John H. Choe, MD, MPH Acting Instructor

1. Colorectal Cancer Beliefs Among Older Chinese Americans:An 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

2. 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

3. 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

4. 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)

5. “There’s 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

6. 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

7. 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

8. Chinese: CRC Screening • Screening reduces colorectal cancer (CRC) mortality • Guidelines recommend screening > 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 >60 had past FOBT

9. 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

10. 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

11. 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

12. Interview Analysis • Transcripts read by six team members • Content codes to group text and develop models • Data management using N5 (NUD*IST) • 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”

13. 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

14. Results: CRC Causes • Food/Diet factors • “Heat” and “Cold” imbalance • Foods with toxins • Foods causing constipation • Emotional well-being

15. 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.”

16. 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.”

17. CRC Cause: Constipation 70 year old man: “The feces is in your body and it is easily changed to produce toxin. That’s why the people with constipation problems can get colorectal cancer easily.”

18. Participants’ Causal Model

19. “Biomedical” Causal Model

20. 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 [enema]—I feel that is pretty good for colorectal cancer.”

21. 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, it’s not just personal hygiene.”

22. 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.”

23. 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

25. 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

26. 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

27. 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 F&A costs

28. 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)

29. Questions?