Awareness, Perceptions, and Communication Needs

American Journal of Health Education

ISSN: 1932-5037 (Print) 2168-3751 (Online) Journal homepage: http://www.tandfonline.com/loi/ujhe20

Awareness, Perceptions, and Communication Needs About the Affordable Care Act Across the Life Span Caroline D. Bergeron, Daniela B. Friedman, Diana C. Sisson, Andrea Tanner, Vance L. Kornegay, Otis L. Owens, Megan A. Weis & Lee L. Patterson To cite this article: Caroline D. Bergeron, Daniela B. Friedman, Diana C. Sisson, Andrea Tanner, Vance L. Kornegay, Otis L. Owens, Megan A. Weis & Lee L. Patterson (2016) Awareness, Perceptions, and Communication Needs About the Affordable Care Act Across the Life Span, American Journal of Health Education, 47:2, 108-116, DOI: 10.1080/19325037.2015.1133341 To link to this article: http://dx.doi.org/10.1080/19325037.2015.1133341

Published online: 01 Mar 2016.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ujhe20 Download by: [Caroline Bergeron]

Date: 01 March 2016, At: 19:02

AMERICAN JOURNAL OF HEALTH EDUCATION 2016, VOL. 47, NO. 2, 108–116 http://dx.doi.org/10.1080/19325037.2015.1133341

Awareness, Perceptions, and Communication Needs About the Affordable Care Act Across the Life Span Caroline D. Bergeron,a Daniela B. Friedman,a Diana C. Sisson,b Andrea Tanner,a Vance L. Kornegay,a Otis L. Owens,a Megan A. Weis,c and Lee L. Pattersond a

University of South Carolina; bAuburn University; cSouth Carolina Institute of Medicine and Public Health; dRichland Library

Downloaded by [Caroline Bergeron] at 19:02 01 March 2016

ABSTRACT

Background: By March 2014, all U.S. citizens were required to have health insurance according to the Affordable Care Act (ACA). Purpose: Study objectives were to explore individuals’ opinions, perceptions, and communication sources and needs about the ACA and to assess differences by age group. Methods: In November 2013, 10 1-hour focus groups (5 with adults aged 40þ ; 5 with adults , age 40) were conducted with 102 individuals in one southeastern county. Audio files were transcribed and organized using NVivo 10. Recurring themes were examined by age group. Results: Younger participants had less awareness of the ACA. Both older and younger groups mentioned benefits of receiving preventive care and being covered for preexisting conditions. Confusion and lack of perceived understanding were evident across age groups. Participants heard about the ACA mainly through media and few interpersonal sources. They preferred to obtain inperson ACA information through state officials or trusted experts. Discussion: Varying knowledge levels, perceptions, and communication sources about the ACA impact use of health insurance and access to care. Translation to Health Education Practice: Clear information should be communicated to each age group using their preferred communication channels to increase understanding of the ACA and its importance to prevent chronic diseases.

Background The Affordable Care Act (ACA) was signed into law in 2010, and the majority of Americans were required to get health insurance by March 2014 or pay a penalty.1 The purpose of the ACA is to provide quality, affordable health insurance coverage for all Americans.1 Specific provisions of the law apply to different age groups. Dependent children can remain on parents’ health insurance policy until they turn 26 years old.2,3 Adults can have affordable access to breast and cervical cancer screenings.4-6 Free preventive services such as flu shots are available for older adults without affecting their Medicare-covered benefits.7,8 Title IV of the Affordable Care Act, Prevention of Chronic Disease and Improving Public Health, specifically focuses on the prevention of diseases and the promotion of health and wellness.9,10 It encourages states to expand and promote coverage of evidence-based preventive services for adults, including obesity-related services, tobacco cessation programs, substance abuse counseling, depression screening, and family planning

ARTICLE HISTORY Received 5 August 2015 Accepted 6 October 2015

services and supplies, among others.4,11 It also provides funding for grants, through the Prevention and Public Health Fund, to encourage businesses to develop workplace wellness initiatives to address and prevent chronic diseases.4,12 Since the beginning of the ACA, U.S. news media heavily covered the ACA rollout.13-15 Insurance advertisements, public service announcements, and news stories overwhelmed the public with information about the ACA deadline and how to sign up through the Health Insurance Marketplace.16 Despite efforts to educate the public about the ACA and its importance in prevention of chronic diseases, many consumers remain confused about the facts and features of the law.17 Further, as the ACA marks its fifth anniversary, the law remains politically divisive. A Kaiser Foundation poll conducted in March 2015 found that 43% of respondents had an unfavorable view of the ACA, with 41% saying that they had a favorable opinion.18 This study explored the awareness, perceptions, and communication needs about the ACA among residents

CONTACT Caroline D. Bergeron [email protected] Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Room 534, Columbia, SC 29208. q 2016 SHAPE America

AFFORDABLE CARE ACT ACROSS THE LIFE SPAN

of South Carolina, a politically conservative state that decided to opt out of Medicaid expansion to cover lowincome individuals not eligible for Medicaid.19 More than 22% of the population in South Carolina is 18 years old or younger, and more than 15% of its population is 65 years of age or older.20 To conduct this formative research in South Carolina, an innovative partnership was developed between a public library system, an academic institution, and a nonpartisan health policy institute. The purpose of this partnership was to use the public library as a trusted vehicle to develop evidencebased messaging strategies to communicate important public health information about the health care law to South Carolinians across the life span.21


Purpose The purpose of this study was to use qualitative research to compare what older and younger adults within one South Carolina county know, think, and hear about the ACA and how they would prefer to receive information about the ACA.21 A comparison by age group was conducted to investigate the similarities and differences across the life span in order to better address the ACA needs of each specific group. This formative research was needed to better know how to reach younger and older individuals with ACA information and ultimately increase access to care, which can help protect the public’s health as well as prevent and delay the onset of major chronic diseases.

Methods Focus groups were conducted with white, African American, and Latino men and women aged 18þ from across one county in South Carolina that is served by the Richland Library system, one of the partner organizations on this project. Public library staff in the 11 county branches led recruitment efforts. Recruitment fliers were provided to the library by the research team and interested participants registered in person at the library or through the library’s website. The research team also partnered with a community-based organization serving the Latino community for recruitment. Ten 60-minute focus groups were conducted in November 2013 with 102 participants. Five focus groups were conducted with younger participants aged 18 to 39; 5 focus groups were conducted with older participants aged 40þ. The cutoff age of 40 years was chosen to facilitate age-related discussions: younger participants could discuss issues relating to being students, early professionals, and young parents, whereas older participants could address other topics such as retirement.

109

Four focus groups were with white participants, 4 with African Americans, and 2 with Latinos. Race and language concordance between moderator and focus group participants was ensured. Participants each received $25 for their time. Audio of focus groups was digitally recorded and transcribed by professionals who also translated Spanish focus groups into English. Identifying information was removed from transcripts prior to analysis to ensure participant anonymity. All study protocols were approved by the university’s Institutional Review Board. Focus group protocol Focus group questions analyzed for this study assessed participants’ awareness, perceived understanding, and perceptions of the ACA; current communication sources about the ACA; and preferred communication channels for themselves and their communities. Participants also completed a 12-item survey with questions regarding demographics, health insurance coverage, and health information sources. This survey was translated into Spanish and culturally adapted for Latino groups with assistance from community partners. Analysis De-identified transcripts were uploaded and organized into NVivo 10.22 Three members of the research team developed a codebook using open coding.23 They independently coded 3 transcripts using the focus group protocol as a guide, discussed any discrepancies in their coding, and reached an agreement on the meaning of each code.24 Their discussion led to the development of a comprehensive codebook that was used by 2 coders to analyze the remaining transcripts. Coders conducted axial coding by merging codes into categories and identifying relationships between codes.23,24 A constant comparison approach was utilized to compare and contrast themes and rank frequency of themes by age.23 Data from the survey were entered into IBM SPSS Statistics 21.0 and analyzed using nonparametric statistics.25

Results Demographics Table 1 presents characteristics of the study participants. Forty-six younger and 56 older individuals participated in the study. Younger participants were between the ages of 18 and 39 (M ¼ 30, SD ¼ 6); older participants were between 40 and 85 (M ¼ 54; SD ¼ 10). About a third of

110

C. D. BERGERON ET AL.

Table 1. Participant demographics by age group (younger versus older), southeastern county, November 2013 (N ¼ 102).

Demographics

Younger (N ¼ 46) Older (N ¼ 56)

Demographics Age Age range Mean age

18 –39 30 (SD ¼ 6) Total N ¼ 46

40– 85 54 (SD ¼ 10) Total N ¼ 54

29% 71% Total N ¼ 45

40% 60% Total N ¼ 55

35% 46% 19% Total N ¼ 46

30% 43% 27% Total N ¼ 55

29% 25% 23% 16% 0% 7% Total N ¼ 44

27% 15% 36% 4% 15% 4% Total N ¼ 55

67% 19% 9% 2% 2% Total N ¼ 43

58% 17% 12% 8% 6% Total N ¼ 52

9% 28%

16% 25%

30%

18%

9% 7% 7% 11% Total N ¼ 46

9% 22% 2% 7% Total N ¼ 55

16%

11%

5% 5% 21% 2% 30%

8% 15% 6% 2% 55%

21% Total N ¼ 43

4% Total N ¼ 53

15% 20% 35% 20%

14% 11% 39% 19%

0%

3%

10% Total N ¼ 20 Main interpersonal source of health informationb Doctor/physician 59% Pastor/religious leader 30% Spouse/partner 24% Family member other than 54% spouse/partner Friends/coworkers 2% Other 17% Total N ¼ 46

14% Total N ¼ 36

Gender Male Female Race White African American Hispanic Employmenta Full-time Part-time Not employed Student Retired Stay-at-home


Table 1 – continued

Household income before taxesa Less than $20 000 $20 000 to $39 999 $40 000 to $74 999 $75 000 to $99 999 Over $100 000 Educationa Less than high school High school graduate or GED Some college, technical, or vocational training Two-year associate degree Bachelor’s degree Some post-bachelor schooling Advanced/graduate degree Main health insurance sourcea Insurance plan through your employer Insurance plan purchased yourself Medicare Medicaid Some other government program I am not covered by health insurance Other a

Reasons for no health insurance Insurance not offered by employer I am not a full-time employee I am unemployed I cannot afford the insurance offered by my employer I am excluded from receiving health insurance due to a preexisting condition Other

54% 32% 25% 25% 7% 23% Total N ¼ 56 (Continued)

Younger (N ¼ 46) Older (N ¼ 56)

Main media source of health informationb Television 57% Internet 83% Newspapers 28% Radio 37% Pamphlets/brochures 26% Magazines 22% Books 17% Other 7% Total N ¼ 46

71% 59% 43% 41% 39% 29% 20% 0% Total N ¼ 56

a

Totals may not equal 100% due to rounding. Totals do not equal 100% because participants could check more than one answer.

b

younger participants (30%) and more than half of older participants (55%) reported not having health insurance. Qualitative findings Six main themes emerged from the discussions: (1) ACA awareness; (2) perceived understanding of the ACA; (3) ACA benefits; (4) ACA concerns; (5) ACA communication sources; and (6) preferred ACA communication. All themes and subthemes are described and compared by age group and supported with quotes. Table 2 provides a list of themes and subthemes ranked by frequency of mention. ACA awareness Three subthemes emerged about participants’ awareness of the ACA: (1) affordability, (2) confusing information, and (3) limited awareness. The primary subtheme that emerged among older groups was regarding whether or not the ACA is affordable. An older male commented: “It’s the way to make health insurance affordable to people who are not covered by employers, underinsured, things of that nature.” An older female, on the other hand, wondered whether it is truly affordable: “What do they mean affordable?” For younger participants, affordability emerged less frequently but was still considered important: “You won’t have to worry about paying out so much at a time, and if you’re in school or unemployed they’ll help you” (younger male). Both age groups agreed that information they received about the ACA was confusing. This confusion stemmed in part from the content and information sources on the ACA: “We hear a little bit of this and we hear a little bit of that, but . . . it’s a ball of confusion” (older female). Confusion was also a common topic among younger participants: “I’m confused by a lot of it. I hear all the politicians on Capitol Hill arguing about specifics of it. I’m just like, can y’all just agree on something, please?” (younger male).


Table 2. Frequency and ranking of emerging focus group themes and subthemes, southeastern county, November 2013.a


Themes and Subthemes Awareness of the ACA Affordable Confusing Limited awareness Perceived understanding of the ACA No: Confusing and complicated Somewhat: (Mis)perceptions of the ACA Benefits of the ACA Cover preexisting conditions Make it affordable to all Preventive care Concerns about the ACA Costs/penalty Quality of care Next administration/politics Current ACA information sources Interpersonal Community Media Preferred communication about the ACA Method and format In person Brochures Booklet Website Content Cost Eligibility General information How to sign up Trusted source Community liaisons Doctors Experts State officials Unbiased sources

Younger

Older

3 2 1

1 1 2

1 2

1 2

2 1 3

1 1 2

1 2 3

1 2 3

2 3 1

2 3 1

1 2 3 4

1 2 3 4

2 3 1 4

2 1 4 3

4 3 1 2 3

3 4 2 1 4

a

ACA indicates Affordable Care Act. Subthemes of each major theme are ranked separately. Rank 1 ¼ most mentioned subtheme.

Participants’ confusion may have been related to their limited awareness of the ACA. This limited awareness was discussed more commonly among younger participants. For example, a younger female “wasn’t completely sure if [the ACA] had passed.” Most younger participants said they typically did not talk with others about the ACA “because I don’t feel like anyone actually knows what’s going on” (younger female). Compared with younger participants, the older age groups stressed that they had limited awareness about where to get ACA information in general: “We don’t have the information that we need. Our [navigators] don’t have it, no one has it” (older male).

111

Overall, most participants expressed that they did not have a good understanding of the ACA. “I don’t think it’s really been explained to a degree that you could understand” (older male). This self-reported lack of perceived understanding was related to the confusing and complicated messages seen and heard by participants. One younger male explained: “They say one thing on TV, your friend tells you something else, and you’re left the same, with nothing.” Most individuals also mentioned that the media plays a big role in what they understand of the law. It was summarized: “It’s hard to get a full grasp of everything when the media and everything has been on one side or the other. You can’t get what it is without actually reading the entire act” (younger female). Younger participants also believed they had low perceived understanding of the ACA because it appears to take “a law degree or medical degree to figure it out” (younger female). Most participants in both age groups agreed that “this thing is the size of a telephone book. I’m glad I’m not a [navigator] because I’d have no idea” (older male). Some participants believed that they somewhat understood the ACA. Younger age groups mentioned different (mis)perceptions more often than older groups. For example, one younger female explained: “A lot of doctor’s offices are saying that they’re not being covered under a portion of it.” Other younger participants discussed the country’s misperceptions. For example, “everyone cries socialism and runs away” (younger female). Older participants had some different (mis)perceptions about the ACA. Discussing what he knew about access to preventive services, one older male stated: “It’s not that I’m scared of health care. I don’t want to see them determine that you’re gonna take this year’s flu shot.” An older female expressed another misperception when discussing potential restrictions: “If you eat junk food supposedly they’re gonna blame that and you’re not gonna get insurance” (older female). Overall, most younger and older participants had poor perceived understanding of the ACA, which in their opinion meant that the health care law remained complicated and confusing, especially due to the various media and interpersonal sources providing unclear, contradicting, and/or misleading information to the general public.

Perceived understanding of the ACA Two key subthemes emerged regarding perceived understanding: either (1) they did not understand it because it was confusing and complicated or (2) they somewhat understood it, but it varied based on people’s ACA (mis)perceptions.

ACA benefits Three benefits of the ACA emerged: (1) affordable to all; (2) covers preexisting conditions; and (3) includes preventive care. The most commonly discussed subtheme among both age groups was that the ACA will make


112


insurance “affordable, especially for low income people or families” (older male). The fact that the ACA covers preexisting conditions was the second most commonly mentioned benefit. This was discussed most often among older participants. For example, one older male stated: “That’s a hindrance. You have an issue already and they don’t want to cover it. With this, that would alleviate a lot of problems to have to pay that out of pocket.” The younger age groups shared stories of other people’s experiences. For example, this younger female reflected on her family: “I have people in my family that are denied coverage for very costly illnesses because they were preexisting, and now, they’re gonna have health insurance, which is gonna cut their bills by thousands.” A younger female agreed that the situation is expected to change because of the ACA: “If someone has cancer now, they can look for insurance that will support them, not like before where they didn’t.” Finally, obtaining preventive care was another ACA benefit commonly mentioned by both age groups but discussed more frequently among older participants. An older male summarized: “If you have coverage for your preexisting conditions and you can get affordable care, it’s preventive care.” The younger age groups discussed preventive care more generally in terms of preventing chronic diseases and providing greater benefits for society. One younger female stated: “A greater focus on preventive care is going to decrease the expenses down the road and create better quality of life.” Concerns about the ACA Three main concerns that emerged were (1) costs; (2) quality of care provided; and (3) political climate. The most commonly discussed concern in all groups were costs associated with buying health insurance and/or the penalties associated with not getting health insurance by the deadline. Most older participants had these concerns. For example: “Why is 1,000 dollars of health care money going to somebody to pay the bill for me? I can pay the bill” (older female). Another older female mentioned her deductibles and co-pays when describing her worries about the ACA: “Because of the Obamacare my deductible and my co-pay are going up. While I have health insurance, I can’t afford to make my co-pays.” Younger groups also discussed the important costs associated with the law. For example, a younger female rationalized it like this: “Someone who’s making $1,000.00 a month, you want them to spend 10 percent of that on health care, which oh, by the way is just the insurance portion.” Others agreed with this next comment made by another younger female: “I’m just

afraid that my paycheck is gonna get another chunk taken out of it.” Finally, penalties associated with not getting insurance on time was also a concern for the younger groups. For example, one younger female asserted: “If I don’t have insurance by February, then I’ll be penalized. If I’m unemployed, I already can’t afford it. How am I gonna afford the penalty?” Quality of care provided was another important concern that emerged from the groups now that many more Americans will have health insurance and access to care. This was most commonly mentioned by older participants. Some worried that “we’re not going to be tended to” at the hospitals because of an overflow of patients (older female). Some younger participants shared similar concerns. One younger female stated: “I think you gonna have a whole bunch of people that are going to be sick and the doctor’s gonna be rushing, not actually taking the time.” Others believed that they will be receiving poorer quality of care due to the physician’s lower income. The political climate regarding the ACA was the third and final subtheme discussed among participants of both age groups. Participants acknowledged the confusion created by the fact that the ACA was also known as Obamacare. An older female explained: “It’s Obamacare or affordable health care, but because it’s called Obamacare, then people may be thinking negative about it.” Most participants worried about the future of the ACA because of the political environment: “What happens with the next administration. I mean is it gonna be overhauled?” (older female). The younger participants also agreed with this concern: “It’s not gonna last. When Obama gets out of office it’s a wrap” (younger female). The undefined future of the ACA could also become another source of confusion: “It’s gonna end up being scrapped and we’re basically gonna go through the exact same confusion” (younger female). ACA communication sources Both age groups heard about the ACA primarily through the media, such as television, radio, newspapers, and the Internet. Discussion among younger participants focused more on the confusion created by all of the information disseminated through television and the radio: “It’s interesting to watch Saturday Night Live when they do skits on it [the ACA], just because you almost need a break from all the overloading of information you’re getting from serious outlets like CNN” (younger female). Another younger female participant confirmed that “it’s pretty much the only thing NPR talks about anymore, so that’s where I hear everything.” Older participants also



heard about the ACA on the Internet, the newspaper, and the news but confirmed that the content was more “about the failure [of the website] . . . and you’re not really getting the information” (older female). In terms of interpersonal sources, both groups reported that most individuals, including their doctors, health insurance providers, employers, and family members, did not provide them with information about the ACA. When discussing what doctors and health insurance providers had told them about the ACA, participants of both age groups nodded with their heads and responded with comments such as “Nothing,” “Nobody wants to talk about it,” and “Talked to my doctor about it? He don’t know about it either.” Compared to older participants who had not heard about the ACA through their employers, a few younger participants reported hearing about it but mentioned that the information was quite vague. A participant explained: “They basically just sent out the new packet that told us that our deductible went up, and that was it. They didn’t tell us anything else” (younger female). Another participant confirmed limited ACA knowledge of these various interpersonal sources: I work part-time in a restaurant and they said, “You can only work X number of hours, because if you’re over that you’re considered full-time,” and they would have to supply insurance. [ . . . ] So they gave me a little thing to sign and that was it, and there was no explanation. (younger female)

Some family members were involved in discussing the ACA, but the content of those conversations remained vague. One older female admitted to talking to her family about it as “this has definitely affected their insurance.” A few younger participants also talked about it with their parents because they were under their health insurance. Both younger and older participants mentioned reaching out to ACA navigators to obtain more information about the ACA but stated that “they had very few resources to talk to people” (younger female) or that they simply took the participant’s “name and phone number and said, ‘Here’s the website,’ but didn’t do anything” (older male). Overall, participants were not receiving complete, accurate information from these interpersonal communication channels. The majority of older participants also revealed that they were unaware of places in the community where they could obtain information about the ACA. One older participant mentioned that her church organized a monthly drop-in information clinic for parishioners to obtain ACA information. One younger participant mentioned learning more about the ACA through a class project in college. In general, however, community organizations such as the library were not being used as

113

communication channels to convey public information about the ACA. Preferred ACA communication Participants had the opportunity to express how they would like to receive ACA information, including in which format, through which sources, and regarding what specific content. The majority of participants in both age groups stated they prefer to receive information about the ACA in person, through some type of community forum, followed by mail and telephone. An older male shared his preference: I want a man from South Carolina, or a lady from South Carolina, to talk my language and tell me what’s going on as it relates to all of the insurance, all of the charges, how do I know that I’ve got insurance once I’ve sent in my form and you say I’ve got it. I want a signed statement from you, in your name, telling me that I have coverage.

An older female also agreed with receiving ACA information in person: “I want to go to a meeting and talk to somebody. I want to hear it. I want to be able to ask questions.” Only older participants mentioned working with community organizations such as churches and libraries to provide this ACA education. Younger participants also discussed their preference to speak with someone directly and ask questions about the ACA, such as ACA experts setting up an information booth at community-based events, such as a Saturday farmers’ market or similar type event. This younger female explained how she would like to receive information about the ACA: “I just wanna sit down with someone, look at them, and be able to ask specific questions about my situation.” Breaking down ACA information into smaller, understandable parts was also mentioned as a preferred format. Different communication tools such as brochures, booklets, and websites were also recommended by participants to provide more details about the ACA. No differences in preferred format were found by age group. Preferred ACA information content varied by age group. Older participants primarily wanted to receive information about eligibility and cost followed by how to sign up compared to younger participants, who were interested in receiving general information about the ACA first, then information on cost and eligibility. One older female participant summarized it well by saying: “Cost. And really what are we getting, you know, what is the bang for the buck.” Younger participants wanted to know how the ACA works and the differences between health insurance plans. They wanted information to be clear and easy to follow (e.g., “who is covered, and then break off into different groups depending on your age

114



group, and then give you information where to get that coverage”; younger female). Participants preferred receiving information about the ACA from different credible and trustworthy sources of information. Older participants prefer to be informed by state officials, experts on the ACA, and community outreach liaisons. Younger participants stated that they preferred experts, state officials, doctors, and unbiased sources. One older participant explained: “I think that maybe the state officials who were for the Affordable Care Act, and even our local government in our community leaders, you know should have some way of getting the information disseminated out into the community” (older male). One younger male wanted the information source to be “the people who are actually legitimately in charge of administering this Act.”

Discussion This communication research study, which qualitatively examined the awareness, perceptions, communication sources and preferences of the ACA among older and younger individuals, was conducted in an effort to gather information on community members in one South Carolina county so that tailored ACA promotional and educational materials could be developed for this audience. Key findings suggested that younger adults were less aware of the ACA, in general, whereas older adults mentioned their limited awareness of how to obtain ACA information. Both age groups, however, discussed their low perceived understanding of the ACA. Though some said they somewhat understood the ACA, at the same time, they mentioned common misperceptions associated with the law that impact their use of health insurance and access to care. Participants discussed some important benefits and concerns of the ACA. Some of these concerns were then reflected in the participants’ current sources of ACA information (e.g., confused by varying viewpoints on the ACA portrayed on television) as well as their preferences to receive more information about the law (e.g., more information on costs). This formative research enabled us to discover which content to focus on—including people’s misunderstandings and misperceptions—to address in future ACA communications, which sources to use to deliver ACA information, and how to develop communication materials such as brochures and booklets to meet individuals’ and communities’ information needs across the life span. Interestingly, though differences in ACA awareness, knowledge, and perceptions between age groups were expected due to specific provisions of the law that apply to different groups,2,7,8 few differences emerged. Results suggest that older participants reported benefits of

gaining access to preventive care and covering preexisting conditions more often than younger participants. Another important difference was that younger participants were less aware of the ACA compared to older participants. Aside from these 2 key differences, this study revealed no major differences in ACA awareness and perceptions by age group. They all expressed confusion, lack of awareness, and limited perceived understanding. Our results are also consistent with recent national studies about the ACA. For example, a March 2015 Kaiser Family Foundation Health Tracking Poll on a nationally representative sample of U.S. adults assessed awareness levels of the ACA and found, similar to our focus group results, that, in particular, uninsured participants of all ages had limited awareness of the ACA and did not feel that they had sufficient understanding of the law.18

Translation to Health Education Practice Findings support greater ACA education and similar messaging strategies and content across age groups so that both younger and older individuals can better understand the ACA and therefore access screening and interventions that can prevent chronic diseases.26,27 Study findings, however, did address several areas in which educational content could be tailored to each age group.28 For example, educational messages for older adults should address how and where to seek more ACA information and focus on ACA coverage of preventive care and coverage for preexisting conditions.29 Health communication messages for younger adults should be tailored to their ACA information needs, address uncertainty and confusion, and emphasize benefits of which they may not be aware.30 Visual representations and photographs depicting people of different ages can also be used to target the different audiences with ACA messages.31 Additional effort should be made to ensure the ACA messages effectively reach the target audiences.30-32 Participants mentioned wanting to receive information about the ACA through experts and state officials, because they considered these sources to be the most credible and knowledgeable sources of information on the health care law. In addition to receiving information in person from these sources, individuals mentioned wanting to receive supplemental ACA information in the form of brochures and booklets. As suggested by the study findings, public meetings could be organized to facilitate rather than restrict communication about ACA.33 Public meetings would allow people to ask questions and obtain the answers they are looking for from their preferred sources of ACA information, while



also receiving written materials they could bring home to review. This study had limitations. First, focus groups were conducted right after the 2013 federal government shutdown, which was partially fueled by critics of the ACA. Participants’ comments may have been influenced by media coverage of this highly politicized event.34 Second, more than half of participants had no health insurance at the time of the focus groups, which may have influenced findings. However, these results were found to be consistent with previous studies on the ACA.18,35 Third, data were only collected in one South Carolina county and thus cannot be generalized to other counties and states. Fourth, some nuances could have been missed in the translation of the audio files from Spanish to English. The research team did not do back translation—that is, translating the transcripts back into their original language—or collaborative and iterative translation, which are preferred methods for quality check.36,37 Finally, this article focused on differences by age group; however, a comparison by participants’ age and race would perhaps provide a broader, more comprehensive depiction of individuals’ awareness and perceptions of the ACA. In conclusion, this study is among the first to qualitatively examine and compare older and younger individuals’ awareness, perceptions, benefits, concerns, communication sources, and preferences about the ACA in an effort to develop an ACA communication campaign, including targeted educational material, for community members in one southeastern county. Specifically, this formative research provided crucial insight that was utilized to develop an ACA promotional campaign.38 More broadly, this study provides public health practitioners and policy makers with a greater understanding of the issues that are important for older and younger adults in terms of the ACA as well as a good baseline and recommendations for further ACA education to increase access to care and prevent and delay the onset of major chronic diseases. Following through on these recommendations will help public health, health care, and health communication experts better reach and educate individuals and groups about the ACA, which will enable them to take advantage of its benefits.

Acknowledgments We thank Dr. Myriam Torres, PhD, and our focus group participants and moderators.

Funding This work was funded by the John S. and James L. Knight Foundation.

115

References 1. The Patient Protection and Affordable Care Act. U.S. Government Printing Office website. http://www.gpo.gov/ fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148. pdf. Published 2010. Accessed November 14, 2014. 2. Health coverage for children under 26. U.S. Centers for Medicare & Medicaid Services website. https://www. healthcare.gov/can-i-keep-my-child-on-my-insuranceuntil-age-26/. Published 2014. Accessed November 14, 2014. 3. Schrager SM, Do C, Holloway IW, Cheng EM, Chen AY. Profile of insurance coverage in a national inpatient sample. Am J Public Health Res. 2013;1:27-31. 4. Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363:1296-1299. 5. Levy AR, Bruen BK, Ku L. Health care reform and women’s insurance coverage for breast and cervical cancer screening. Prev Chronic Dis. 2012;9:E159-E167. doi:10.5888/ pcd9.120069 6. Edwards J. Building one America through universal health care. Am J Health Educ. 2008;39:5-6. 7. The Affordable Care Act helps seniors. The White House website. http://www.whitehouse.gov/sites/default/files/ docs/the_aca_helps_seniors.pdf. Published 2014; Accessed November 14, 2014. 8. Pomeranz JL, Yang YT. The Affordable Care Act and state coverage of clinical preventive health services for working-age adults. J Public Health Manag Pract. 2015;21:87-95. 9. Title IV. Prevention of chronic disease and improving public health. The White House website. https://www. whitehouse.gov/health-care-meeting/proposal/titleiv. Published n.d. Accessed August 1, 2015. 10. Title IV—Prevention of chronic disease and improving public health. U.S. Department of Health and Human Services website. http://www.hhs.gov/healthcare/rights/ law/title/iv-prevention-of-chronic-disease.pdf. Published n.d. Accessed August 1, 2015. 11. Prevention of chronic disease. Centers for Medicare & Medicaid Services website. http://www.medicaid.gov/ affordablecareact/provisions/prevention.html. Published n.d. Accessed August 1, 2015. 12. Anderko L, Roffenbender JS, Goetzel RZ, et al. Promoting prevention through the Affordable Care Act: workplace wellness. Prev Chronic Dis. 2012;9:120092. http://dx.doi. org/10.5888/pcd9.120092 13. Gollust SE, Barry CL, Niederdeppe J, Baum L, Fowler EF. First impressions: geographic variation in media messages during the first phase of ACA implementation. J Health Polit Policy Law. 2014;39:1253-1262. 14. Kaiser health tracking poll: June 2014. Kaiser Foundation website. http://kff.org/health-reform/poll-finding/kaiserhealth-tracking-poll-june-2014/. Published 2014. Accessed August 1, 2015. 15. O’Rourke T. Health care reform: insights for health educators. Am J Health Educ. 2002;33(5):297-300. 16. Individuals and families. U.S. Centers for Medicare & Medicaid Services website. https://www.healthcare.gov/ marketplace/b/welcome/. Published 2014. Accessed August 1, 2015.


116


17. Patel K, Parker R, Villarruel A, Wong W. Amplifying the voice of the underserved in the implementation of the Affordable Care Act. Institute of Medicine website. http:// www.iom.edu/∼/media/Files/Perspectives-Files/2013/ Discussion-Papers/BPH-AmplifyingtheVoice.pdf. Published 2013. Accessed November 15, 2014. 18. Kaiser health tracking poll: March 2015. Kaiser Foundation website. http://kff.org/health-costs/poll-finding/kaiserhealth-tracking-poll-march-2015. Published 2015. Accessed August 1, 2015. 19. South Carolina Medicaid moving forward in 2014. U.S. Centers for Medicaid and Medicare Services website. http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-State/south-carolina.html. Published 2014. Accessed August 1, 2015. 20. State & county quickfacts: South Carolina. U.S. Census website. http://quickfacts.census.gov/qfd/states/45000.htm l. Published 2013. Accessed November 15, 2014. 21. Scharff DP, Mathews K. Working with communities to translate research into practice. J Public Health Manag Pract. 2008;14(2):94-98. 22. NVivo [computer program]. Version 10. QSR International Pty Ltd; 2012. 23. Glaser BG, Strauss AL. The Discovery of Grounded Theory: Strategies for Qualitative Research. Piscataway, NJ: Transaction Publishers; 2009. 24. Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage Publications, Inc; 2014. 25. IBM SPSS Statistics for Windows [computer program]. Version 20.0. Armonk, NY: IBM Corp; 2011. 26. Freudenberg N, Olden K. Getting serious about the prevention of chronic diseases. Prev Chronic Dis. [serial online] 2011;8(4):A90. http://www.cdc.gov/pcd/issues/ 2011/jul/10_0243.htm. Accessed January 24, 2016. 27. Gross W, Stark TH, Krosnick J, et al. Americans’ attitudes toward the Affordable Care Act: would better public understanding increase or decrease favorability? Stanford University website. https://pprg.stanford.edu/wp-content/ uploads/Health-Care-2012-Knowledge-and-Favorability. pdf. Published 2012. Accessed November 15, 2014.

28. Klein SJ, Nokes KM, Devore BS, Holmes JM, Wheeler DP, Hilaire MBS. Age-appropriate HIV prevention messages for older adults: findings from focus groups in New York State. J Public Health Manag Pract. 2001;7(3):11-18. 29. Slonim A, Benson W, Anderson LA, Jones E. Strategic priorities to increase use of clinical preventive services among older U.S. adults. Prev Chronic Dis. 2013;10(4):E52E57. 30. Stellefson ML, Hanik BW, Chaney BH, Chaney DJ. Challenges for tailored messaging in health education. Am J Health Educ. 2008;39(5):303-313. 31. Parrott R. Point of practice: keeping “health” in health communication research and practice. J Appl Commun Res. 2011;39(1):92-102. 32. Bergeron CD, Friedman DB. Developing an evaluation tool for disaster risk messages. Disaster Prev Manag. 2015;24(5):570– 582. 33. McComas KA. Citizen satisfaction with public meetings used for risk communication. J Appl Commun Res. 2003;31(2):164-184. 34. Foster C, Tanner AH, Kim S-H, Kim SY. National conversations about the costs of U.S. health care: a content analysis of media coverage, 1993 –2010. Sci Commun. 2014;36:519-543. 35. Bositis DA. The Deep South and Medicaid expansion: the view from Alabama, Georgia, Louisiana, Mississippi, and South Carolina. Joint Center for Political and Economic Studies website. http://jointcenter.org/sites/default/files/ The%20Deep%20South%20and%20Medicaid%20Expansi on.pdf. Published 2013. Accessed November 15, 2015. 36. Chen H-Y, Boore JRP. Translation and back-translation in qualitative nursing research: methodological review. J Clin Nurs. 2010;19:234-239. 37. Douglas SP, Craig CS. Collaborative and iterative translation: an alternative approach to back translation. J Int Mark. 2007;15:30-43. 38. Tanner A, Owens OL, Sisson DC, et al. Dodging the debate and dealing the facts: using research and community partnerships to promote understanding and communication of the Affordable Care Act. Libr Q. In press.