexual activity and screening guidelines Misconceptions about cost of screenings

Broader issues Confusion about Misconceptions about cost of screenings Recommended ages for screening Misconceptions about the relationship between sexual activity and screening guidelines Who creates guidelines and how, and why are they always changing Misconceptions about cost of screenings Given the number of barriers to screening adherence, shouldn’t cost be removed since it is no longer a barrier?

What do you do once barriers have been identified? Plan education to reach Patients Caregivers Providers Develop, test, and deploy