administrators
(December 2003 – October 2004)
Telephone interviews conducted in states with the highest Asian population counts, primarily with outreach coordinators
28 interviews conducted in 8 states
Phase 3: Site visits / interviews with Asian American women
(California, New York and New Jersey)
(March – June 2004)
i) Site visits/observations/ interviews with outreach coordinators/health department personnel
ii) Interviews with Asian American women who are participants and non-participants of the NBCCEDP
62 interviews were conducted with Asian American women (40 NBCCEDP participants and 22 non-NBCCEDP participants)
In the next section, I present the three phases of the study together with the sample description, data collection and analysis plan for each phase. First, I will provide some details of the pre-testing phase.
Prior to Phase 1: Pre-Testing of Data Collection Instruments
The program director’s survey (Appendix 7) and the program administrator/service provider’s interview guide (Appendix 8) were pre-tested with the program director and her staff at the NBCCEDP in North Carolina. The Asian American women’s interview guide (Appendix 9) was pre-tested in North Carolina with Asian American women similar to those eligible for the study. All the surveys and interview guides were revised according to
Phase 1: Written Survey of NBCCEDP Program Directors
In this phase, NBCCEDP Program directors in all 50 states in the United States were invited to complete a written survey to provide national data for the study. Program directors were chosen to participate in this phase as they are administratively responsible for the NBCCEDP program in their state. Hence they are able to provide information on statewide recruitment, retention and service delivery aspects of the NBCCEDP as well as statistics on NBCCEDP participants in their state.
Sampling
Purposeful sampling is the sampling of choice for qualitative descriptive studies (Sandelowski, 2000). The rationale for using purposeful sampling is to study information rich cases. The NBCCEDP has one state program director in each of the 50 U.S. states. Surveys were mailed to all program directors in the 50 states eliciting information about the state’s recruitment and retention as well as screening services for Asian American women. There were 41 completed surveys mailed back for a response rate of 82%.
Completed surveys were received from the following 41 states: Alabama, Alaska, Arizona, Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wyoming. Refer to Appendix 7 for a copy of the survey.
Data Collection Procedures
The steps taken to administer the program director’s survey are shown in Figure 7 and followed closely Dillman’s (2000) mail survey methodology.
Figure 7. Steps taken to administer the program director's survey
As CDC is the organization contracting the evaluation as well as the organization that is administering the NBCCEDP, a CDC representative first sent a letter of invitation to all 50 program directors. A few days letter, the UNC researchers mailed the survey and consent form (Appendix 7) with a return stamped envelope to the program directors. A thank you and reminder postcard was sent out to all program directors two week after the survey and
consent form were mailed out to thank those who had sent back their surveys and to remind those who had not replied to send them in. Each time a survey was received, an email was sent to thank the program director who sent it in. A month after the survey was sent out, a replacement survey was sent out to those program directors who had not yet responded. This was followed up with phone calls and/or emails to program directors to check in on them to
CDC emailed letter of invitation to all 50 program directors introducing UNC researchers, purpose of study and notifying them to expect the survey from the UNC researchers.
UNC researchers mailed survey and consent form to all program directors. UNC researchers mailed thank you and reminder postcards to all program directors. UNC researchers mailed a replacement survey to program directors who have not yet responded.
see if they had questions or needed more time for the survey. A detailed schedule for how the program director’s survey was implemented is available in Appendix 3.
Instrument
The development of the program director’s survey (Appendix 7) was guided by the cultural competency conceptual framework (Figure 4), a review of the literature as well as concerns voiced by the advisory group. The questions were first developed with the cultural competency strategies (Figure 4) as a guide. The questions were then further expanded to include questions related to recruitment, retention and service delivery (see also Table 10). In Table 10, the study topics included in each of the three data collection instruments in the three phases of the study were integrated.
The survey components covered the following topics: program infrastructure,
organizational structure, partnerships, cultural competency training, interpreter services, and recruitment, retention and service delivery issues. The advisory group reviewed the survey and provided further recommendations for revision. The program director’s survey was projected not to take more than 45 minutes to complete and included both closed and open- ended questions. Program directors were also asked to provide contact information for outreach coordinators and service providers to be interviewed for the second phase of the study.
Table 10. Integration of the study topics in the 3 data collection instruments: Program director's survey, program administrator/service provider's phone interviews and Asian American women's interviews
Study Topic / Sub-Topic Phase 1
P.D. Survey* Phase 2 P.A./S.P. Interview# Phase 3 A.A. Women Interview@ Program Infrastructure
•Types of contract organizations
•Staff recruitment and retention
•Providing services to culturally diverse populations
•Ways of sharing successful strategies
X X X X X Organizational Structure •Services/Programs offered X Partnerships
•Collaborative activities with effective partner organization
•Effectiveness of working with partnerships
•Keys to successful collaborations
X X X X X X Traditional Medicine
•Partnerships with traditional medicine practitioners (organizational level)
•Use of traditional medicine and feelings regarding discussing use of traditional medicine with providers (individual level)
X X
X
Cultural Competency Training
•Staff involvement in cultural competency training
•Effectiveness of cultural competency training
•Barriers to offering cultural competency training
•Cultural competency training feedback
X X X X X X Recruitment Issues
•Personnel involved in recruiting Asian American women
•Budget for recruitment efforts
•Challenges in recruiting Asian American women
•Strategies for recruiting Asian American women
•Effective recruitment strategies
•Lessons learned in recruitment strategies
•Future recruitment strategies
•Challenges with trying new recruitment strategies
•Resources needed to provide better services
•Access barriers facing Asian American women
•Steps in developing effective recruitment strategies
•Differences in recruitment strategies between ethnic groups
•Differences in recruitment strategies for breast vs. cervical cancer screening X X X X X X X X X X X X X X X X X X X X X X X X X
Study Topic / Sub-Topic Phase 1 P.D. Survey* Phase 2 P.A./S.P. Interview# Phase 3 A.A. Women Interview@
Service Delivery/Interpreter Services
•Provision of interpreter services
•Types of interpreter services
•Asian languages provided
•Effectiveness of interpreter services
•Barriers to providing interpreter services
•Challenges faced in providing interpreter services to Asian American women
•Organizational accommodations for Asian American women
•Lessons learned in providing services
•Future strategies to providing better service
•Challenges to trying new strategies to provide better services
•Resources needed to provide better services
•Types of health education materials available in Asian languages
•Types of health education materials well received by Asian American women
•Differences in providing services between ethnic groups
•Difficulties Asian American women face in coming for screening
•Asian American clients and their English literacy and understanding levels
•Experience with making appointments
•Experience during the screening exam
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Retention Issues
•Personnel involved in retention efforts
•Budget for retention efforts
•Challenges in retaining Asian American women
•Strategies for retaining Asian American women
•Effective retention strategies
•Lessons learned in retention strategies
•Future retention strategies
•Challenges in trying new retention strategies
•Resources needed to provide better services
•Barriers facing Asian American women
•Steps in developing effective retention strategies
•Differences in retention strategies for other ethnic groups
X X X X X X X X X X X X X X X X X X X X X X Future Plans
•Suggestions for changes in policy/guidelines in serving Asian
American women X X X
* Program Director’s Survey
# Program Administrator/Service Provider’s Telephone Interview @ Asian American Women’s Interview
Study Topic / Sub-Topic Phase 1 P.D. Survey* Phase 2 P.A./S.P. Interview# Phase 3 A.A. Women Interview@
Socio Demographics of Study Participants
•Demographics of study participants
•Breast and cervical cancer screening history of study participants
X X
Social Support and Beliefs Regarding Screening Services
•People who provide information on screening services
•Types of support for going for screening services
•Perceived need for going for screening
•Motivators to get screened
•Knowledge of NBCCEDP programs
X X X X X
* Program Director’s Survey
# Program Administrator/Service Provider’s Telephone Interview @ Asian American Women’s Interview
Phase 2: Telephone Interviews With Program Administrators/Service Providers After the program director’s survey was completed in phase 1, telephone interviews were conducted with key NBCCEDP program administrators/service providers working with Asian American women in the 10 states with the highest Asian American population counts based upon Census 2000 (U.S. Census Bureau, 2002a). The 10 states listed by decreasing Asian American population size were the following: California, New York, Texas, Hawaii, New Jersey, Illinois, Washington, Florida, Virginia and Massachusetts. Refer to Appendix 8 for a copy of the survey.
Sampling
In this phase, purposeful sampling was again used as in the previous phase, so as to recruit information rich cases (Sandelowski, 2000; Patton, 1990). Program administrators and service providers working with Asian American women in the NBCCEDP programs were recruited for this phase. A minimum of 3 key informants from each of the 10 states were to be recruited for a total of 30 interviews. Eight of the 10 states responded to participate in phase 2 of the study (neither Hawaii nor Massachusetts responded). Therefore, a total of 28 interviews were conducted. Recruitment for this phase of the study was made primarily through referrals from program directors who provided contact information for three key informants defined on the basis of the following criteria:
a) Program administrator working to recruit/retain Asian American women into the NBCCEDP program at the state level
b) Program administrator working to recruit/retain Asian American women into the NBCCEDP program at the local level
c) Service provider working with Asian American women at NBCCEDP screening facilities
Characteristics of the study participants in this phase are reported in Table 11. In the same table, demographic profiles of the organizations where the study participants were based in were also reported. In summary, New York was the state where the most number of interviews were conducted as there were many programs dedicated to Asian American women, especially in New York City. Also, 71.4% of the program administrators and service providers interviewed were local program administrators, most of whom were outreach coordinators or were involved in outreach activities working directly with Asian American women. Of those who were interviewed, 64.3% were bilingual in English and in one or more Asian languages. One outreach coordinator was even effectively fluent in English, Korean and Spanish. The majority of the study participants were from health departments (28.6%) and community-based organizations (21.4%). Also, the organizations where the study participants were based in served a variety of Asian ethnic groups including Chinese (78.6%), Vietnamese (71.4%), Korean (67.9%), Filipino (46.4%), Asian Indian (39.3%), Indonesian/Malay (32.1%), Cambodian (28.6%), Laotian (25%), Thai (21.4%), Hmong (14.3%) and Japanese (7.1%).
Table 11. Characteristics of the study participants from the Program Administrator/Service Provider’s Interviews (N=28)
Characteristic N (%) States Represented Washington 3 (10.7) Illinois 3 (10.7) Florida 3 (10.7) New York 5 (17.9) Virginia 2 (7.1) Texas 4 (14.3) New Jersey 3 (10.7) California 5 (17.9) Organizations Represented Health department 8 (28.6) Community-based organizations 6 (21.4)
American cancer society 4 (14.3)
Health center 4 (14.3)
Cancer-related organization 3 (10.7)
Hospital 3 (10.7) Asian ethnic groups Served
Chinese 22 (78.6) Vietnamese 20 (71.4) Filipino 13 (46.4) Korean 19 (67.9) Cambodian 8 (28.6) Hmong 4 (14.3) Laotian 7 (25.0) Thai 6 (21.4) Indonesian/Malay 9 (32.1) Asian Indian 11 (39.3) Japanese 2 (7.1) Type of Program Administrator/Service Providers
State administrator 4 (14.3)
Local administrator 20 (71.4)
Service provider at screening facility 4 (14.3) Number of Years in Job Position
< 2 years 8 (28.6) 2 to 5 years 7 (25) > 5 years 7 (25) Missing 6 (21.4) Bilingual Yes 18 (64.3) No 10 (35.7)
Data Collection Procedures
The steps taken to administer the program administrator/service provider’s telephone interview are shown in Figure 8:
Figure 8. Steps taken to administer the program administrator/service provider's interview
Program directors were asked in the program director’s survey to provide six names and contact information of key informants who fit the eligibility criteria. Although only three key informants were necessary, getting an additional three more names not only to help obscure comments or results being attributed to one person but also it helped when some key informants could not be contacted. An invitation letter, fact sheet and interview guide
(Appendix 8) was first emailed/mailed to potential key informants. Approximately a week after the packet was mailed, a phone call was made to the key informants to provide more information about the study, answer any questions that the key informants had regarding the
Program directors in the 10 selected states were asked in the program director’s survey to provide contact information for key informants who met the criteria.
Extra: If additional key informants were needed because the original contacts could not be reached, other program administrators and service providers were asked to provide referrals.
An invitation letter, fact sheet and interview guide were mailed/emailed to all potential key informants eligible to participate in the study.
Phone call made to key informant to provide information about the study, answer questions, get verbal consent for the study and to schedule an interview appointment.
Phone call made to key informant at appointed time to conduct telephone interview. A note of thanks sent via email.
study, to get verbal consent and to schedule an appointment for the telephone interview. At the appointed time, the phone interview was conducted and a note of thanks was sent via email to the key informant after that.
Instrument
The telephone interview was used to gather more detailed information about
recruitment and retention efforts as well as screening services for Asian American women in the NBCCEDP. Like the program director’s survey in phase 1, the telephone interview guide (see Appendix 8) was developed taking into consideration feedback from advisory group members as well as through review of the literature and the cultural competency conceptual framework. Consistent with UFE, the advisory group reviewed the interview guide and provided further recommendations for revision. On average, the telephone interview took between 30 to 45 minutes to administer.
Topics for the telephone interview (see also Table 10) include: organizational structure, partnerships, interpreter services/appropriate health education materials, cultural competency training, recruitment issues, service delivery and retention issues. The major difference between the topics included in phase 1 and phase 2 are that the topics became more focused in phase 2 as the interview allowed for more in-depth probing with program administrators and service providers who work directly with Asian American women.
Phase 3: Site Visits and Interviews with Asian American women in New Jersey,