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Report Title:	CMRI's Asian American and Pacific Islander Medicare Mammography Brochure Focus Group Report
*Abstract:*	The AAPI mammography brochures were created in response to concerns that while Asian American women were facing increasing cancer risk, there are many myths and language and cultural barriers that result in relatively fewer AAPI women from having an annual mammogram. This may be even truer among elder women over the age of 65, despite the fact that Medicare covers an annual mammogram. The focus groups conducted for the CMRI brochures were an opportunity to learn more about AAPI women’s preference in regard to mammography and learn more about the key messages that would serve as an effective “call to action” in obtaining their necessary health care. All stages of the focus groups brochure development represented a collaborative effort between the three agencies that were contracted to conduct the focus groups and assist in the development of the key messages and brochures. While the groups varied a bit in some of their preferences, the following themes emerged overall: The elder women responded to the words and images about family and community. Women wanted to have the message reflect their concerns about their families and communities. Furthermore, many groups commented that they wanted multigenerational photographs, and wanted photos of men, to either show that the issue affects families, not just individuals, and that men were at risk for breast cancer too. The elder women said the images and colors in the brochures should be bright, colorful and friendly. While a few focus group participants said the brochure should be frightening, most wanted bright colors. They liked the brochures with flowers. They also said they preferred photographs of people, with drawings illustrating how a mammogram is performed. Different colors represent different meanings. Unlike Western culture, there is no universally acceptable color to Asian cultures. While red means health, happiness and prosperity in some cultures, it represents death in other cultures. Other colors such as purple can also represent death. These issues should always be discussed and verified with a number of community representatives. The elder women wanted information on local referral networks. Nearly all the groups wanted information or a phone number where they could get information on a local provider or network to get a mammogram. The elder women wanted AAPI statistics. The elder women liked the idea of having more specific statistics on AAPI elder women's risk for breast cancer. The community partners that conducted English speaking focus groups, and the community partners whose languages were not addressed continually offered their interest in the project, and in seeing similar materials being developed and offered to the their communities in the future.
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Agency:	Centers for Medicare & Medicaid Services
Date of Report:	6/7/2000

2

Report Title:	Provider-Targeted Interventions to Increase Mammography Screening Among Older Women: Report of Literature Review Findings
*Abstract:*	Physician referral for mammography screening is one of the strongest predictors of mammography utilization among women of all ages. Although the risk for breast cancer increases with age, older women appear to be referred for regular mammography screening less often than younger women. To increase the number of women, particularly those ages 65 and older with Medicare, who are referred for regular breast cancer screening, the National Cancer Institute’s (NCI) Office of Communication and the Centers for Medicare & Medicaid Services (CMS) have partnered to develop a health care providers outreach campaign. As a first step in this endeavor, published literature from the past 10 years (found through a stringent MEDLINE search) and internal research documents (from NCI, CMS, and Prospect Associates) were reviewed to explore: 1) Why physicians are less likely to make a mammography referral to older patients 2) What tools would facilitate/encourage mammography referral 3) What are the best methods to reach providers 4) What provider-targeted strategies most effectively increase mammography use among older women The review found that while physicians hold a positive opinion about mammography screening, they perceive certain barriers to screening older women, such as the likelihood of noncompliance, increased competing comorbid conditions, and lack of efficacy trials with women over age 75 to support screening guidelines. Other barriers mentioned by physicians include lack of continuity of care with older women, difficulties with followup, and forgetfulness on the part of the provider. Older women, on the other hand, were likely to cite the lack of a physician referral as the primary barrier to obtaining a mammogram. Studies with older women demonstrate the added effectiveness of an enthusiastic physician referral. A review of methods to reach physicians showed that physicians preferred to be reached through medical journals/newsletters, educational sessions, and mass media. The review also revealed that preferred methods for educating patients on breast cancer include mass media, print materials, and teaching aids. Five intervention studies targeted at providers and aimed at increasing mammography screening among older women were reviewed. Multifaceted interventions, which include both provider (physician and/or nonphysician) and patient-targeted strategies, were most effective at increasing mammography screening. Components of these multifaceted interventions included physician education, physician and nurse reminders (such as computer-generated prompts and chart stickers), patient education (which includes the distribution of educational material), and patient reminders. This report recommends that provider-targeted interventions should include both physician and nonphysician provider reminders and education, as well as patient reminders and education. Efforts to educate providers should emphasize the importance of the mammography referral with older women and the importance of being enthusiastic when making the referral. Future research is recommended for testing the effectiveness of individual components of multifaceted interventions and for exploring the role of specialist physicians in referring older women for mammography screening.
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Agency:	NIH:National Cancer Institute
Date of Report:	8/1/2001

3

Report Title:	Assessment of the Child Preventive Care Timeline: Results from a Series of In-Depth Inteviews
*Abstract:*	In-depth interviews with 15 primary care providers, including 13 pediatricians and 2 family practice physicians, were conducted between September 3-12, 2003 on the format and organization of the Childcare Preventive Care Timeline, a part of the Put into Prevention Practice toolbook. Providers were selected to represent a variety of geographic and clinical settings, and treated patients from a mix of socioeconomic and ethnic backgrounds. For the majority of pediatricians, 95% or more of their patients are under 18 years old; among family practitioners, 25% of patients are under age 18. In nearly every pediatric practice, the majority of patients are five years old or younger.
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Agency:	Agency for Healthcare Research and Quality
Date of Report:	9/12/2003

4

Report Title:	Mammography and Breast Cancer Motivational Messages: A Focus Group Study of their Effectiveness across Ethnic Groups
*Abstract:*	NCI's Office of Communications conducted a series of focus groups with women of diverse ethnic backgrounds. The overall purpose of the research was to find out whether there are particular mammography and breast cancer motivational messages that resonate across ethnic groups, as opposed to having appeal only to a single group.
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Agency:	NIH:National Cancer Institute
Date of Report:	8/1/2000

5

Report Title:	Focus Groups with Older Women to Test Motivational Messages on Cervical Cancer and the Pap Test
*Abstract:*	During October 1999, National Cancer Institute's (NCI) Office of Communications (OC) conducted a series of focus groups with women ages 65 to 75. The specific objectives of these groups were: · To learn what older women know about cervical cancer and Pap tests; · To better understand their attitudes, perceptions, and practices with regard to Pap tests and cervical cancer; · To assess their reactions to messages encouraging women to get Pap tests; and · To obtain their feedback on a physician's pad tear-sheet containing consumer information on Pap tests. Four focus discussions were conducted in two locations - Richmond, VA (two groups) and Chicago, IL (two groups). Each group included a mix of African American and Caucasian women drawn from diverse socio-economic backgrounds. Women were excluded from participating if they had had a hysterectomy, a Pap test in the past four years, or if they had ever had a cancer diagnosis. Each group was composed of nine to ten women. During each two-hour discussion, participants were asked first about the health conditions or illnesses that concern them most, followed by their perceived risk for cervical cancer. Subsequent questions concerned their knowledge, perceptions, and personal experiences with the Pap test. The remaining time was spent in message testing: first, asking participants to react to and discuss the strengths and weaknesses of 11 messages designed to motivate women to get regular Pap tests; and second, having them provide feedback on an informational tear-sheet titled “Why Get Pap Tests?” Transcripts were prepared from audiotapes and then content analyzed as a basis for the findings in this report. Focus group participants showed a striking lack of knowledge or concern about cervical cancer. In general, they did not think about cervical cancer very much, being far more worried about other potential medical problems. A host of personal beliefs and misconceptions contributed to this general indifference to cervical cancer and Pap tests. Participants were unsure of the anatomical location of the cervix. They also seemed to confuse cervical cancer with ovarian or uterine cancer, feeding a misperception that cervical cancer is especially perilous. A similar confusion surrounded Pap tests: participants were not certain how they worked, when they were needed, or what they could detect. On a personal level, women in these focus groups felt they were at virtually no risk for the disease. To them, cervical cancer posed a danger only to women with detectable symptoms, an unhealthy lifestyle, a history of the disease in their family, or an active sex life more characteristic of younger women. Participants also indicated that cervical cancer receives little attention from their doctors or the media. They said their doctors are mainly concerned about the more publicized, high-profile medical tests such as those for colon or breast cancer. Most of the focus group members saw little reason to visit their doctor unless they were very ill. As a result, they stated that they do not typically get medical screening tests. When they do see their doctors, they said they might bring up some tests, but Pap tests are not among them. The family practice doctors and internists whom they visit do not usually recommend Pap tests, perhaps because the cervix is considered to be the domain of the gynecologist. Some have not been to a doctor in 15 years or more. Focus group participants acknowledged that having Pap tests could bring them peace of mind and the benefit of early detection, but felt that their lack of symptoms or risk factors for the disease (in particular family history) outweighed any need for having the test. They felt it unnecessary to endure the discomfort, inconvenience, cost, and potential inaccuracy of the Pap test. When participants were exposed to 11 messages encouraging women, especially older women, to have Pap tests, their attitudes began to change. They found the following two messages most convincing: · Cervical cancer can develop without symptoms. Getting regular Pap tests can find the disease before you do. · You can develop cervical cancer at any age, so make regular Pap tests a habit for life. These messages resonated well because they explained that women can get cervical cancer without symptoms, at any age, and that the disease can be detected early. Participants were generally unenthusiastic about messages that told them to talk to their doctors, a practice they said was becoming increasingly more difficult under the prevailing system of managed care. They also disliked messages that mentioned advancing age as a consideration for Pap test screening, as this made them feel old. Women offered some of their own suggestions for message concepts they thought could be effective. One suggestion was to explain that all women are at risk for cervical cancer even if they are not currently sexually active (a reference to the human papillomavirus). Another suggestion was to explain that women need Pap tests at specified intervals to help them live long, healthy lives. When participants reviewed an information sheet (“Why Get Pap Tests?”) designed as take-home information for doctors to give their patients regarding cervical cancer, participants found it informative and convincing -- enough to change their minds about their personal risk for cervical cancer. They particularly liked the explanations for what the human papillomavirus (HPV) is, why there is risk for the disease at older ages, and how Pap tests detect abnormal cells. Women indicated, however, that this fact sheet would be more effective if it had less text, a definition of what “regular” testing means (so that they did not have to discuss frequency of Pap tests with their doctors), and less emphasis on the test’s limitations. Nonetheless, this sheet was enough to convince most participants that they should get a Pap test.
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Agency:	NIH:National Cancer Institute
Date of Report:	9/1/2000

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