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«Co-Principal Investigators Jerome Seliger, Ph.D. & Carl A. Maida, Ph.D. Department of Health Sciences California State University, Northridge August ...»

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Analogues to addressing barriers to transition are available from current state efforts, including California’s SB 485 program that moves eligible families from fee-forservice Medicaid to managed care arrangements. Findings from experiences in five states suggest strategies for facilitating transition experiences for cash assistance recipients (Gold, et al, 1996). Albeit related to transitions within the cash assistanceMedicaid program, the findings have implications for persons transitioning from the CalWORKs system. Relatively successful strategies assume that barriers start with consumer confusion at the start of the transition. Interventions designed to mitigate confusion include distribution of easily understood materials in various languages, tollfree telephone numbers with the capacity for responding to a large calling volume, a means for providing individual counseling, and aggressive outreach immediately prior and after beginning of the transition period. While not a panacea for overcoming knowledge, experience, world-view, and value barriers these activities appear to be helpful in reducing compliance failure rates.

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The project had dual aims. The first aim was to develop information about health insurance and TMC held by persons formally or currently receiving cash assistance. The second aim was to involve respondents representative of the cash assistance population in development of a questionnaire that assesses respondent (1) knowledge of the TMC entitlement, (2) interest in obtaining TMC, and (3) the extent to which they have or value other health insurance. This product, the TMC Questionnaire, is appended as Attachment C (English version) and Attachment D (Spanish version).

Research was conducted in three phases during the period, November, 1997 -July, 1998. The activities associated with each phase are briefly described below.

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Activities during this phase involved (1) definition of the study universe and (2) development of survey methodology. The investigators, the Senate Office of Research, and the cognizant State agencies, the Department of Health Services - Medi-Cal Eligibility Branch, and the Department of Social Services agreed to the limited scope of the research and to a methodology for identifying respondents for Phase II and III activities.

As a result of conversations during this period we agreed to recruit respondents for both the field work and testing of the draft TMC questionnaire through communitybased organizations in Los Angeles county. Doing so expedited the research process, and considerably reduced costs.

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In this phase we developed baseline information about TMC and health insurance held by respondents demographically representative of the CalWORKs participant universe. Working collaboratively with community-based family and child welfare agencies in Los Angeles county we assembled four focus groups of former cash assistance recipients. The focus group respondents were involved in a 2-hour structured group brainstorming and Delphi-priority setting experience. Focus groups were conducted at host agency sites convenient to respondents in Pacoima in the northeast San Fernando Valley of Los Angeles county, East Los Angeles, and Long Beach. A total of 50 persons participated. Instructions and dialogue were in Spanish and English for the two groups in which Spanish speakers predominated. A by-lingual group facilitator conducted the sessions offering interpreting to individuals as needed as well as group facilitation in Spanish. The aim of the focus groups was to gather information about respondent (1) knowledge of TMC, (2) barriers to accessing TMC, (3) verbalized satisfaction with prior and current experiences as a Medi-Cal consumer, (4) knowledge of health insurance and perceived valuing of health insurance, and (5) suggestions for improving communication with Medi-Cal consumers.

The focus group facilitator used a five-part set of questions distributed to focus group members and prepared in both English and Spanish versions. Questionnaire items were also posted on large sheets of newsprint. The facilitator read each item aloud as she brainstormed the group for responses. She posted responses on the newsprint as well.

The purpose in using this procedure was to minimize embarrassment to those respondents unable to read or comprehend written instructions in either English or Spanish. We wanted to keep respondents positive and focused on the issues under discussion. The technique was designed to encourage respondents and probe for underlying issues. The findings of the process and a demographic profile of the respondents are included in the outcomes statements below.

A copy of the Focus Group Interview Schedule/Questionnaire is appended as Attachment A Respondent Universe The 50 participants in the focus groups were predominately Latina and African Americans. All were female. The groups, the primary ethnicity of respondents, and the

hosting community based organization were:

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Data Gathering Methodology Focus Groups were used in this phase because they offer a relatively efficient and inexpensive means of collecting qualitative data. Our intent was to identify the broad range of CalWORKs stakeholder sentiment about TMC and health insurance generally.

We used a standardized protocol for each administration of the four focus groups.

Respondents met in one large room and were introduced to the purpose of the meeting simultaneously. The facilitator, fluent in Spanish, moved from Spanish to English as frequently as necessary to stimulate brainstorming and priority setting. The methodology involved the facilitator asking the respondents as a group to respond to a series of questions. The facilitator lead the group in English or Spanish as needed and assisted individuals to complete their responses. As respondents brainstormed their ideas in response to a question the facilitator simultaneously posted the findings on easel chart for everyone to see. The facilitator then brainstormed the group a second time to identify reasons behind the score distribution and to identify “solutions.” As each newsprint sheet was filled she posted them on the walls of the room so that everyone could see the product of the group’s work and that “their” ideas were respected. Next she asked the group to rank-order their responses from most important or most urgent to least. This prioritizing method enabled the group to achieve some consensus without polarizing opinions or overwhelming minority opinion sentiment. The latter was particularly important because the group facilitator intervened in the process as often as needed to assure that ideas and recommendations were not overlooked or ignored. The protocol minimized “group think” while assuring that all voices were heard.

The focus group method is commonly used in field work and formative evaluation. It generates qualitative information. Outcomes from homogeneous groups following similar protocols provide an unusual opportunity for contrasting values and perceptions within and between distinct stakeholder populations. Holding the focus group sessions in familiar and “non-government” community-based organizations seemed to help people feel more at ease.

The focus group process yielded three types of data: (1) individual responses to objective and perception items, (2) group unanimity or lack thereof regarding the items individually and as a whole, and, (3) small group recommendations. Data from the four focus groups, presented in summary form in Attachment B, were used in constructing the survey instrument.

Outcomes brainstormed in the focus groups are reported in Attachment B, below.

We used the focus group generated information as our source for qualitative information about CalWORKS participant sentiment in developing the Draft TMC Questionnaire.

That instrument was further refined by field testing in Phase III.

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Drawing on the results of the four focus groups, we constructed a draft survey questionnaire with items intended to assess respondent knowledge, attitudes and practices related to TMC. We exposed 32 individuals as a group to a “cognitive interview” to determine how respondents interpret the items. With their feedback we revised the questionnaire and field tested it with 24 individual respondents. The participants in both the cognitive interviews and the field test with individuals were Spanish-speaking MediCal insured and medically indigent women. This cohort was selected because Spanishspeaking persons are the cultural and linguistic population least benefiting from TMC.

Results of the field test were used to develop a recommended future survey process and methodology, and to construct a recommended TMC Survey Questionnaire. The questionnaires refined in this activity, in English and Spanish versions, are included as Attachments C and D.

The research process undertaken in this phase involved three steps:

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Identifying Respondents In identifying respondents for this research segment we selected Spanish speaking and bi-lingual English and Spanish speaking respondents. Far fewer of this TMC eligible population enrolls in TMC than do other eligible populations. An intended and important byproduct of this activity, therefore, was to develop a procedure for more easily and effectively delivering outreach to this population frequently “overlooked” by traditional health and social services safety net providers. According to Castro et al, 1995, “from a systems perspective, churches serve as miniature, dynamic communities that present an opportunity for developing and implementing a program of health promotion.” We initiated a church-based outreach process. Respondents for the cognitive interviews were recruited from the Hispanic Congregation of the Temple Baptist Church, an 800-member congregation near Downtown Los Angeles serving Latino citizens and immigrants. We selected a Protestant congregation for this outreach project because Latino members of Protestant churches tend to be poorer and have a lower level of acculturation than their Catholic counterparts, suggesting greater resource deficits and a relatively higher need for outreach services for women of the smaller Protestant congregations (Castro et al, 1995).

This church-based process proved very successful because we were able to readily recruit a sufficient respondent sample. An invitation from the Pastor was made from the pulpit, requesting those who had received or were receiving Medi-Cal to attend a meeting after church. Following the Pastor’s remarks a Spanish speaking member of the congregation, acting as facilitator for the project, asked church members to join with him in testing the project’s survey instrument. He used the criterion of current or former cash assistance in requesting volunteers. The questionnaire was administered to one large group of respondents. Respondents readily agreed to participate because the church setting (1) was a “safe” place to disclose feelings about welfare and associated feelings of stigma and (2) because the church is valued as a trusted place outside of the reach of the INS.

Cognitive Interviewing Cognitive interviewing is a technique used to determine the response process of individuals completing questionnaires. The information gathered about the cognitive processes in reading and answering questions is used to construct questions that minimize response error and maximize the accuracy of information giving.

The cognitive group interview session at the church averaged ninety minutes in length. Thirty-two respondents, all women, attended the scheduled session. An experienced bi-lingual, culturally representative group facilitator conducted the interviews. The purpose of the session and study were explained. Copies of the Spanish language questionnaire were distributed. The participants were told about the purpose of the study. They were asked to listen to the instructions for each question and then to choose/circle their personal answers. The facilitator read the items aloud and gave respondents time to complete the Likert-scaled questionnaire items.

The reactions of respondents were used to identify those questionnaire items which were unclear, needed rewording, or were difficult for respondents to comprehend.

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