Identifying correlates of salt reduction practices among rural, middle-aged Muslim Indonesians with hypertension through structural equation modeling.

Background: In 2016, the World Health Organization recommended salt reduction strategies. In most low- and middle-income countries, little is known about what causes people to reduce their salt intake. Aim: In rural West Java, Indonesia, we conducted a cross-sectional survey to describe self-reported salt reduction practices among middle-aged Muslims with hypertension (n = 447) and to identify correlates of salt reduction. Methods: We developed a questionnaire with Likert scales to measure self-reported frequency of efforts to reduce salt intake, and degree of agreement/disagreement with 51 statements about variables hypothesized to influence salt reduction practices. We compared groups using t-tests and one-way ANOVAs. Through one-factor confirmatory factor analysis and structural equation modeling, we identified correlates of salt reduction practices. Results: About 45% of participants reported regularly reducing their salt intake; only 12.8% reported never attempting. Men reported higher social barriers, while women reported higher family support and spiritual support. Overall, we found that participants' frequency of effort to reduce their salt intake was associated with a constellation of six correlates. Salt reduction practices were directly positively associated with prior health/illness experiences (ß = 0.25), and by seeking health information (ß = 0.24). Seeking health information was in turn positively associated with prior health/illness experiences (ß = 0.34), receiving support from health professionals (ß = 0.23) and Islamic spiritual practice (ß = 0.24). Salt reduction practices were negatively associated with environmental barriers to healthful eating practices (ß = -0.14). Conclusion: In this population, reinforcing positive correlates identified in this study and mitigating against negative correlates may foster salt reduction practices.

Uncovering Philip Morris International's Fundamental Strategies for Product Placement in Thailand: Spotlighting Industry Penetration to Advance the Endgame.

BACKGROUND: Tobacco companies and their associated businesses know that placement - where one can see and purchase their products - is critical to their success. Placement is one of the four fundamental Ps of marketing along with product, price and promotion. Placement includes identifying retail locations in important places such as in shopping districts, within neighborhoods, near schools, at beaches, and in parks. In Southeast Asia, counteracting tobacco company placement strategies that result in market penetration is essential to advancing the endgame, namely ending tobacco use. However, in Southeast Asia research on the placement of tobacco products has been limited. OBJECTIVES: We undertook to analyze how Philip Morris International (PMI) through its subsidiary Philip Morris Asia Inc. (PMAI), from the time the company entered Thailand's market once it was forced open in 1990, developed its successful product placement strategies and tactics. METHODS: We examined over 4,000 PMI and PMAI internal documents using an historical, iterative and thematic approach. We analyzed the most relevant and illuminating documents, particularly those in which PMAI discussed retailer supply, retailer acceptance and retailer cooperation. RESULTS: Even before foreign tobacco brands were legally allowed to be sold in Thailand, PMAI was already doing customer research in Thailand. In 1989, PMAI conducted a study of potential Thai customers in which 24% of respondents' lack of availability (i.e., product placement) was one of the main reasons for not smoking PMI's products. Based on these findings, PMAI engaged in intensive internal efforts to address the placement barrier to gain share. PMAI placed considerable emphasis on "stimulating retail trade acceptance" by making payments to retailers who met agreed upon and contracted product sales targets. PMAI's initial successes incentivizing Thai retailers by essentially buying prime retail space for placement of their brands, to crowd out local and other foreign brands, became the foundation of what evolved into a sophisticated program to make placement highly lucrative for retailers. CONCLUSION: PMAI viewed aggressive product placement as essential to success as a new entrant in Thailand, and their product placement strategies contributed substantially to capturing a large share of the market. Therefore, endgame strategies must focus on restricting product placement through surveillance of tobacco industry legal, investment and retailer actions and through stricter tobacco retailer licensing requirements and penalties.

The Implementation Activist: How One Determined Person with a Camera Has Achieved Enforcement of Smoke-Free Laws throughout Thailand.

BACKGROUND: Smoking and exposure to secondhand smoke are leading causes of disease and premature death in low- and middle-income countries (LMICs), where over 80% of smokers live. Over 152 LMICs, including Thailand, have passed laws designating that indoor and outdoor public spaces should be smoke-free. Throughout LMICs, implementation of laws has been a persistent problem. We identified one activist in Thailand who developed his own highly effective strategy for ensuring implementation of smoke-free laws, and whose approach has potential for being a model for implementation activists in other LMICs. OBJECTIVES: We set out to describe the implementation activist's strategy and impact, and to explore his perspective and motivations. METHODS: We conducted in-depth interviews with the activist, reviewed video recordings and transcripts, and used narrative analysis to identify key themes and illuminating statements. FINDINGS: In the implementation activist's assessment, administrators and officials were not being held accountable for their responsibilities to enforce laws, resulting in low public compliance. The activist developed his strategy to first identify public places where no-smoking signs were not posted and/or where people were smoking; take photographs of violations and make notes; and file citizen's complaints at police stations, submitting his photographs as evidence. The implementation activist documented over 5,100 violations of smoke-free laws throughout Thailand and reported violations to police. Often, police officers were unsure how to deal with his complaints, but when he educated them about the law, most undertook enforcement actions. The activist's work has contributed substantially to creating smoke-free schools, sports facilities and parks. CONCLUSION: This implementation activist's approach can be a model for preventing youth from using tobacco/nicotine, and preventing exposures to secondhand smoke and e-cigarette emissions. Based on his successes, we provide a list of elements that implementation activists can use to be effective, along with recommendations for policy and practice.

Positive Deviance: Frequent Blood Pressure Monitoring Among Non-hypertensive Middle-aged Women in Rural Indonesia.

BACKGROUND: In Indonesia, as in many low and middle-income countries, hypertension is a significant health issue. Community health nurses need to identify those with early onset of hypertension by promoting frequent blood pressure (BP) checks, even among those with normal BP. Positive deviance approaches focus on identifying people who undertake uncommon preventive actions. Among middle-aged women in rural West Java, Indonesia, we aimed to identify covariates of the positive deviant practice of having one's BP checked at least once every three months even when having normal BP.  Methods: We conducted a cross-sectional survey recruiting participants at health centers. Our structured questionnaire measured socio-demographic characteristics, frequency of BP checks, BMI, beliefs and practices. We used binomial logistic regression to identify covariates. RESULTS: Among 520 participants, 265 had normal BP, and of those 156 had obtained frequent BP checks, making them positive deviants. For women with normal BP, significant covariates of obtaining frequent BP checks were: 1) having BMI ≥25.0 (adjusted odds ratio (AOR)  =2.57, 95% confidence interval (CI)=1.39-4.78), 2) greater tendency to seek health information (AOR=1.13, 95% CI=1.03-1.24), 3) receiving less support from family members (AOR=0.87, 95% CI=0.77-0.97), and 4) receiving greater support from health volunteers (AOR=1.12, 95% CI=1.01-1.23). CONCLUSION: Positive deviants were more likely to be proactive because of the convergence of their own individual-level tendencies to learn about  their health, family-level conditions that allowed for greater autonomy, and community-level capacity of health volunteers to provide them with support. Community health nurses should focus simultaneously on activating individual-level, family-level, and community-level capacity to prevent hypertension.

Unboxed: US Young Adult Tobacco Users' Responses to a New Heated Tobacco Product.

The heated tobacco product (HTP) IQOS was authorized for sale in the US in 2019. We investigated how young adults with experience using multiple tobacco products reacted to, perceived, and developed interest in IQOS, informing policies that might prevent HTPs from becoming ubiquitous. We used a novel qualitative method in which 33 young adult tobacco users in California (fall 2019) "unboxed" an IQOS device, tobacco sticks, and marketing materials and narrated their impressions and opinions. We conducted content and thematic analyses of participants' reactions, sensory experiences, and interest. Multiple attributes influenced appeal for participants, including sleek electronic design, novel technology, perceived harmfulness, complexity, and high cost. The "no smoke" claim and heating technology suggested that smoking IQOS was safer than smoking cigarettes. Public health programs should closely monitor HTP marketing and uptake, particularly as "reduced exposure" claims were authorized in July 2020. Evidence-based regulations (e.g., requiring plain packaging for tobacco sticks), actions addressing IQOS' unique attributes (e.g., regulating device packaging to reduce high-tech appeal), and public education might help to counter the appeal generated by potentially misleading IQOS marketing tactics.

Cigarette Waste in Popular Beaches in Thailand: High Densities that Demand Environmental Action.

Thailand, like all nations, has a responsibility to initiate environmental actions to preserve marine environments. Low- and middle-income countries face difficulties implementing feasible strategies to fulfill this ambitious goal. To contribute to the revitalization of Thailand's marine ecosystems, we investigated the level of tobacco product waste (TPW) on Thailand's public beaches. We conducted a cross-sectional observational survey at two popular public beaches. Research staff collected cigarette butts over two eight-hour days walking over a one-kilometer stretch of beach. We also compiled and analyzed data on butts collected from sieved sand at 11 popular beaches throughout Thailand's coast, with 10 samples of sieved sand collected per beach. Our survey at two beaches yielded 3067 butts in lounge areas, resulting in a mean butt density of 0.44/m². At the 11 beaches, sieved sand samples yielded butt densities ranging from 0.25 to 13.3/m², with a mean butt density of 2.26/m² (SD = 3.78). These densities show that TPW has become a serious problem along Thailand's coastline. Our findings are comparable with those in other countries. We report on government and civil society initiatives in Thailand that are beginning to address marine TPW. The solution will only happen when responsible parties, especially and primarily tobacco companies, undertake actions to eliminate TPW.

Secondhand smoke point-source exposures assessed by particulate matter at two popular public beaches in Thailand.

Background: Throughout Asia, smoking is commonplace at crowded public beaches. Evidence has clearly shown the dangers of secondhand smoke (SHS) indoors, but no naturalistic studies have determined levels of SHS in outdoor air. Methods: We measured SHS exposure at two public beaches in Thailand where families lounge in beach chairs under beach umbrellas. Researchers unobtrusively collected PM2.5 in close proximity to smokers by placing instruments downwind from smokers. We collected 88 samples of second-by-second measurements over 10-min periods. The density of people, smokers and children in each sampling area was also recorded. Results: At the two beaches, mean levels were 260 and 504 µg/m3; peak levels reaching up to 716 and 1335 µg/m3. Five of the 88 samples were below the outdoor standard for Thailand of 50 µg/m3. Density counts in sampled zones were up to 4 smokers and 15 children under 12 years of age. Findings show high beach exposures suggesting regulatory protections, especially for children whose exposures can produce multiple health consequences. Conclusions: Action should be taken to prohibit smoking on Thai beaches as in other outdoor settings because peak levels of PM2.5 almost always exceeded the outdoor standard in Thailand and pose a danger to health.

How Thailand's greater convergence created sustainable funding for emerging health priorities caused by globalization.

BACKGROUND: Global health is shifting gradually from a limited focus on individual communicable disease goals to the formulation of broader sustainable health development goals. A major impediment to this shift is that most low- and middle-income countries (LMICs) have not established adequate sustainable funding for health promotion and health infrastructure. OBJECTIVE: In this article, we analyze how Thailand, a middle-income country, created a mechanism for sustainable funding for health. DESIGN: We analyzed the progression of tobacco control and health promotion policies over the past three decades within the wider political-economic and sociocultural context. We constructed a parallel longitudinal analysis of statistical data on one emerging priority - road accidents - to determine whether policy shifts resulted in reduced injuries, hospitalizations and deaths. RESULTS: In Thailand, the convergence of priorities among national interest groups for sustainable health development created an opportunity to use domestic tax policy and to create a semi-autonomous foundation (ThaiHealth) to address a range of pressing health priorities, including programs that substantially reduced road accidents. CONCLUSIONS: Thailand's strategic process to develop a domestic mechanism for sustainable funding for health may provide LMICs with a roadmap to address emerging health priorities, especially those caused by modernization and globalization.

Culture, acculturation and smoking use in Hmong, Khmer, Laotians, and Vietnamese communities in Minnesota.

BACKGROUND: Southeast Asian communities in the United States have suffered from high rates of tobacco use and high rates of chronic diseases associated with firsthand and secondhand smoking. Research is needed on how best to reduce and prevent tobacco use and exposure to secondhand smoke in these communities. The objective of this study was to examine how tobacco use patterns in Minnesota's Southeast Asian communities have been shaped by culture, immigration, and adjustment to life in America in order to inform future tobacco control strategies. METHODS: The study consisted of semi-structured interviews with 60 formal and informal leaders from Minnesota's Hmong, Khmer (Cambodian), Lao, and Vietnamese communities and incorporated principles of community-based participatory research. RESULTS: Among Khmer, Lao and Vietnamese, tobacco in the homeland was a valued part of material culture and was used to signify social status, convey respect, and support social rituals among adult men (the only group for whom smoking was acceptable). Among the Hmong, regular consumption of tobacco was unacceptable and rarely seen until the civil war in Laos when a number of Hmong soldiers became smokers. In Minnesota, social norms have begun to shift, with smoking becoming less acceptable. Although older male smokers felt social pressure to quit, smoking functioned to reduce the stress of social isolation, economic hardship, prior trauma, and the loss of power and status. Youth and younger women no longer felt as constrained by culturally-rooted social prohibitions to smoke. CONCLUSIONS: Leaders from Minnesota's Southeast Asian communities perceived key changes in tobacco-related attitudes, beliefs, and behaviors which were embedded in the context of shifting power, status, and gender roles within their communities. This has practical implications for developing policy and interventions. Older Southeast Asians are likely to benefit from culturally-tailored programs (e.g., that value politeness and the importance of acting in ways that benefit the family, community, and clan) and programs that work with existing social structures, as well as initiatives that address smokers' psychological distress and social isolation. Leaders remained uncertain about how to address smoking uptake among youth, pointing to a need for additional research.

Determining the burden of secondhand smoke exposure on the respiratory health of Thai children.

BACKGROUND: The impact of secondhand smoke (SHS) on Southeast Asian children's health has been assessed by a limited number of studies. The purpose of this study was to determine whether in Thailand, pre- and postnatal exposure to SHS is associated with acute lower respiratory conditions in young children. METHODS: We conducted a case control study of 462 children under age five admitted with acute lower respiratory illnesses, including asthma and pneumonia, at a major hospital in Bangkok. We selected 462 comparison controls from the well-child clinic at the hospital and matched them by sex and age. We used a structured questionnaire to collect information about exposure to SHS and other factors. We conducted bivariate and multivariate analyses to identify risk factors for acute lower respiratory conditions. RESULTS: The number of cigarettes smoked at home per day by household members was significantly greater among cases. A greater number of household caregivers of cases held and carried children while smoking as compared to controls (26% versus 7%, p <0.05). Cases were more likely to have been exposed to SHS in the household (adjusted OR = 3.82, 95% CI = 2.47-5.9), and outside (adjusted OR = 2.99, 95% CI = 1.45-6.15). Parental lower educational level and low household income were also associated with respiratory illnesses in Thai children under five. CONCLUSIONS: Thai children who are exposed to SHS are at nearly 4 times greater risk of developing acute lower respiratory conditions. Continued effort is needed in Thailand to eliminate children's exposure to SHS, especially at home.

Success counteracting tobacco company interference in Thailand: an example of FCTC implementation for low- and middle-income countries.

Transnational tobacco companies (TTCs) interfere regularly in policymaking in low- and middle-income countries (LMICs). The WHO Framework Convention for Tobacco Control provides mechanisms and guidance for dealing with TTC interference, but many countries still face 'how to' challenges of implementation. For more than two decades, Thailand's public health community has been developing a system for identifying and counteracting strategies TTCs use to derail, delay and undermine tobacco control policymaking. Consequently, Thailand has already implemented most of the FCTC guidelines for counteracting TTC interference. In this study, our aims are to describe strategies TTCs have used in Thailand to interfere in policymaking, and to examine how the public health community in Thailand has counteracted TTC interference. We analyzed information reported by three groups with a stake in tobacco control policies: Thai tobacco control advocates, TTCs, and international tobacco control experts. To identify TTC viewpoints and strategies, we also extracted information from internal tobacco industry documents. We synthesized these data and identified six core strategies TTCs use to interfere in tobacco control policymaking: (1) doing business with 'two faces', (2) seeking to influence people in high places, (3) 'buying' advocates in grassroots organizations, (4) putting up a deceptive front, (5) intimidation, and (6) undermining controls on tobacco advertising, promotion and sponsorship. We present three case examples showing where TTCs have employed multiple interference strategies simultaneously, and showing how Thai tobacco control advocates have successfully counteracted those strategies by: (1) conducting vigilant surveillance, (2) excluding tobacco companies from policymaking, (3) restricting tobacco company sales, (4) sustaining pressure, and (5) dedicating resources to the effective enforcement of regulations. Policy implications from this study are that tobacco control advocates in LMICs may be able to develop countermeasures similar to those we identified in Thailand based on FCTC guidelines to limit TTC interference.

Building tobacco control research in Thailand: meeting the need for innovative change in Asia.

INTRODUCTION: In low- and middle-income countries (LMICs) over the past two decades locally relevant tobacco control research has been scant. Experience shows that tobacco control measures should be based on sound research findings to ensure that measures are appropriate for local conditions and that they are likely to have an impact. Research should also be integrated within tobacco control measures to ensure ongoing learning and the production of knowledge. Thailand, a middle-income country, has a public health community with a record of successful tobacco control and a longstanding commitment to research. Thailand's comprehensive approach includes taxation; bans on tobacco advertising, sponsorship and promotion; smoke-free areas; graphic cigarette pack warnings; social marketing campaigns; cessation counseling; and an established tobacco control research program. The purpose of this study was to document and analyze the development of tobacco control research capacity in Thailand and the impact of research on Thai tobacco control measures. METHOD: We used mixed methods including review of historical documentation and policy reports, qualitative interviews with key members of Thailand's tobacco control community, and an analysis of research productivity. FINDINGS: In Thailand, tobacco control research has evolved through three phases: (1) discovery of the value of research in the policymaking arena, (2) development of a structure to support research capacity building through international collaborations supported by foreign funding agencies, and (3) delivery of locally relevant research made possible largely through substantial stable funding from a domestic health promotion foundation. Over two decades, Thai tobacco control advocates have constructed five steppingstones to success: (1) adapting foreign research to inform policymaking and lobbying for more support for domestic research; (2) attracting foreign funding agencies to support small-scale research and capacity building; (3) participating in multi-country research and capacity building programs; (4) using collaborative experiences to demonstrate the need for domestic support of locally relevant research; and (5) maintaining an unwavering commitment to research while being vigilant to ensure continued research support. CONCLUSION: The evolution of tobacco control research in Thailand provides examples of steppingstones that LMICs may be able to use to construct their own tobacco control research pathways.

Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women.

OBJECTIVES: We sought to promote cervical cancer screening among Vietnamese American women in Santa Clara County, Calif. METHODS: In 2001-2004, we recruited and randomized 1005 Vietnamese American women into 2 groups: lay health worker outreach plus media-based education (combined intervention) or media-based education only. Lay health workers met with the combined intervention group twice over 3 to 4 months to promote Papanicolaou (Pap) testing. We used questionnaires to measure changes in awareness, knowledge, and Pap testing. RESULTS: Testing increased among women in both the combined intervention (65.8% to 81.8%; P<.001) and media-only (70.1% to 75.5%; P<.001) groups, but significantly more in the combined intervention group (P=.001). Among women never previously screened, significantly more women in the combined intervention group (46.0%) than in the media-only group (27.1%) obtained tests (P<.001). Significantly more women in the combined intervention group obtained their first Pap test or obtained one after an interval of more than 1 year (became up-to-date; 45.7% to 67.3%, respectively; P<.001) than did those in the media-only group (50.9% to 55.7%, respectively; P=.035). CONCLUSIONS: Combined intervention motivated more Vietnamese American women to obtain their first Pap tests and to become up-to-date than did media education alone.

Papanicolaou testing among Vietnamese Americans: results of a multifaceted intervention.

BACKGROUND: Vietnamese-American women have the highest incidence of cervical cancer of any ethnic group, and they underutilize Papanicolaou (Pap) tests. DESIGN: Development and implementation of a multifaceted intervention using community-based participatory research (CBPR) methodology and evaluated with a quasi-experimental controlled design with cross-sectional pre-intervention (2000) and post-intervention (2004) telephone surveys. Data were analyzed in 2005. SETTING: Santa Clara County, California (intervention community) and Harris County, Texas (comparison community). PARTICIPANTS: Vietnamese-American women aged 18 and older (n =1566 at pre-intervention and 2009 at post-intervention). INTERVENTION: A community-academic coalition developed and implemented six components: Vietnamese-language media campaign, lay health worker outreach, Vietnamese Pap clinic, patient registry/reminder system, restoration of a government-funded low-cost screening program, and continuing medical education for Vietnamese physicians. OUTCOME MEASURE: Pap test receipt. RESULTS: Overall response rate was 56%. Pap test receipt increased in the intervention (77.5% to 84.2%, p <0.001), but not in the comparison community (73.9% to 70.6%, p >0.05). In multivariate analyses, the intervention was associated with increased Pap test receipt (odds ratio [OR]=2.02, 95% confidence interval [CI]=1.37-2.99). Other factors associated with increased Pap testing included longer U.S. residence, having health insurance, having a regular site of care, having a respectful physician, having a non-Vietnamese or a female Vietnamese physician, and recalling exposure to Vietnamese-language media about Pap testing. Factors associated with reduced likelihood of Pap test receipt were age 65 years and older, never married, less than high school education, and income below poverty level. CONCLUSIONS: A multifaceted CBPR intervention was associated with increased Pap test receipt among Vietnamese-American women in one community.

Processes and capacity-building benefits of lay health worker outreach focused on preventing cervical cancer among Vietnamese.

The authors organized a lay health worker (LHW) outreach program with Vietnamese women that produced significant increases in Pap testing. The program was conducted by five partner agencies and 50 LHWs and involved 1,005 women. This article reports on the roles of the agencies and coordinators, the selection of LHWs, the processes LHWs used in identifying and recruiting participants, the ways they conducted their outreach work, and their strategies for maintaining participation. The article also reports on the LHWs' perspectives about how they benefited and what they found to be most rewarding and challenging about being a LHW. Based on the analysis of this information, the authors present a conceptual framework for understanding how different contextual factors shape the processes and capacity-building benefits of LHW outreach, describing four contextual domains that shape LHW outreach: the sociocultural domain and organizational domain, which overlap in the programmatic domain, all of which are framed by the structural domain. This analysis provides an approach for understanding how lay health work is shaped by a broader context.

Disparities in colorectal cancer screening rates among Asian Americans and non-Latino whites.

Among Asian Americans, colorectal cancer (CRC) is the second most commonly diagnosed cancer, and it is the third highest cause of cancer-related mortality. The 2001 California Health Interview Survey (CHIS 2001) was used to examine 1) CRC screening rates between different Asian-American ethnic groups compared with non-Latino whites and 2) factors related to CRC screening. The CHIS 2001 was a population-based telephone survey that was conducted in California. Responses about CRC screening were analyzed from 1771 Asian Americans age 50 years and older (Chinese, Filipino, South Asian, Japanese, Korean, and Vietnamese). The authors examined two CRC screening outcomes: individuals who ever had CRC screening and individuals who were up to date for CRC screening. For CRC screening, fecal occult blood test (FOBT), sigmoidoscopy/colonoscopy, and any other form of screening were examined. CRC screening of any kind was low in all populations, and Koreans had the lowest rate (49%). Multivariate analysis revealed that, compared with non-Latino whites, Koreans were less likely to undergo FOBT (odds ratio [OR], 0.40; 95% confidence interval [95% CI], 0.25-0.62), and Filipinos were the least likely to undergo sigmoidoscopy/colonoscopy (OR, 0.62; 95% CI, 0.44-0.88) or to be up to date with screening (OR, 0.68; 95% CI, 0.48-0.97). Asian Americans were less likely to undergo screening if they were older, male, less educated, recent immigrants, living with >or= 3 individuals, poor, or uninsured. Asian-American populations, especially Koreans and Filipinos, are under-screened for CRC. Outreach efforts could be more focused on helping Asian Americans to understand the importance of CRC screening, providing accurate information in different Asian languages. Other strategies for increasing CRC screening may include using a more family-centered approach and using qualified translators.

Highlights/best practices of San Francisco's Asian American Network for Cancer Awareness, Research, and Training (AANCART).

The Asian American Network for Cancer Awareness, Research, and Training in San Francisco (AANCART-SF) consists of two distinct entities, working in cooperation to advance cancer awareness, research, and training among Asian Americans: a university-based group with expertise in the Vietnamese community and a community-based health plan with expertise in the Chinese community. In addition to the goals shared with other AANCART sites, AANCART-SF is a unique effort in capacity building in that it aims to expand and export community-academic research expertise from one Asian population, the Vietnamese, to other Asian populations. It also aims to build the research capability of those serving the Chinese community through a health plan.

Qualitative research: contributions to the study of drug use, drug abuse, and drug use(r)-related interventions.

This article describes how qualitative social science research has and can contribute to the emerging field of drug and alcohol studies. An eight-stage model of formative-reformative research is presented as a heuristic to outline the different ways in which qualitative research may be used to better understand micro and macro dimensions of drug use and distribution; more effectively design, monitor and evaluate drug use(r)-related interventions; and address the politics of drug/drug program representation. Tobacco is used as an exemplar to introduce the reader to the range of research issues that a qualitative researcher may focus upon during the initial stage of formative research. Ethnographic research on alcohol use among Native Americans is highlighted to illustrate the importance of closely examining ethnicity as well as class when investigating patterns of drug use. To familiarize the reader with qualitative research, we describe the range of methods commonly employed and the ways in which qualitative research may complement as well as contribute to quantitative research. In describing the later stages of the formative-reformative process, we consider both the use of qualitative research in the evaluation and critical assessment of drug use(r)-intervention programs, and the role of qualitative research in critically assessing the politics of prevention programs. Finally, we discuss the challenges faced by qualitative researchers when engaging in transdisciplinary research.

Increasing Vietnamese-American physicians' knowledge of cervical cancer and Pap testing: impact of continuing medical education programs.

Vietnamese-American women who regularly see Vietnamese-American physicians are less likely to obtain Pap tests, perhaps because of the physicians' limited training in preventive medicine and the women's discomfort receiving Pap tests from male physicians. To address this problem, during 2001-2003, the University of California, San Francisco's (USCF) Vietnamese Community Health Promotion Project collaborated with the Vietnamese Physician Association of Northern California to organize 3 continuing medical education (CME) seminars on cervical cancer for association members. Experts gave lectures and answered questions about screening, diagnosis, and treatment to train physicians to identify risk factors, recommend Pap tests, and evaluate and conduct follow up of abnormal tests. To evaluate the seminars, we administered pre- and post-CME pencil-and-paper questionnaires. Data analysis employing the McNemar chi-squared test demonstrated significant changes in knowledge and understandingfrom pre- to post-CME in multiple areas. Results suggest that CME seminars can significantly increase Vietnamese physicians' knowledge about cervical cancer diagnosis and treatment.