1. Increasing Utilization of Preventative Care in Asian American Women in MA

2. 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

3. 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

4. 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

5. 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)

6. 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)

7. 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?

8. 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

9. 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

10. 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

11. 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.

12. Recruitment
Social media
Flyers
Community events
Word of mouth

13. 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

14. 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?

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