Abstract A90: Redefining access: A mixed-methods approach to evaluating access to appropriate cancer services for underserved limited English-proficient populations
Authors: Nguyen Kim Hanh , Icarus Tsang , Pasick Rena 
Published: June 2012

Abstract
Background: In the most diverse state in the country and home to the largest Asian and Hispanic populations of any state, California has a high proportion of the country's Asian cancer deaths (43%) and Hispanic deaths (28%). Early detection with mammography screening is essential, enabling timely treatment and reducing breast cancer mortality. Despite improvements for the general population, the screening rates of minority women, especially those with limited English-proficiency (LEP), remain lower than the average. Previous investigations have shown that multiple barriers impede access to health services for minority immigrants including SES, discrimination, cultural and linguistic factors. More recently studied is the role of geography on access: a sparse literature suggests that the locations of mammography facilities are not equitably distributed to meet the need of underserved populations. Moreover, residents of socially disadvantaged neighborhoods have to travel a greater distance. This paper uses a sequential mixed-methods design to provide a rich understanding of access to mammography services for low-income LEP women.
Methods: The first component is a quantitative study that evaluates geographic access among uninsured, low-income women participating in Every Woman Counts (EWC), a California statewide free breast cancer screening program. Two primary data sources were used: (1) phone survey information collected from EWC-participating mammography facilities about their interpreter/language services (n=196), and (2) sociodemographic data including primary language and residential address of EWC-eligible participants, 2007–2008 (n=15,199). Network street distances were computed to determine the average distance of participants to the nearest EWC facility and to the nearest language-concordant facility. The second is a qualitative case study of low-income LEP Chinese women living in Oakland. We employed a grounded theory approach to broadly inquire about the Chinese experience in seeking mammography services. In-depth interviews (n=20) were conducted in Chinese; transcripts were coded and content analyzed for relevant themes.
Results: Most facilities reported having language/interpreter services available for patients obtaining mammography screening (84%) though 16% reported none. Use of bilingual staff was most common (90%) followed by professional interpreters (58%). Of the 15,199 EWC participants, 56% reported English as their primary language, 40% Spanish, and 4% Asian language (Cantonese, Mandarin, Korean, or Vietnamese). The average distance individuals must travel to reach the nearest facility is 8 miles. Monolingual Asian women must travel further for language-concordant services than those who speak Spanish or English. The spatial study findings suggest a gap corresponding to the distribution of language-appropriate cancer screening facilities and the language needs of low income and uninsured women requiring mammograms. The qualitative study revealed a dynamic interaction between language access, geography, and perceived quality care influencing women's decision on where to go for mammography. Although only two mammography facilities are available for low-income Oakland residents, Chinese women consider these three factors in citing preference for one location over the other. Transportation challenges are exacerbated by language barriers and older age.
Easy access to affordable and quality cancer screening services is important for all populations but particularly to those with significant language barriers. Limited English-proficient women have low geographic access to language-appropriate services. Language, geography, and perceived quality care are intertwined in a complex way to influence the choice of providers. This paper addresses the different dimensions of access and can inform allocation of resources to increase accessibility to low-income immigrant populations.
Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A90.