Assessing multilevel barriers and facilitators to implementing strategies for cancer screening among Asian Americans in federally qualified health centers: a case study of a community–clinic partnership to improve care for safety-net patients

Abstract

Background

Cancer screening disparities among medically underserved Asian Americans are well documented. Assessing determinants of success in implementing multilevel cancer screening strategies in safety-net settings is critical to improve screening and cancer equity.

Methods

Academic, clinic, and community partners established the Advancing Care Together (ACCT) formal network to implement multilevel strategies that promote cancer screening among low-income Chinese, Korean, and Vietnamese adults in Orange County, California. ACCT focused on breast, cervical, and colorectal cancer. From August 2018 to January 2021, meetings, surveys, and interviews were conducted with community and clinic partners before implementing evidence-based strategies (EBS) such as educational workshops and community navigation, aligned with cultural and linguistic factors, to increase cancer screening. We evaluated formative data, collected during meetings and interviews and via patient navigator intake forms, to identify barriers and facilitators to implementing EBS in Asian-serving community clinics. We assembled a code book, aligned with the exploration, preparation, implementation, and sustainment framework to guide data analysis of implementation determinants of cancer screening.

Results

During the implementation of cancer screening EBS, ACCT staff and community navigators identified barriers in the inner context (lack of language-concordant providers, staff turnover) and outer context (referral wait times, transportation, and cultural stigma). Academic and community partnerships can support multilevel EBS to increase cancer screening (bridging factors). Additional support for clinic and quality improvement staff may be needed to evaluate cancer screening outcomes, and routine training on evaluating electronic medical records is needed (innovation factors).

Conclusion

Community–clinic–academic partnerships can increase cancer screening and awareness in Asian American communities, including addressing cultural screening barriers and identifying adaptation needs for educational materials. Additionally, longstanding clinic- and community-level barriers persist in federally qualified health centers serving underrepresented Asian American communities. These barriers in the cancer screening process include high turnover among clinic quality improvement teams and difficulty prioritizing cancer screening throughout the COVID-19 pandemic.

Leveraging community–clinic–academic partnerships to support multilevel EBS may be an effective approach to address barriers and improve cancer screening in FQHCs serving Asian Americans.

Implications.

• Practice: The use of multilevel evidence-based strategies (EBS) may reduce barriers to cancer screening services among Asian American communities.

• Policy: Follow-up rates can be improved by addressing inner (e.g. language discordance, transportation issues) and outer (e.g. long referral wait times) barriers to referrals.

• Research: Research studies seeking to improve cancer screening in federally qualified health centers serving Asian Americans should utilize community-clinic-academic partnerships to provide complimentary support to alleviate multilevel barriers to cancer screening.

Introduction

Incidence rates per 100 000 people in 2021 for colon and rectal (36.0), female breast (133.8), and cervical (7.0) cancers demonstrate the urgent need for cancer prevention efforts [1]. Cancer burden and screening behavior varies by Asian subpopulation and insurance type [2]. Delayed cancer screening can lead to adverse health outcomes. Early cancer screening and detection may drastically improve cancer outcomes among Asian Americans. Cancer screening disparities among Asian Americans have been well documented in the literature, especially for breast, cervical, and colorectal cancers [3–5]. Disparities in screening have been attributed to multiple factors (e.g. low level of knowledge and awareness, cultural beliefs, and limited access) [6]. Lower rates of screening can lead to later stages at cancer diagnosis and ultimately, higher mortality rates among Asian Americans. In fact, cancer is the leading cause of death for Asian Americans [7, 8]. Asian American patients served in safety-net health care settings may be particularly vulnerable to late-stage cancer diagnosis and higher mortality due to barriers to health care treatment.

Evidence-based strategies (EBS), interventions based on scientific studies demonstrated to improve health outcomes [9], have been recommended by the Community Preventive Services Task Force. Few studies have focused on the adoption and implementation of EBS in federally qualified health centers (FQHCs) serving predominantly medically underserved Asian Americans. Previous studies have evaluated breast, cervical, and colorectal cancer screening strategies in safety-net health care settings [10–13]. However, few studies have focused on Asian American groups at highest risk of cancer (e.g. non-English-speaking populations) served by FQHCs or addressed cultural considerations needed to reach such groups effectively. FQHCs serving predominantly Asian American patients may be well-positioned to improve cancer screening among this population, given their familiarity with cultural values and resources to meet the linguistic needs of this population. One systematic review of 620 colorectal cancer screening studies in FQHCs found no studies focused on Asian Americans [14]. To address cancer inequities among Asian Americans at high risk of cancer disparities, we first need to identify barriers and facilitators to implementing EBS in FQHC settings serving Asian American patients.

The exploration, preparation, implementation, and sustainment (EPIS) framework [15] provides the opportunity to explore multilevel (inner setting, outer setting) barriers and identify strategies that can facilitate improved health outcomes. In this study, inner setting factors pertaining to clinic-specific barriers were identified by patients or clinic partners. Outer setting factors are external barriers identified by patients or community clinics that impede patients’ ability to receive cancer screening services. Next, this study identified supportive facilitators that support the successful EBS implementation (bridging factors) and opportunities for improvement (innovative factors).

We describe a case study to document barriers and facilitators to implementing EBS to improve breast, cervical, and colorectal cancer screening among Asian American beneficiaries of Medi-Cal (California’s Medicaid program) to inform implementation and adaptation requirements. Our research question was: What barriers and facilitators occur when implementing EBS to support cancer screening and awareness among Asian American FQHC patients?

Methods

Through a multiyear partnership with two FQHCs primarily serving three Asian American ethnicities (Chinese, Korean, and Vietnamese) in Southern California, we examined barriers and facilitators to cancer screening and implementation of EBS to increase awareness and connect patients to screening services. This project adapted a hub-and-spoke model used for cancer screening [16, 17] to inform the study design and engagement with community clinics in Southern California with the goal of increasing efficiency among underserved Asian Americans who experience persistent disparities in screening, early detection, and access to cancer treatment (Fig. 1). Our hub-and-spoke model arranged service delivery assets into a network of community organizations through culturally and linguistically competent and trained community health navigators, Orange County primary and specialty Medi-Cal care providers for patients of low to moderate complexity, and UCI Chao Family Comprehensive Cancer Center (UCI CFCCC) for high-complexity cancer treatment. UCI CFCCC was the anchor establishment (hub) and offered a full array of services. This was complemented by community providers and care coordinators at local FQHCs (spokes), which offered culturally tailored primary prevention services. Community patient navigators at community-based organizations routed patients needing more tailored services to the spokes or hub for screening or treatment.

Figure 1.

Adapted hub-and-spoke model [16, 17] for advancing care together network.

Participants

Community and academic partners

One community-level partner, Orange County Asian and Pacific Islander Community Alliance, led partnership selection for participation in Advancing Cancer Care Together (ACCT), a formal network of strategically selected partners to address Asian American cancer disparities. ACCT’s mission was to improve cancer prevention and screening among Asian communities in Orange County, California. Thus, two Asian-serving FQHCs were recruited to participate from the Coalition of Orange County Community Health Centers. The Coalition of Orange County Community Health Centers is the umbrella organization of FQHCs and other health clinics serving underinsured and uninsured patients in Orange County. Three policy- and payer-level partners—the Coalition of Orange County Community Health Centers, CalOptima and UCI CFCCC—were then recruited to inform change. ACCT partners received a percentage of salary compensation as part of the ACCT collaborative to support research strategies and study participation. Each community-based organization and FQHC received the equivalent of 50% effort to support a community-based educator/navigator, and 10% effort for an agency lead (e.g. executive director) to participate in monthly meetings.

Three community partners (Orange County Asian and Pacific Islander Community Alliance, Orange County Herald Center, and Vital Access Care Foundation, formerly known as Vietnamese American Cancer Foundation) provided: (a) cultural and linguistically competent outreach; (b) cancer education to community members; and (c) support for navigation efforts related to cancer screening, treatment, and survivorship experiences for Asian patients. Providers from CalOptima (the Medicaid health care organization for Orange County) were enlisted to deliver primary and specialty care for patients of low to moderate complexity. The UCI CFCCC partnership was intended to streamline referrals of patients with advanced cancer treatment needs. Together, community partners established ACCT with the intention to improve knowledge and attitudes regarding screening and follow-up behaviors among low-income Chinese, Korean, and Vietnamese individuals in Orange County, California.

Patients and clinical partners

Patients were Chinese, Korean, and Vietnamese Medi-Cal beneficiaries from Korean Community Services; Southland Integrated Services; UCI Health Family Health Center; and UCI CFCCC. CalOptima Health, a health payer, was invited to ACCT meetings to discuss and strategize ways to reduce insurance barriers to the continuum of care and expand CalOptima’s cancer care network of community oncologists.

Inner setting planning process (clinic implementation)

In August 2018, the UCI CFCCC. community engagement team lead the effort to establish the ACCT network to carry out a 4-year project. During this time, the ACCT partners held monthly meetings in person, transitioning to fully remote during the COVID-19 pandemic. In Year 1, ACCT developed outreach education materials for community members, designed pre- and postsurvey evaluation tools, and formed supportive navigation services. Educational materials were adapted from American Cancer Society materials and made available in both simplified and traditional Chinese, Korean, and Vietnamese. In Year 2, ACCT led outreach education to community residents and provider and staff trainings following US Preventive Service Task Force guidelines on cancer screening measures for Asian Americans that support Uniform Data System (UDS) clinical quality measures.

In the last year of the project, the ACCT network pilot tested a quality improvement study to assess change in cancer screening rates from Year 2 to Year 3. ACCT provided EBS as options for consideration to two clinics. Clinic team members ranked the EBS, and top choices were selected by verbal consensus. ACCT meetings were used to identify goals and objectives to increase knowledge and screening services for breast, cervical, and colon cancers. By December 2021, clinic-based EBS were selected to facilitate cancer screening and follow-up through community navigators and deliver staff and provider trainings on cancer screening guidelines for Asian Americans. Five community navigators with Mandarin, Korean, or Vietnamese fluency were supported to work at the community-based organizations to link community members interested in screening to the clinics. After each patient navigation encounter, community navigators completed an intake form to document patient barriers to cancer screening services. FQHC quality improvement staff members were tasked with monitoring cancer screening rates to assess change. ACCT partners met with the clinical team and chief medical officer to document workflow, identify gaps, and discuss opportunities for workflow improvement. Data pulls and check-ins with the staff occurred every 2 months.

Outer setting planning process (community outreach and engagement)

The ACCT network also selected outer setting EBS to improve cancer screening among Asian Americans. This included identifying with which non-FQHC Medi-Cal providers and independent physician association members to collaborate and providing community health education on cancer screening. The ACCT network created recruitment flyers in English, Chinese, Korean, and Vietnamese. Flyers were disseminated with the help of local community-based organizations and programs (e.g. COVID-19 food distribution events). Outreach and educational activities were provided in community members’ preferred language over the phone due to COVID-19. Pretest and posttest surveys were disseminated over the phone. Participants were asked to report their cancer screening history and need for support with accessing care. Additionally, they were asked if they were Medi-Cal patients. If so, they were asked if they wanted additional services (e.g. cancer screening) and received referrals accordingly. Participants received navigation support and in-language interpretation throughout their screening process. Participants also received education and collateral materials (e.g. branded bags from health care providers, hand sanitizers, masks, etc.).

Data analysis

We used the EPIS framework to guide our analysis of these data and identify multilevel (inner and outer setting) determinants of implementing cancer screening EBS with input from the ACCT network [15]. This framework describes the interconnection of the outer context (e.g. system leadership, environment, policies, funding, patient characteristics, etc.); inner context (e.g. clinic leadership, organizational characteristics, quality and fidelity monitoring and support, organizational staffing processes, clinic staff characteristics); bridging factors (e.g. community–academic partnerships); and innovation factors (e.g. EBS and related characteristics). Process measures were collected via listening sessions on Zoom for each clinic site at baseline and study completion. Listening sessions were designed to evaluate reach, effectiveness, and barriers to cancer prevention screening. All data collected was de-identified. We evaluated multilevel formative data, collected during meetings and interviews and via patient navigator intake forms, to identify barriers and facilitators to implementing EBS for breast, cervical, and colorectal cancer screening and follow-up in Asian-serving community clinics. Two coders used inductive and deductive coded qualitative and quantitative data to assemble a code book, aligned with the EPIS framework [15], to identify determinants of implementation of EBS for cancer screening. Meetings to discuss discrepancies between codes were held to ensure consistency across coding. Subsequently, five research staff (S.G., J.H.T., S.J.P., and J.T.) held immersion and crystallization meetings [18] to interpret codes, develop themes, and align with EPIS constructs. Positionality of each research staff provided unique experiences to data interpretation. S.G. is an Orange County resident and a Mexican American postdoctoral implementation science researcher with experience working in FQHCs. She has a background in behavioral health, intervention development and dissemination, and works primarily with medically underserved communities. J.T. is a health services, mixed methods, implementation science researcher and a Chinese American faculty member at a large university in Los Angeles. She partners broadly with community and health care delivery partners, including organizations serving Asian American communities locally and nationally, to address barriers to cancer prevention and cancer care. J.H.T. is an Orange County resident and Vietnamese American independent consultant with experience as a community-based researcher with deep ties with the Orange County nonprofit (health and social services) sector. J.H.T. has a background in public health with expertise in addressing health disparities and advancing social justice, particularly with Asian Pacific Islander and Latino/a communities. She specializes in strategic evaluation, community-engaged research and capacity building, with extensive experience in developing evaluation frameworks, conducting mixed-methods research and supporting policy and systems change. S.P.T. is a cancer prevention and early detection researcher who applies community-based participatory research principles to the conduct of community partnered studies. She has longstanding research and/or service relationships with all the community social service and clinical organizations involved in this study, including serving on the board of directors for one of the participating social service agencies.

Results

Between August 2018 and January 2021, eight community partners formed an alliance, the ACCT network, to increase cancer knowledge, awareness, and screening services among Asian Americans. ACCT held 2-h monthly in-person meetings prior to COVID-19, then transitioned to 1-h Zoom meetings as needed. Meetings were used to plan the implementation of cancer screening EBS for Chinese, Korean, and Vietnamese Americans. As a result, ACCT provided cancer awareness education to 3088 individuals through community education and outreach events. Five bilingual community navigators delivered navigation services to 307 patients in four languages (Chinese, English, Korean, and Vietnamese) to overcome cultural and structural barriers to cancer screening services. Three provider trainings and one staff training with community clinic oncologists were delivered to increase knowledge and confidence addressing patient hesitancy about screening for cancer. Additionally, ACCT delivered a training to the clinical quality improvement staff at the two FQHCs to go over workflow findings and discuss implementation changes to increase cancer screenings.

Of the 307 patients (Table 1) contacted via community navigation efforts, 31% spoke Mandarin, 41% spoke Korean, and 27% spoke Vietnamese as their primary language. Of the 307 patients receiving navigation services, 247 (80%) completed exit interviews and surveys to document screening barriers. Of the 247 completed exit navigation forms, 207 (84%) patients indicated barriers to cancer screening. We adapted the exploration, preparation, implementation, sustainment framework (Fig. 2) to demonstrate barriers and facilitators to implementing EBS to increase cancer screening among Asian American patients in FQHCs and have organized themes by context (Table 2).

Table 1.

Sociodemographic characteristics of navigated patients (N = 307)

Characteristic	n (%)
Participant
Gender
Female	212 (69)
Male	95 (31)
Ethnicity
Chinese	98 (32)
Korean	129 (42)
Vietnamese	80 (26)
Marital status
Married	83 (27)
Never married	40 (13)
Divorced	15 (5)
Widowed	6 (2)
No response	163 (53)
Education
High school diploma or GED	37 (12)
Some college/vocational/postsecondary	61 (20)
Postcollege/graduate school	15 (5)
No response/other	190 (62)
Primary language
Mandarin	95 (31)
Korean	126 (41)
Vietnamese	83 (27)
English	3 (1)

Figure 2.

Adapted framework to demonstrate barriers and facilitators to implementing evidence-based strategies to increase cancer screening among Asian American patients in federally qualified health centers.

Table 2.

Themes organized by EPIS framework domains to identify barriers and facilitators to implementing EBS to support cancer screening among Asian American FQHC patients

Domains	Themes
Outer context
	Asian American patients’ preference for language-­concordant providers may exacerbate already long referral wait times
	Asian American patients noted cultural stigma as a barrier to engaging in cancer education
	Limited access to transportation may delay cancer screening
Inner context
	Language barriers limited provider communication for the majority of Asian American patients receiving navigation services
	Frequent staff turnover may limit the capacity of FQHCs to evaluate cancer screening outcomes
Bridging factors
	Providing additional support for clinics and quality improvement staff may increase clinics’ capacity to evaluate cancer screening rates
Innovation factors
	Sustainable staff education trainings are needed to consistently analyze EHR despite the inevitable staff overturn common among FQHC settings

Outer context

Outer context barriers to implementation included limited in-network specialists to serve Medi-Cal patients. As a result, patients had long referral wait times, delaying access to screening and follow-up. Additional barriers delaying screening and follow-up services included cultural stigma can influence patient hesitancy to screen for cancer and limited access to transportation.

Asian American patients’ preference for language-concordant providers may exacerbate already long referral wait times

Wait times for referrals of (a) Medi-Cal patients to a CalOptima specialist and (b) FQHC patients to oncology specialists were persistent barriers to timely follow-up care. Community navigators documented patient barriers to cancer screening and follow-up due to long wait times to see an in-network specialist for screening and oncology appointments, some of which were prolonged due to preference for a linguistically concordant provider. Especially when there is a preference for language-concordant care. As a result, ACCT attempted to expand referral networks by conducting trainings on National Comprehensive Cancer Network guidelines for cancer treatment with community-based clinicians, providing three continuing medical education credits, with the hopes that they would be interested in having patients referred to their clinics. ACCT was unsuccessful in establishing additional specialists to serve Medi-Cal patients. Although payers recognize the barriers involved with cancer screening and continuity with Medi-Cal patients, they could not establish referrals from FQHCs to comprehensive cancer centers. ACCT meeting notes revealed persistent barriers to establishing connections between FQHCs and comprehensive cancer centers to deliver care for moderate to severe cancer. Navigator exit forms indicated 2% of patients had no established primary care, 5% lacked access to a specialist, and 23% encountered system issues with scheduling appointments or coordinating care.

Asian American patients noted cultural stigma as a barrier to engaging in cancer education

Asian American patients described cultural stigma about receiving specific cancer education. Some patients described discomfort receiving certain types of education for breast, cervical, and colorectal cancer from community navigators due to cultural norms. These attitudes and beliefs were documented on patient navigation exit forms, with approximately 18% of patients indicating that failure to acknowledge their cultural and personal beliefs and attitudes about cancer screening was a personal barrier to receiving cancer screening services. This personal barrier was prominent among Chinese patients (96%). Few Vietnamese (4%) and no Korean patients cited cultural beliefs as a barrier to cancer screening.

Limited access to transportation may delay cancer screening

Limited patient access to transportation can hinder cancer screening appointments. Formative interviews and patient navigation intake forms with community navigators revealed 7% of patients encountered limited access to transportation, which delayed their cancer screening. Of those indicating transportation issues, many patients (67%) were Vietnamese.

Inner context

Notable inner context barriers included difficulty linking patients with language-concordant specialists to provide screening and follow-up services, and staff turnover.

Language barriers limited provider communication for the majority of Asian American patients receiving navigation services

Language discordance can lead to poor patient–provider communication and make it challenging to schedule an appointment, which can ultimately delay cancer screening appointments. Community navigation is an effective strategy to provide support to diverse underserved communities that experience an array of structural barriers. Among patients indicating barriers to screening on navigation exit forms (n = 207), approximately 88% indicated they encountered language barriers. Korean patients (95%) predominately cited language barriers, followed by Chinese (26%) and Vietnamese (9%) participants. Of those who received cancer screening services, 8% indicated they had challenges communicating with their provider. A formative evaluation with community navigators informed the need for language-concordant care in cancer screening and follow-up.

Frequent staff turnover may limit the capacity of FQHCs to evaluate cancer screening outcomes

Staff turnover was a barrier to obtaining electronic health records (EHRs) to evaluate screening and follow-up services. In both clinics, clinic staff members took on multiple responsibilities, including quality improvement-related tasks. ACCT worked collaboratively with the clinic staff tasked with quality improvement projects to acquire necessary data to evaluate cancer screening rates. Throughout this study, both clinics experienced staff turnover, requiring a need to restart training related to data entry and access. EHR data collection and assessment required ongoing effort throughout implementation. Staff turnover, competing responsibilities and priorities (e.g. COVID-19 pandemic), and limited resources to collect and evaluate EHR data were barriers to monitoring cancer screening.

Bridging factors

Successful implementation of cancer screening EBS in FQHCs serving a high percentage of Asian Americans required establishing multisectoral partnerships to address multilevel (e.g. clinic and structural) barriers adequately.

Community–clinic–academic partnerships may increase the feasibility of EBS that support cancer screening among Asian American patients in FQHCs

Community–clinic–academic partnerships were leveraged to identify feasible interventions, successfully implement EBS, and evaluate outcomes. Asian Americans encountered individual, clinic, and structural barriers to cancer screening. To address multilevel barriers, multisectoral partners were used to provide needed expertise. Community navigators helped patients who experienced language barriers by scheduling appointments and assisted those with transportation needs with applying for transportation vouchers. Academic partners presented the ACCT network with potential EBS proven to be effective in cancer screening and provided technical support to clinic staff members tasked with quality improvement responsibilities who lacked familiarity with UDS cancer screening codes to evaluate program effectiveness. FQHC partners provided clinic access, support with implementing provider and staff trainings on cancer screening guidelines, and access to de-identified patient data to evaluate intervention outcomes.

Innovation factors

Determinants of implementing cancer screening EBS among Asian American FQHC patients were restricted to clinic capacity. Specifically, ongoing challenges affected the ability to obtain patient-level EHR data to assess screening uptake in FQHC partner clinics before and after the intervention. Quality improvement staff members had limited familiarity with cancer-specific UDS codes needed to evaluate the impact of the interventions, and staff turnover posed challenges to completing tasks in a timely manner. Additionally, one clinic implemented a new EHR system, which presented further challenges to retrieving and analyzing cancer screening data.

Providing additional support for clinics and quality improvement staff may increase clinics’ capacity to evaluate cancer screening rates

Clinics and quality improvement staff may need additional support to evaluate cancer screening rates. Clinic capacity to implement and evaluate EBS for cancer screening can vary. ACCT members also noted challenges in obtaining EHR to verify cancer screening appointments and results. Specifically, one clinic that transitioned to a new EHR system had little data initially populated in the system to evaluate cancer screening rates. Another challenge was the low capacity of the quality improvement clinic staff to evaluate EHR data independently to assess clinical outcomes, along with other job priorities. In some cases, clinic staff members (e.g. nurses) were assigned to assist with quality improvement duties (e.g. generating reports) and tasked with assisting ACCT by extracting EHR information. Because ACCT sought to evaluate screenings for breast, cervical, and colorectal cancers, both cancer screening and data analyst expertise were needed to extract accurate data. Academic partners guided the clinic staff in this task by providing necessary UDS codes and variables in the EHR system.

Sustainable staff education trainings are needed to consistently analyze EHR despite the inevitable staff overturn common among FQHC settings

Routine staff education on how to analyze EHRs can be a sustainable approach to evaluate screening and follow-up services. Staff turnover has been well-documented as a barrier to the implementation of EBS in the literature. Our FQHC partners also experienced staff turnover, which caused delays in data extraction and analysis. In addition, evaluation of cancer screening behaviors requires expertise to identify relevant data to analyze. To overcome future challenges, routine staff education on how to analyze EHRs might reduce delays when evaluating cancer screening among patients.

Discussion

This study sought to identify how community- and clinic-driven priorities and activities can identify barriers and facilitators to implementing cervical, breast, and colon cancer screening EBS for Asian American communities served by FQHCs in Southern California. Our study found inner (e.g. language discordance, transportation issues) and outer (e.g. long referral wait times) context barriers to implementation. Bridging factors to successful implementation included multisectoral partnerships that united, academic, community, and clinic stakeholders to design, implement, and evaluate three multilevel EBS to promote cancer screening knowledge and behavior among low-income Chinese, Korean, and Vietnamese individuals in Orange County, California.

Community navigators played an important role in providing cancer screening guidance in patients’ preferred language, at an appropriate literacy level, and in a culturally sensitive way, and identifying cultural and structural cervical cancer screening barriers when implementing EBS. California’s Assembly Bill 2697, now signed into legislation, prioritizes increasing access to prevention services for culturally and linguistically diverse patients [19]. The literature has extensive documentation of cultural and structural barriers to cancer screening for Asian Americans [20]. Consistent with previous work, our study found cultural and structural barriers are common among Asian Americans served in FQHCs, affecting screening and follow-up. Cultural and structural barriers coupled with FQHC health system barriers (e.g. long referral wait times) may further contribute to cancer disparities observed among Asian American populations. Community navigators may offer effective support services needed to remediate cultural and structural barriers to receiving cancer screening.

Similar to other hub-and-spoke models [16, 21, 22], our study found that community partnerships may be beneficial when implementing cancer screening outreach among underserved populations. Previous studies have leveraged community partners to increase cancer screening among rural populations. Multisectoral partnerships (a bridging factor) among FQHCs, specialists, and community navigators, advocates, and social service providers can be used to identify and address multilevel cancer screening barriers and inform and strengthen community (e.g. cancer education, community navigation) and clinic (e.g. staff and provider training) services. One study using a step-wedged design to disseminate cancer prevention activities found partnerships among community, academic, and health care delivery stakeholders were successful in addressing cancer screening disparities with sustainable change [23]. How academic, community, and health service partnerships can support cancer screen for Asian American has yet to be explored. Our study provided preliminary evidence that such partnerships can be leveraged to help Asian American communities that require cultural and linguistic support to overcome clinic and structural barriers. Community-engaged implementation science research is a promising approach to build capacity and address health equity [24].

This study focused on Medicaid patients in Orange County. Providers serving Medicaid patients receive lower payments for services compared to providing the same services for non-Medicaid patients, which could lead them to limit the number of Medicaid patients they see, thus creating additional challenges for underrepresented patients [25]. Community navigator intake forms showed patients cited a difficult time finding in-network specialists. Engagement with payers can identify potential solutions to increase the number of culturally diverse providers in the network. Independent physician associations that have the capacity to provide locally accessible ­language-concordant care to Asian American communities may reduce cancer screening barriers identified in this study. Having access to out-of-network providers is one proposed solution [26]. Out-of-network access to meet the needs of patients with no or limited English fluency may be a solution to reducing disparities in screening and follow-up. Engaging payers and effectively expanding networks of independent physician associations may increase timely cancer screening and follow-up appointments. However, reducing delays in referral authorizations is an important step to alleviating delays in care and reducing cancer disparities.

Strengths and limitations

Strengths of this study include a multilevel evaluation of an academic–community–clinic partnership working toward improving cancer screening and follow-up among Asian American patients in FQHCs, an understudied area critical to understanding how to address long-term equity cancer for Asian American communities. However, this study is not without limitations. First, we did not have additional details on patients who did not need navigation services. Second, screening guidelines changed throughout the study, potentially affecting the sustainability of chosen EBS. For example, reporting of the proportion of breast, cervical, and colorectal cancer screenings with UDS was not required until 2020, with data unavailable until 2021. Also, receipt of prior screening was self-reported by patients at community education events and may have been susceptible to reporting bias.

Conclusion

Academic–community–clinic partnerships provide multisectoral expertise that can facilitate successful implementation of EBS geared toward increasing cancer screening among Asian American communities. Still, barriers in the inner and outer context persisted. Although community navigators were successful in identifying and addressing some barriers (e.g. helping non-English-speaking patients make appointments, providing vouchers for transportation), systemic barriers, such as limited specialist in-networks, are not unique to Asian American-serving clinics, but further hindered the ability to address health inequities. Future studies should explore how multisectoral partnerships can better address linguistic and cultural barriers in limited provider networks.

Funding Source

This project was supported by the Bristol-Myers Squibb Foundation (no grant number) and the National Cancer Institute (grant number 2P30CA062203-21). S.G.’s effort on this study was supported in part by the Multidisciplinary Training in Ethnic Diversity and Cancer Disparities (5T32CA229110-04; PI: Loic Le Marchand). The funders did not play a role in study design, implementation, analysis or approval of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funder.

Conflicts of Interest

None declared.

Human Rights

This study was exempt under the University of California Irvine’s Institutional Review Board self-determination process.

Transparency Statements

Study Registration

This study was not formally registered.

Analytic Plan Pre-Registration

The analysis plan was not formally pre-registered.

Analytic Code Availability

There is not analytic code associated with this study.

Materials Availability

Materials used to conduct the study are not publicly available.

Data Availability

De-identified data from this study are not available in a public archive. De-identified data from this study will be made available (as allowable according to institutional IRB standards) by emailing the corresponding author.