Colorectal Cancer Beliefs Among Older Chinese Americans: An example of qualitative research informing health intervention

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Colorectal Cancer Beliefs Among Older Chinese
AmericansAn example of qualitative research
informing health intervention

• John H. Choe, MD, MPH
• Acting Instructor
• University of Washington, Division of General
  Internal Medicine
• Affiliate Investigator
• Fred Hutchinson Cancer Research Center,
• Cancer Prevention Program
• EPI/HSERV 590, July 21, 2005

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Outline

• Rationale for using qualitative methods
  strengths for qualitative methods
• Study background, methods, results
• Implementation of study findings
• Limitations to using qualitative methods
• Timeline
• Budget
• Other design challenges

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Projects Using Qualitative Methods

• Definitions of domestic violence for Asian
  immigrants
• Goal Adapt survey measures to quantify DV
• Methods Focus groups among advocates, church
  pastors, ( victims and batterers)
• Hepatitis B testing and vaccination beliefs among
  Chinese and Korean Americans
• Goal Inform the development of educational
  material as part of future interventions
• Methods In-depth interviews (30 for each group)
  and small number of focus groups
• Colorectal cancer screening beliefs in older
  Chinese

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Chinese CRC Study Collaborators

• John H. Choe, MD, MPH
• Shin-Ping Tu, MD, MPH
• Jeanette Lim, RN, MPH
• Nancy J. Burke, PhD
• Elizabeth Acorda, BA
• Vicky M. Taylor, MD, MPH
• International Community Health Services (ICHS)

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• Theres no such thing as qualitative data.
  Everything is either 1 or 0.
• Fred Kerlinger
• All research ultimately has
• a qualitative grounding.
• D.T. Campbell
• Qualitative Data Analysis, Miles Huberman, 1994

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Qualitative Research

• Family of methods, including ethnographic
  interviews, focus groups, direct observation
• Inductive (hypothesis-generating), not deductive
  (hypothesis-testing)
• Often in-depth in narrower population, not
  broadly applied to wider population
• Entire range of values for a characteristic in a
  defined population, not the average value

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Rationale for Qualitative Methods

• Helpful in describing social and cultural factors
  influencing behaviors
• Useful for complex or embarrassing beliefs
• Unanticipated information often explored in
  greater detail than more structured methods
• Existing educational material and survey
  instruments may contain biases? irrelevant to
  target population
• Similar skills in doctor-patient communication

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Chinese CRC Screening

• Screening reduces colorectal cancer (CRC)
  mortality
• Guidelines recommend screening gt age 50
• U.S 2.4 million Chinese (0.9) Seattle 19,000
  (3.4)
• Fecal occult blood tests (FOBT) in Asians
• 12 of Asian Americans in previous year
• 25 of Chinese Americans gt60 had past FOBT

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Study Aim

• Collect in-depth information on CRC prevention
  knowledge, behaviors, and beliefs in foreign-born
  older Chinese Americans
• Information to inform the eventual educational
  intervention program to increase FOBT screening
  rates in a clinic-based group of Chinese Americans

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Study Clinic and Participants

• International Community Health Services (ICHS)
  that uses FOBT as main screening method
• Multiethnic community-based clinic, 46 Chinese
• 70 (50,000 visits/yr.) public insurance
• 30 Chinese foreign-born clinic patients
  purposefully selected (not randomly)
• 50-79 years of age
• Mandarin, Cantonese, or English-speakers

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Qualitative Interviews

• Bilingual staff led semistructured in-person
  qualitative interviews
• Interview guide provided
• Began with general health and disease prevention
  probed about CRC screening
• Participants shown FOBT kits
• Audiotaped, translated, then transcribed

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Interview Analysis

• Transcripts read by six team members
• Content codes to group text and develop models
• Data management using N5 (NUDIST)
• Intended initially to use focus groups to
  triangulate
• Analysis presented back to interview
  participants, clinic personnel (member-checking)
  
• Because of translation challenges and budget,
  chose 30 interviews rather than until thematic
  saturation

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Results

• Causes of colorectal cancer
• Prevention of colorectal cancer
• Stool testing / Fecal occult blood testing
• Attitudes and beliefs about prevention
• Expectations of medical providers
• Role of complementary / traditional meds

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Results CRC Causes

• Food/Diet factors
• Heat and Cold imbalance
• Foods with toxins
• Foods causing constipation
• Emotional well-being

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CRC Cause Heat in Foods
73 year old man It has something to do with
what you eat, what you drink. Like those
deep-fried and stir-fried foods that cause huo qi
heat in our body. I think those foods are bad,
are the cause of the problem.
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CRC Cause Constipation
76 year old woman People not eating
vegetables, eating too much meat, get colorectal
cancer because they often have constipation So
the stomach and the intestine protests, then the
cancer grows.
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CRC Cause Constipation
70 year old man The feces is in your body and
it is easily changed to produce toxin. Thats why
the people with constipation problems can get
colorectal cancer easily.
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Participants Causal Model
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Biomedical Causal Model
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Prevention Bowel Habits
54 year old woman And I do fasting every year
too That is to say, not eat for a few days to
let it clean up the dirty stuff in the
intestine Every year you give your intestine a
rest for a period of time and also a main clean
up enemaI feel that is pretty good for
colorectal cancer.
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Prevention Bowel Habits
68 year old man You eat too much fried food or
sour food, remember you have to clear it out once
a day. If food stays in your body for a long
time, its not just personal hygiene.
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FOBT Testing Symptoms
70 year old man I don't want to have FOBT
because my bowel movement is normal, and if it's
normal I won't get this disease. But if you are
abnormal and you have a constipation problem,
then you need to do the test.
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Intervention Implications

• Educational interventions tailored to the
  cultural framework of target group
• Intervention programs continue to emphasize
  primary preventive practices, while educating
  about complementary secondary preventive practices

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Limitations of Qualitative Methods

• Participant recruitment targeted, not necessarily
  representative of all Chinese may not apply to
  other settings depth vs. breadth
• Not meant to find the average does not meet
  statistical assumptions
• Generalizability

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Limitations for Physician-Researchers

• Researcher as instrument
• Generalizability
• Can be difficult to synthesize, present, publish
  (e.g. N)
• Publishability, fundability
• Alien theory framework (social sci,
  anthropology)
• Not completely consistent methods and taxonomy
• Time and opportunity costs
• Economic costs

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Budget

• 500 Computer program
• 1100 Participant incentives
• 3480 Transcriptionist
• 500 Supplies including audio tapes, xerox
• 21,600 RA, interviewers (translations)
• 175 hrs of direct interviewing (1/4 time)
• Remainder translation, mileage
• 28,900 Direct costs
• 21,100 Indirect FA costs

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Timeline

• 4 months IRB approval
• 3 months Staff hire, training
• 6 months Data collection
• Recruitment
• Interviews
• Audiotaping, transcription
• Entry into computer program
• 6 weeks Focus groups
• 9 months Data analysis (concurrent)

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Questions?