Using focus groups to develop interventions to promote colorectal cancer screening among Vietnamese Americans

Abstract

Background

Colorectal cancer is the third most common cancer in Vietnamese Americans. Their colorectal screening rates are lower than the rates of whites.

Methods

Four focus groups were conducted to identify Vietnamese American sources and credibility of health information, media utilization, and intervention approaches.

Results

Vietnamese Americans trusted doctors and patient testimonials, and had access to, and received most of their health information from, Vietnamese-language print and electronic media. Recommended intervention approaches include promoting doctors' recommendation of screening and using Vietnamese-language mass media, print materials, and oral presentations.

Conclusions

Focus groups are useful in determining communication channels and intervention approaches.

I. Introduction

Colorectal cancer is the second leading cause of cancer-related deaths and fourth most common cancer in the United States (1). It is the third most common cancer in Vietnamese American men and women (2). Colorectal cancer screening can reduce mortality by removing premalignant polyps and detecting early cancers (3-7). Despite the effectiveness of colorectal cancer screening in reducing mortality, screening rates remain low (8). Colorectal cancer screening rates among Vietnamese Americans are lower than in the general U.S. population and non-Hispanic whites. An earlier study showed that only 35% of Vietnamese American men and women aged 40 years and older had ever had a FOBT, compared to 39% of the U.S. adults in the same period (9). A recent study showed that only 25% of Vietnamese aged 50 to 74 had ever had sigmoidoscopy compared to 50% of non-Hispanic whites in the same age group and only 23% of Vietnamese had ever had colonoscopy compared to 34% of non-Hispanic whites (10). Research has shown that public communication campaigns are effective means for promoting smoking cessation and breast and cervical cancer screening in the Vietnamese American community (11-12). Focus groups have been used for developing campaign messages (13-14). They allow community members to participate in a process of defining and shaping the campaign messages, making these messages culturally and linguistically appropriate for the community. Although numerous studies have identified facilitators and barriers to colorectal cancer screening (15-22), few have focused on developing media approaches for promoting colorectal cancer screening (23-24). In addition, very few studies have reported focus group research among Vietnamese (25). The purpose of this study is to report the conduct of focus groups among Vietnamese American men and women to identify sources and credibility of health information, media utilization, and intervention approaches for promoting colorectal cancer screening among Vietnamese Americans.

II. Materials and Methods

A. Sites, settings, and participants

We conducted 4 total focus groups in the city of Oakland in Alameda County and the city of San Jose in Santa Clara County, California at 2 community-based organizations serving Vietnamese American elders from June to August, 2003. We chose 4 focus groups because the participants are moderately diverse and the topic reasonably complex (26) and 8 participants per group because this size is large enough to get a variety of viewpoints and yet small enough for participants to have opportunities to express themselves. Because the issues discussed might be sensitive, we segmented the groups by gender at each site to ensure that all participants felt comfortable in expressing their opinions (26). The eligibility criteria for the focus group participants were: 1) self-identified as Vietnamese American, 2) age 50 to 74 years old, 3) an Alameda or Santa Clara county resident, and 4) ability to speak Vietnamese. We used the lower age limit of 50 years old because all major professional organizations recommended colorectal cancer screening to begin at this age (27) and restricted the upper age criteria to 74 years old because people older than 74 often have co-morbidities that might preclude cancer screening. We conducted the focus groups in Vietnamese language because previous studies found that the vast majority of Vietnamese (99.6%) in this age group were less acculturated and preferred to communicate in Vietnamese (10). To achieve ethnic and language concordance, trained facilitators with the same ethnic and language capabilities were assigned to the groups. We recruited focus group participants from community-based organizations and senior centers.

B. Procedures

Focus group facilitators and assistants verbally explained the informed consent process prior to obtaining written consent and permission to audiotape the sessions. We interviewed the participants individually to collect their demographic data. At each focus group, we asked the participants about their usual sources of health information and how credible they considered these sources, with the intention to deliver subsequent intervention messages through sources identified as credible. We also asked the participants to specify their media utilization and recommend intervention approaches in order to use these means to promote colorectal cancer screening among Vietnamese Americans. Each session lasted from 90 minutes to two hours.

C. Data analysis

We transcribed the focus group tapes verbatim and analyzed data in Vietnamese in order to capture cultural concepts and nuances that are embedded in the language. To protect participants, no links to personal identifiers were left on the transcripts. Through the process of reviewing the transcripts, we developed a coding framework to classify the respondents' comments into broad topics and key highlights, and then to identify themes that overlap (28-31). Analysis was done from this coding. The Institutional Review Boards of the Northern California Cancer Center and the University of California, San Francisco approved the protocols for this study.

III. Results

A. Demographic characteristics

Table 1 shows the demographic characteristics of the 34 participants. All came from Vietnam with the majority having been in the United States between 10 to 20 years. Half of the participants were married. The majority had not completed high school and only about 10% had graduated from college. About one-fifth were unemployed and only 15% were employed. Almost 40% of the participants earned less than $10,000 per year, while the majority had an annual income between $10,000 and $20,000. Over 80% had public medical insurance (MediCal/Medicaid or Medicare) and 12% had no health insurance.

Table 1.

Demographic Characteristics of Vietnamese American Focus Group Participants

Demographics	n	%
Sex
Male	15	44
Female	19	56
Age
50-60	10	29
61-70	10	29
71 +	14	41
Years in U.S.
Less than 10 years	9	26
10-20 years	19	56
More than 20 years	6	18
Marital Status
Married	17	50
Separated/Divorced/Widowed/Unmarried	17	50
Education
Elementary school	7	21
Some high School	12	35
High school graduate/GED	12	35
College graduate	3	9
Employment
Employed	5	15
Retired	12	35
Unemployed	6	18
Homemaker	9	26
Disabled	2	6
Income
Less than $10,000	13	38
$10,000 to less than $20,000	18	53
More than $20,000	3	9
Health Insurance
MediCal/Medicaid or Medicare	28	82
Other	2	6
None	4	12

B. Sources of health information

Most focus group participants reported that they usually received health information from Vietnamese-language newspapers, magazines, radio, and television. An illustrative comment was, “I watch TV, listen to the radio, or I read … newspapers and magazines.” While most participants from Santa Clara County reported spending a lot of time listening to Vietnamese-language radio programs, participants from Alameda County said they almost never listened to radio because they could not tune in to Vietnamese-language stations. In addition, participants received health information from presentations made by representatives of local hospitals, community health centers, and non-profit organizations at community-based organizations serving the Vietnamese American community.

C. Credibility of health information

When the facilitators asked the focus group participants from whom they trusted receiving health information, they emphatically said they placed their trust in doctors. In addition, they trusted in testimonials of patients and information from health booklets, newspapers, and health programs. Examples of the statements reflecting their trust were: “I believe in doctors… what doctors say.” “The patients. They let us know so we believe them the most.” “What I like the most is the health program that has the booklet…” “I read the weekly magazine Mo. I read the advertisements on health.”

D. Media access and utilization

The vast majority of the focus group participants had access to and utilized Vietnamese-language mass media; only a few utilized English-language media. Table 2 shows the print and electronic media utilized by the focus group participants in the previous 2 years. The most common newspapers were “Thoi Bao” daily newspaper, “Thoi Bao” weekly magazine, and “Bao Mo.” The most common television program was “Little Saigon.”

Table 2.

Print and Electronic Media Utilized in Previous 2 years by Focus Group Participants

Media
Newspapers
Thoi Bao daily newspaper
Thoi Bao weekly magazine
Bao Mo
Song Manh
Saigon Nho
Viet Nam Nhat Bao
Viet Nam Tu Do
Viet Nam
Song Moi
Tin Viet
Cali Today
Trieu Thanh
Viet Tide
The San Francisco Chronicle.
Radio stations and programs *
1120 AM Que Huong
1430 AM
1500 AM
Bolsa
Little Saigon
Television stations and programs
Little Saigon
Dien Dan Viet Nam
Vien Thao
Bolsa

^*From Santa Clara County focus group participants only

E. Intervention approaches

To promote colorectal cancer screening among Vietnamese Americans, the participants suggested having doctors make recommendations, utilizing Vietnamese-language newspapers, radio, television, and print materials to publicize information, and making presentations at community centers. Examples of the comments were: “Invite a doctor to speak, that's the most effective way.” “Speak on the radio, then everyone listens.” “You have to publicize these programs in the newspapers… (and) on television.” “…Come to the community centers each month to make presentations about diseases…” Many participants recommended that bilingual Vietnamese and English versions of printed health education materials be available so that patients could communicate with non-Vietnamese-speaking doctors.

IV. Discussion

There are several important findings from this study. First, it was feasible to conduct focus groups among Vietnamese American men and women. Second, Vietnamese Americans aged 50 to 74 years old had access to, and received most of their health information from Vietnamese-language print and electronic media. Third, the participants placed their trust in doctors, testimonials of patients, and information from health booklets, newspapers, and health programs.

An unanticipated finding was that residents in only one part of the planned intervention area were able to receive Vietnamese-language radio station broadcasts, while residents in another part could not receive these broadcasts. We had anticipated that a common media approach would work for both Alameda and Santa Clara Counties since they are geographically adjacent and described by the mainstream media industry as sharing the same media market. As a result of this unexpected finding, we have revised our intervention plans to reach the Vietnamese community in Alameda County primarily by television and newspapers. The unanticipated result shows that it is essential to conduct formative research in proposed locations prior to intervention implementation in order to understand from consumers the unique characteristics of the study areas (31).

As with most focus groups, the findings are tentative and the samples are not representative of the population. In the future, we plan to conduct probabilistic sampled quantitative surveys to measure knowledge, attitudes, beliefs, and behaviors regarding colorectal cancer and screening among Vietnamese Americans.