Chinese Immigrant Women's Experiences as Community Health Workers in Korea: A Focus Group Study

ABSTRACT Background The number of immigrant women in Korea is rapidly increasing. Immigrant women in Korea experience a host of health problems associated with living in a new country. Community health workers (CHWs) may be effective at delivering health promotion programs to vulnerable groups such as recent immigrants. Purpose Qualitative analysis was performed to identify the main themes characterizing the experiences of CHWs in recommending and guiding preventive screening tests for immigrant women. Methods This focus-group study was designed to investigate the experiences and perceptions of CHWs. We conducted interviews with 15 Chinese immigrant women who served as CHWs in a cancer screening program. We asked questions about the attitudes and perceptions that CHWs had from their research experiences. Each interview was audio-recorded and transcribed verbatim. Results Three main themes emerged: (a) recognizing the need for preventive healthcare, (b) becoming the CHWs who help people to be healthy, and (c) challenges to overcome to make CHWs more active. The CHWs in this study were willing to help other Chinese immigrant women and to improve their competency to help more effectively. However, they recognized limitations on their ability to address problems when delivering a breast and cervical cancer screening program. Conclusions When training CHWs for immigrants in Korea, frequent opportunities for consultation should be provided during program delivery to facilitate troubleshooting and help CHWs overcome challenges. A program that utilizes CHWs for various minority groups is needed.

Upon completion of study activities, the CMIW who participated in the intervention trial as CHWs were interviewed and shared their experiences. By analyzing the experiences of these CHWs, the authors aimed to elucidate CMIW awareness of the activities of CHWs and to identify priorities for improving the CHW training program. The results of this study are expected to help promote effective CHW training by offering insights into how CHWs act as intermediaries between experts and CMIW in Korea. The authors hope that the results of this study may help promote effective CHW training by providing insight into how CHWs act as an intermediary between Korean experts and CMIW.

Research Design
Focus groups and one-on-one interviews were used in this qualitative study. A typical focus-group study involves three or four focus groups, each containing five to eight subjects (Krueger & Casey, 2014). One commonly cited guideline is that focus-group research requires at least two groups to define demographic characteristics, with three groups needed to find the most prevalent themes (Guest et al., 2017). As only a small number of participants and groups were available for this study, expert advice was sought during the design phase. The expert gave the opinion that individual interviews would be required to better understand the research concept during the research. In addition, using an individual interview approach would allow the study team to explore personal experiences, whereas focus group interviews would elicit shared opinions and perceptions (Lambert & Loiselle, 2008). Thus, in this study, two focus-group interviews were planned and the individual interviews were based on each focus group.

Ethical Considerations
The institutional review board at the university approved this study (IRB No. 1044396-201512-HR-060-01). Before the interviews, all the participants received an explanation of the study procedures and aims, which involved the experiences and perceptions about the activities performed by CHWs. The right of withdrawal, data privacy, and participants' feedback about the study results were also explained.

Participants
The research participants comprised CMIW who met the following inclusion criteria: (a) aged between 30 and 64 years, (b) able to communicate in Korean, and (c) agreed to participate in the interview.
To recruit study participants, the researcher approached the multicultural centers in two cities where many multicultural families live to identify women who had immigrated to Korea from China and who held leadership roles in their communities. These women were then asked to help recruit people who wanted to work as CHWs in the community. Ten women were recruited from City S, and seven were recruited from City A, both of which are in metropolitan areas and have a high number of multicultural couples.
Briefly, the parent study involved a randomized controlled trial in which 17 CMIW were trained as CHWs to deliver the study intervention, which consisted of education about breast and cervical cancer screening tests followed by monthly phone follow-ups and counseling for a period of 6 months. The CHWs received 6 hours of training to deliver the study intervention. CHW training was delivered by the bilingual research team at two community locations and addressed the following topics: cancers in women, recruitment, study questionnaire, education on breast and cervical cancers and related screening tests, phone counseling, and participation in meetings. Seventeen CHWs received training in June 2015. Upon completion of training, one CMIW decided not to work as a CHW, resulting in 16 CMIW working as CHWs during the study period. Once each month, CHWs and the research team gathered in groups and held roundtables to review the progress of the research.
For this qualitative study, 16 CHWs who participated in the parent study agreed to join. Each interview participant received 50,000 Korean won (≅U.S. $45) from the research fund to compensate for their effort and time. The 16 CMIW in this study consisted of nine CHWs in City S and seven CHWs in City A. For the individual interview, one CHW was selected in each region. One CHW who was planned to do the individual interview in City A took a new job and was no longer available to participate in the interview. Thus, the two focus groups were composed of eight and six women, respectively, with one additional participant receiving a oneon-one interview. The mean age of the 15 participants was 37 years (range: 30-46 years). The characteristics of the participants are summarized in Table 1.

Setting and Data Collection
The interviews were conducted in a quiet room. All the participants signed informed consent after the study was explained to them. CHWs were seated around a rectangular table with their colleagues and the research team. Each interview was audio-recorded, and the research team also kept notes on the answers provided. Beverages and snacks were served during the interview to provide a relaxing and comfortable environment. The time taken to participate was 5 minutes to complete the brief demographics questionnaire and 50 minutes to complete the interview.
The principal investigator of the parent study served as the facilitator, and a trained research assistant operated the audio recorder and took notes. Each interview was mainly conducted in Korean. However, the participants were allowed to speak in Chinese when they found it difficult to express themselves in Korean. A bilingual member of the study team translated Chinese into Korean as needed. The facilitator encouraged the participants to speak freely to enhance group interactions. She made eye contact evenly while responding, listening to CHWs, and waiting for members of the focus group to vocalize what they wanted to express.
The focus group interviews for Group 1 were held on November 26, 2015; the focus group interviews for Group 2 were held on December 10, 2015; and the individual interview was held on February 26, 2016.
The interview guide consisted of open questions and provided a printed interview guide to all subjects and research teams. The interview guide was constructed in consultation with qualitative research experts. The questions included in the interview guide are presented below: 1. What do you think of CHWs? 2. How does this experience influence the service you deliver? 3. Please tell us how your life has changed by working as a CHW. 4. What do you think is needed to be a good CHW? 5. How did you feel while working as a CHW?

Data Analysis
Qualitative data were analyzed using the qualitative descriptive method. This method has the advantage of conveying a given situation vividly by describing the characteristics of the subject, lifestyle behaviors, and living situation in detail (Sandelowski, 2000). This methodology is the most appropriate for understanding the specific situation of women migrating to other countries for reasons of marriage. The focus-group and individual interviews were audio-recorded and subsequently transcribed verbatim. Trained research assistants listened to the audio recordings and read the transcriptions repeatedly to ensure familiarity, then coded the meaningful text, and grouped this text into categories. We then repeatedly discussed the main codes and main categories. In July 2016, it was confirmed by two researchers that the content of the manuscript material reflected the recorded content accurately. In September 2016, on the basis of the manuscript data, the summary of interviews by major question categories was reviewed by two focus group participants. Two researchers analyzed the data and exchanged opinions with each other 3 times. In June 2017, June 2018, and August 2018, the two researchers analyzed each other's analysis. A community nursing researcher who did not participate in the analysis reviewed this analysis in April 2019. ATLAS.ti software (Version 8) was used for data analysis.

Results
Each focus group and the individual interview resulted in similar themes, which allowed the data to be pooled. Three main themes with eight subthemes emerged from the interviews. The main themes included (a) recognizing the need for preventive healthcare, (b) becoming the CHWs who help people to be healthy, and (c) challenges to overcome to make CHWs more active. Subthemes included (a) obtaining regular health screening even if one is not sick, (b) looking back on one's own health management, (c) being trained to deliver a health program, (d) immersing in the CHW role as a health advocate, (e) women's limited understanding of CHW roles, (f ) experiencing challenges while juggling multiple roles as a CHW, (g) worry about confidentiality and potential financial burdens, and (h) one-time activities as a CHW.

Theme 1: Recognizing the Need for Preventive Healthcare
At the beginning of this study, CHWs were unfamiliar with breast and cervical cancer screening tests. They came to recognize the importance of regular screening tests after being trained as CHWs. Two subthemes related to this theme included obtaining regular health screening even if one is not sick and looking back on one's own health management.
Obtaining regular health screening even if one is not sick CHWs did not understand the necessity of health screening for disease prevention before they came to Korea. CHWs pointed out that if they had not come to Korea, they would not have sought health checkups while healthy. One middle-aged CHW who had been in Korea for 7 years and another participant relayed the perception of health management among Chinese: Chinese people do not go to a hospital unless they get sick. (Group 1) Looking back on one's own health management When the CHWs learned about regular screening for cancer prevention and delivered cancer education, they thought about their own health management as well as the health of the clients (friends who were CMIW) in the program. One CHW expressed her perception about usual healthcare: Theme 2: Becoming the Community Health Workers Who Help People to Be Healthy As CHWs gained new knowledge about screening for cancer prevention, they became appreciative of this health knowledge and information in maintaining personal health and of their role as health agents. When trained, CHWs found that new health information was not only relevant but also useful for their health and that of others. CHWs were eager to learn more medical knowledge as they wanted to help their friends. Two subthemes emerged related to this theme: being trained to deliver a health program and immersing in a CHW role as a health advocate.
Being trained to deliver a health program CHWs expressed that the information they gained from CHW training and participating in the parent study offered them an opportunity to learn about diseases and the importance of breast and cervical cancer screening tests. They conveyed that they obtained useful information through the CHW training program: As I participated in this program, I gained a lot of medical knowledge and learned about the process of breast and cervical cancer screening tests. (Group 1) When I worked, I became active; I tried to find something out about the disease and the prevention test. (Group 2) Immersing in the community health worker role as a health advocate The CHWs unanimously agreed that the prevention program gave them feelings of vigor and enthusiasm. They actively searched for information about diseases, health management, screening tests, and navigation information (e.g., clinics) in Korea. CHWs expressed that they enjoyed the activities as CHWs and acknowledged that the activities were helpful to them and their friends. They described themselves as health advocates who help neighbors and friends in the immigrant community. Often, changed behavior (i.e., uptaking cancer screening test for the first time) among them resulted in positive emotions about CHW roles, as expressed by one participant: When I heard my friend got an exam, I was so happy! (Group 1) I think the work of CHWs is helpful for my friend's health. (individual interviewer) Theme 3: Challenges to Overcome to Make Community Health Workers More Active CHWs often felt troubled about their roles and responsibilities and expressed a desire to overcome the related challenges to be good CHWs. They felt worthwhile working as CHWs and wanted to continue in this role. Four subthemes emerged related to this theme: women's limited understanding of CHW roles, experiencing challenges while juggling multiple roles as a CHW, worry about confidentiality and potential financial burden, and one-time activities as a CHW.
Women's limited understanding of community health worker roles When the CHWs conducted phone follow-ups, some women asked them about what roles and responsibilities a CHW plays. Some CHWs shared that they had difficulty explaining their roles clearly. However, CHWs work to help ensure the health of CMIW, so they overcame their discomfort: Experiencing challenges while juggling multiple roles as a community health worker As CHWs work to deliver health education and counseling about breast and cervical cancer and related screening tests, they must schedule their own work and receive questions from the clients. CHWs noted that they sometimes failed to give adequate answers to questions that they had not expected such as the types and methods of hysterectomy and the prognosis of cervical cancer. Some CHWs noted that they had felt burdened and overloaded by these activities. They also noted that they felt anxious when the women reported that they had yet received a screening test: When I select a subject, I have a friend who was not selected because of the research criteria. It's hard to tell her that she can't participate in the study.

(Group 2)
It was difficult for me because the period of time spent on recruiting and telephone counseling was too long. I have to make repeated phone calls. (Group 2) We need to have knowledge about our activities. Worry about confidentiality and potential financial burdens CHWs expressed concern about certain questions on the study survey that were considered sensitive privacy. CHWs noted that the demographic question about income level was perceived by some CMIW as intrusive and unnecessary. Another source of concern for CHWs was the potential financial burden on women to have screening tests done. A CHW stated: When I invited my friend to participate in the study and encouraged her to be tested [for breast and cervical cancers], I became worried that she would spend a lot of money on the test if there is any kind of disease. (Group 1) One-time activities as a community health worker CHWs' work was conducted in this study to promote screening tests to prevent breast cancer and cervical cancer and was separate from the public community health program in Korea. Thus, the funding for this program was limited, and the activities of the CHWs ended at the conclusion of the program. The CHWs expressed the opinion that it is necessary to retain the CHWs to do activities in various ways for the immigrants who need help with their health.
When immigrants come to Korea for the first time, they don't know much about the healthcare system, so I think it would be great if CHWs could help immigrants. (Group 1) CHW activities were difficult, but I hope I can continue. I also want to learn about other diseases and health management. (Group 2) Women from other countries also need help, and many have health problems. Therefore, CHWs like us are in a good position to help them. (Group 2)

Discussion
This study was performed to evaluate the experiences of CHWs who facilitate preventive screening tests for CMIW in Korea. The perceptions of CHWs regarding their activities and roles found in this study were similar to those found in a previous study (Glenton et al., 2013). The main themes and subthemes that emerged from the focus-group and individual interviews revealed that, although CHWs deliver preventive screening tests to the CMIW, they perceived various aspects of their experiences and realized the necessity of preventive healthcare.
The first theme, which highlighted the Chinese CHWs' recognition of the need for preventive healthcare, is consistent with the finding of a prior study that interviewed 19 CHWs recruited from four health centers conducting health promotion activities (Seutloali et al., 2018). CHWs, who were exposed to healthcare in China and more inclined to therapeutic services than preventive services (Meng et al., 2019), expressed that they had taken on a new awareness regarding the importance of using preventive services while healthy rather than only visiting hospitals when sick. When CHWs perceive a need for preventive health management, they also consider that their health management is important (Aseyo et al., 2018). Vietnamese MIW in Korea are more willing to take preventive tests if they have had experience receiving pap tests (F.-H. Lee et al., 2016). It is necessary to perform regular health screening tests and increase their interest in their personal health status. This makes them a role model, which is a key aspect of CHWs (Gale & Sidhu, 2019).
The second theme addressing the CHWs' perception of their role to help people remain or become healthier is also consistent with previous studies. The CHWs in this study expressed happiness with their overall activities, which seems to reflect their perceived empowerment as a "helper" or "health advocate" (Han et al., 2007). Moreover, learning new knowledge by doing CHW activities has been shown to serve as a motivating factor (George et al., 2017). In Korea, MIW work in government-funded multicultural centers to help their friends from other countries by providing translation and counseling services (J. Lee, 2021). Our evaluation of the activities of CHWs delivering health promotion programs revealed the need to implement and assess diverse types of programs using immigrants as CHWs.
MIW can easily obtain medical insurance in Korea. Korean health insurance is compulsory, and all Koreans (hereinafter referred to as "the insured") and their dependents are insured (National Health Insurance Act, 1999/2017). The insured pays medical insurance premiums depending on his or her income and assets (National Health Insurance Act, 1999/2016). Dependents are usually supported by their family, mainly by the insured, and do not receive other remunerations or income. The insured are categorized as either local subscribers or employees (National Health Insurance Act, 1999/2017). In the case of MIWs, if a Korean husband is the insured, then the MIW is registered as a dependent. If the MIV is an employee, then she can be the insured as an employee subscriber (National Health Insurance Act, 1999. The insured and dependent may use medical services at a relatively low price if they are sick, give birth, or attend a regular medical checkup (National Health Insurance Act, 1999. However, in a survey, 11.9% of MIW who were sick during a previous 1-year period reported not going to Immigrant Community Health Workers VOL. 29, NO. 5, OCTOBER 2021 a hospital (Choi et al., 2019). MIW who are relatively new to Korea often do not speak Korean and do not know what kind of hospital to go to and so are unable to go to a hospital even when they are sick (Choi et al., 2019). CHWs may help facilitate MIW to successfully access healthcare services upon immigrated to Korea through helping them overcome language problems, facilitating mobility, aiding in decision making, and providing information about health issues (Simon et al., 2018).
The third theme addressed the challenges necessary to overcome to make CHWs more active. Although CHWs can effectively deliver interventions in the community, they had difficulty explaining their roles clearly because of program recipients' misconceptions about CHW roles (Austin-Evelyn et al., 2017). They also felt a burden of responsibility, a lack of knowledge, and concerns about the interventions they were delivering (Glenton et al., 2013). The CHWs perceived that their activities for CMIW were fruitful and necessary, but they felt burdened by their promises made to their friends and worried when the women chose not to participate. The findings of a recent study suggest that ambivalence may signal competence and act as a kind of adaptive function (Pillaud et al., 2018). Those authors explained that mixed feelings may be helpful in facilitating rapid adaptation to varying situations (Pillaud et al., 2018). This can involve achieving an equilibrium between the education provided in the intervention and their perception of it, and the study team can help them adapt to new activities by explaining the intervention program in more detail and giving feedback when difficult situations are encountered during program activities.
Although the present research team met regularly to check the progress of program delivery and to give feedback to the CHWs, the Chinese CHWs in this study expressed concern over their ability to disseminate health information. In addition to solving problems via face-to-face conversations with the research team and the CWHs, it may be helpful to provide feedback by observing the CHW in action and/or video recording during CHW activities (Parker et al., 2016). It may also be helpful to provide characteristics related to the health-related behavior of immigrants and appreciate that the information improves awareness among CHWs of promoting receiving cancer screening among immigrant women (Bhandari & Kim, 2016;F.-H. Lee, 2018). Similar to providing ongoing training to CHWs in low-income countries (O'Donovan et al., 2018), providing supportive supervision while CHWs perform interventions helps them be confident in their work.
The CHWs in this study expressed a desire to increase their competence. The CHWs wanted to continue their activities and wanted CHW activities to expand to other sectors. Besides, they said that immigrants from countries other than China also have CHW requirements. In the future, it will be possible to use CHWs in various fields related to multicultural families in Korea, and it will be possible to provide basic data from multicultural family support programs by closely examining the experiences of CHWs while they work.
CHWs are an important part of the healthcare system, especially for those who experience barriers to accessing adequate healthcare for cultural, linguistic, or other societal reasons (Herman, 2011). On the basis of the evidence that one-onone training in concert with educational brochures is effective in increasing the cervical cancer screening rate (Kurt & Akyuz, 2019), teaching cancer screening promotion techniques to CHWs is recommended. The themes identified in this study may be used as components of educational programs for training immigrant CHWs who will promote health behaviors among the same ethnic group. Adequate training programs that utilize common elements for competency evaluation and ongoing support should be considered to establish CHWs as part of the healthcare system, which eventually should be considered a reimbursable workforce in communities (e.g., immigrant communities) with unique needs. Foreign caregivers face unexpected situations when working in other countries. Thus, providing appropriate support plays an important role in initial adaptation (Nursalam et al., 2020). In addition, supervision of their work and strategies to ensure the quality of their service need to be developed.
This study was affected by several limitations. First, obtaining qualitative descriptive results from a small number of immigrants from a single country limits the generalizability of the findings and conclusions. Immigrants from various countries and CHW activities in various fields should be considered in future studies. Second, the perspectives of Chinese CHWs living in metropolitan areas may differ from their peers living in rural areas because of potential differences in exposure to preventive care and in CHW burdens. Hence, further study needs to be done in rural areas to improve trustworthiness. Third, although the study team intended to enrich the data by combining individual interviews and focus groups in each region, one individual interviewee withdrew from the study because of personal reasons. With the limited chance of an interview, the facilitator created an atmosphere that allowed CHWs to express their opinions freely and responded well to help them fully represent both the experience and awareness of CHW that recommended and guided cancer screening in Korea. Despite its limitations, this study analyzed immigrant CHWs' experiences and perceptions related to healthcare-related activities in Korea and thus provides basic data on guidance that may be used to improve CHW training courses and activities in the future.

Conclusions
The focus group interviews conducted in this study provide information regarding the perceptions of CHWs among CMIW. Whereas the activities of CHWs increased the enthusiasm of the CMIW, the themes identified in this study reveal the necessity of improving the information provided and managing the ambivalence of CHWs. Therefore, health promotion programs involving CHWs should include training courses that increase the amounts of information and empowerment via the management of various cases.

The Journal of Nursing Research
Jiyun KIM et al.