Impact of the Cancer Prevention and Control Research Network: Accelerating the Translation of Research Into Practice.

The Cancer Prevention and Control Research Network (CPCRN) is a thematic network dedicated to accelerating the adoption of evidence-based cancer prevention and control practices in communities by advancing dissemination and implementation science. Funded by the Centers for Disease Control and Prevention and National Cancer Institute, CPCRN has operated at two levels: Each participating network center conducts research projects with primarily local partners as well as multicenter collaborative research projects with state and national partners. Through multicenter collaboration, thematic networks leverage the expertise, resources, and partnerships of participating centers to conduct research projects collectively that might not be feasible individually. Although multicenter collaboration is often advocated, it is challenging to promote and assess. Using bibliometric network analysis and other graphical methods, this paper describes CPCRN's multicenter publication progression from 2004 to 2014. Searching PubMed, Scopus, and Web of Science in 2014 identified 249 peer-reviewed CPCRN publications involving two or more centers out of 6,534 total. The research and public health impact of these multicenter collaborative projects initiated by CPCRN during that 10-year period were then examined. CPCRN established numerous workgroups around topics such as: 2-1-1, training and technical assistance, colorectal cancer control, federally qualified health centers, cancer survivorship, and human papillomavirus. This paper discusses the challenges that arise in promoting multicenter collaboration and the strategies that CPCRN uses to address those challenges. The lessons learned should broadly interest those seeking to promote multisite collaboration to address public health problems, such as cancer prevention and control.

Hepatitis B ESL education for Asian immigrants.

Asian communities in North America include large numbers of immigrants with limited English proficiency. Hepatitis B virus (HBV) infection is endemic in most Asian countries and, therefore, Asian immigrant groups have high rates of chronic HBV infection. We conducted a group-randomized trial to evaluate the effectiveness of a hepatitis B English as a second language (ESL) educational curriculum for Asian immigrants. Eighty ESL classes were randomized to experimental (hepatitis B education) or control (physical activity education) status. Students who reported they had not received a HBV test (at baseline) completed a follow-up survey 6 months after randomization. The follow-up survey assessed recent HBV testing and HBV-related knowledge. Provider reports were used to verify self-reported HBV tests. The study group included 218 students who reported they had not been tested for HBV. Follow-up surveys were completed by 180 (83%) of these students. Provider records verified HBV testing for 6% of the experimental group students and 0% of the control group students (P = 0.02). Experimental group students were significantly (P < 0.05) more likely than control group students to know that immigrants have high HBV infection rates, HBV can be spread during sexual intercourse and by sharing razors, and HBV infection can cause liver cancer. Our ESL curriculum had a meaningful impact on HBV-related knowledge and a limited impact on HBV testing levels. Future research should evaluate the effectiveness of ESL curricula for other immigrant groups and other health topics, as well as other intervention approaches to increasing levels of HBV testing in Asian immigrant communities.

Factors associated with hepatitis B testing among Vietnamese Americans.

BACKGROUND: Chronic hepatitis B and hepatitis B-associated liver cancer is a major health disparity among Vietnamese Americans, who have a chronic hepatitis B prevalence rate of 7-14% and an incidence rate for liver cancer six times that of non-Latino whites. OBJECTIVE: Describe factors associated with hepatitis B testing among Vietnamese Americans. DESIGN: A population-based telephone survey conducted in 2007-2008. PARTICIPANTS: Vietnamese Americans age 18-64 and living in the Northern California and Washington, DC areas (N = 1,704). MAIN MEASURES: Variables included self-reports of sociodemographics, health care factors, and hepatitis B-related behaviors, knowledge, beliefs, and communication with others. The main outcome variable was self-reported receipt of hepatitis B testing. KEY RESULTS: The cooperation rate was 63.1% and the response rate was 27.4%. Only 62% of respondents reported having received a hepatitis B test and 26%, hepatitis B vaccination. Only 54% knew that hepatitis B could be transmitted by sexual intercourse. In multivariable analyses, factors negatively associated with testing included: age 30-49 years, US residence for >10 years, less Vietnamese fluency, lower income, and believing that hepatitis B can be deadly. Factors positively associated with testing included: Northern California residence, having had hepatitis B vaccination, having discussed hepatitis B with family/friends, and employer requested testing. Physician recommendation of hepatitis B testing (OR 4.46, 95% CI 3.36, 5.93) and respondent's request for hepatitis B testing (OR 8.37, 95% CI 5.95, 11.78) were strongly associated with test receipt. CONCLUSION: Self-reports of hepatitis B testing among Vietnamese Americans remain unacceptably low. Physician recommendation and patient request were the factors most strongly associated with test receipt. A comprehensive effort is needed to promote hepatitis B testing in this population, including culturally-targeted community outreach, increased access to testing, and physician education.

Constructing a theoretically based set of measures for liver cancer control research studies.

OBJECTIVE: Measurement tools such as surveys assessing knowledge, attitudes, and behaviors need to be theoretically consistent with interventions. The purpose of this article is to describe the first steps in the process of constructing a theoretically based set of measures that is currently used in three trials to reduce liver cancer disparities. METHODS: Guided by a common theoretical formulation-the Health Behavior Framework-we identified constructs relevant for liver cancer control research, compiled items from previous studies and constructed new items, and translated and pilot tested items in collaboration with members of the Vietnamese, Korean, and Hmong communities. RESULTS: We constructed three questionnaires in Vietnamese, Hmong, and Korean languages that are slightly different due to cultural and language nuances but contain a core set of measures assessing identical constructs of the Health Behavior Framework. Initial research demonstrates that items are easily understood and that they are generally related to hepatitis B screening as expected. CONCLUSIONS: Researchers are encouraged to follow a similar process for creating theory-based assessment tools. Measuring common theoretical constructs can advance liver cancer control and other health research by facilitating a more systematic comparison of findings across different populations and intervention strategies.

Integrating theory into community interventions to reduce liver cancer disparities: The Health Behavior Framework.

Mitigating the unequal burden of cancer often involves conducting community-based trials to develop effective intervention strategies to promote cancer-related health behaviors. However, this is challenging due to the simultaneous influence of numerous factors, at multiple levels in the socio-ecological context, on health behavior. A sound conceptual framework can bring order to this complex environment and provide a roadmap for systematically addressing the multiple determinants of the behavior in question. This paper describes the application of The Health Behavior Framework, an integrative conceptual model, in an ongoing Program Project, "Liver Cancer Control Interventions for Asian-Americans." The Framework has been integral to shaping all aspects of the three component research trials from selection of the study designs to development of the interventions and data collection instruments. We advocate universal adoption of theory into community-based intervention research as a way to accelerate our ability to develop effective interventions and facilitate synthesis of study results across populations and behavioral outcomes: critical steps in advancing the field of health disparities research.

Hepatitis B knowledge and practices among Cambodian immigrants.

BACKGROUND: Chronic hepatitis B infection is the most common cause of liver cancer among Cambodians. Our objective was to describe Cambodian Americans' hepatitis B knowledge, testing, and vaccination levels. METHODS: A community-based telephone survey was conducted in Seattle. Our study sample included 111 individuals. RESULTS: Less than one half (46%) of our study group had received a hepatitis B blood test, and about one third (35%) had been vaccinated against hepatitis B. Only 43% knew that Cambodians are more likely to be infected with hepatitis B than whites. CONCLUSIONS: Over 50% of our respondents did not recall being tested for hepatitis B. We identified important knowledge deficits about hepatitis B. Continued efforts should be made to implement hepatitis B educational campaigns for Cambodians.

Evaluation of a hepatitis B lay health worker intervention for Chinese Americans and Canadians.

Hepatitis B testing is recommended for immigrants from countries where hepatitis B infection is endemic. However, only about one-half of Chinese in North America have received hepatitis B testing. We conducted a randomized controlled trial to evaluate the effectiveness of a hepatitis B lay health worker intervention for Chinese Americans/Canadians. Four hundred and sixty individuals who had never been tested for hepatitis B were identified from community-based surveys of Chinese conducted in Seattle, Washington, and Vancouver, British Columbia. These individuals were randomly assigned to receive a hepatitis B lay health worker intervention or a direct mailing of physical activity educational materials. Follow-up surveys were completed 6 months after randomization. Self-reported hepatitis B testing was verified through medical records review. A total of 319 individuals responded to the follow-up survey (69% response rate). Medical records data verified hepatitis B testing since randomization for 9 (6%) of the 142 experimental group participants and 3 (2%) of the 177 control group participants (P = 0.04). At follow-up, a higher proportion of individuals in the experimental arm than individuals in the control arm knew that hepatitis B can be spread by razors (P < 0.001) and during sexual intercourse (P = 0.07). Our findings suggest that lay health worker interventions can impact hepatitis B-related knowledge. However, our hepatitis B lay health worker intervention had a very limited impact on hepatitis B testing completion. Future research should evaluate other intervention approaches to improving hepatitis B testing rates among Chinese in North America.

Hepatitis B testing and vaccination in immigrants attending English as a second language classes in British Columbia, Canada.

BACKGROUND: Hepatitis B virus (HBV) is a growing health issue in Canada, especially given that population growth is now largely the result of immigration. Immigrants from countries with high HBV prevalence and low levels of HBV vaccination have an excess risk of liver disease and there is a need for increased diligence in HBV blood testing and possibly vaccination among these populations. OBJECTIVE: This study describes the sociodemographic characteristics associated with a history of HBV testing and HBV vaccination in immigrants from several countries with high HBV prevalence who are attending English classes. METHODS: 759 adult immigrants attending English as a Second Language classes completed a self-administered questionnaire asking about sociodemographic characteristics and history of HBV testing and HBV vaccination. Descriptive statistics and adjusted ORs were calculated to explore these associations. RESULTS: 71% reported prior HBV testing, 8% reported vaccination without testing, and 21% reported neither testing nor vaccination. Age, education and country of birth all showed significant effects for both testing and vaccination. CONCLUSIONS: Health care practitioners need to be cognizant of HBV testing, and possibly vaccination, in some of their patients, including immigrants from countries with endemic HBV infection. Infected persons need to be identified by blood testing in order receive necessary care to prevent or delay the onset of liver disease as well as to adopt appropriate behaviours to reduce the risk of transmission to others. Close contacts of infected persons also require HBV testing and subsequent vaccination (if not infected) or medical management (if infected).

Heart disease prevention practices among immigrant Vietnamese women.

BACKGROUND: Cardiovascular disease is a leading cause of death in the United States as well as in many countries around the world, including Vietnam. METHODS: Using data from a household survey of Vietnamese American women aged 20-79 years in Seattle, Washington, collected in 2006 and 2007, we examined heart disease prevention practices. Multivariable analyses were conducted to examine the relationship between demographic factors and preventive behaviors. RESULTS: A total of 1523 immigrant women completed interviews. The average daily consumption of fruits and vegetables was 3.5 servings, and 31% of our sample reported being physically active (engaging in at least 30 minutes of physical activity 5 or more days per week). Few respondents reported being current smokers (1.5%). Over three quarters of women had received a recent blood pressure check and a recent cholesterol check. Age and length of time in the United States were strongly associated with several cardiovascular prevention behaviors. CONCLUSIONS: Our findings confirm the need for continued efforts to develop and implement targeted educational campaigns to reduce the risk of cardiovascular disease among Vietnamese American women.

Knowledge and behaviour regarding heart disease prevention in Chinese Canadian immigrants.

OBJECTIVE: Although Chinese are one of the fastest growing minorities in Canada, there is little information about heart disease prevention behaviour in Chinese immigrants. Our objective was to examine the knowledge and practices of Chinese immigrants regarding heart disease prevention. METHODS: 504 randomly selected Chinese adult immigrants participated in a community-based, in-person survey in Vancouver during 2005. The survey included questions on heart disease prevention knowledge and practices. RESULTS: Although respondents were quite knowledgeable about heart disease risk factors, their behaviours to reduce heart disease risk were generally low. Thirteen percent of respondents consumed five or more servings of fruit/vegetables per day; 37% engaged in regular physical activity; 54% never used tobacco; 81% had received a blood pressure check in the past 2 years; and 54% had received a cholesterol test in the past 5 years. Differences were found in these behaviours by gender, age, English fluency, birth country and duration of residence in North America. The associations are presented between these demographic variables and heart disease prevention behaviours. CONCLUSION: Heart disease prevention programs are needed in Chinese immigrant populations, especially aimed at increasing fruit/vegetable consumption and regular physical activity. Efforts are also needed to decrease tobacco use and to increase cholesterol testing.

Heart disease prevention among Chinese immigrants.

There is little information about the heart disease prevention behavior of Asian immigrants. Chinese are the largest Asian sub-group in the United States (US), and 69% of Chinese Americans are foreign-born. Our objective was to describe Chinese immigrants' heart disease prevention practices. A community-based, in-person survey of Chinese men and women was conducted in Seattle during 2005. Our study sample included 395 Chinese immigrants. Only 15% of the respondents consumed five or more servings of fruit/ vegetables per day, and less than one-third (31%) engaged in regular physical activity. Smoking rates were significantly higher among men (21%) than women (1%). About three-quarters (74%) of the study group had received a cholesterol test in the previous five years. Recent immigrants had higher levels of fruit/ vegetable consumption and physical activity than those who had been in the US for 10 years or more. Conversely, longer duration of US residence was positively associated with recent cholesterol testing. Heart disease prevention programs should be developed, implemented, and evaluated in Chinese immigrant populations. These efforts should specifically aim to increase fruit/ vegetable consumption and regular physical activity. Future efforts to increase cholesterol testing should focus on recent immigrants.

Cost effectiveness of cervical cancer screening among Chinese women in North America.

BACKGROUND: Chinese North American women have high invasive cervical cancer rates and low screening rates. The cost-effectiveness of strategies to improve Pap testing rates for Chinese women living in Seattle, Washington and Vancouver, British Columbia was examined. OBJECTIVES: To calculate the costs and cost-effectiveness of implementing two strategies to motivate women to obtain a Pap smear. RESEARCH DESIGN: A three-armed randomized, controlled trial was conducted. Women in each of two interventions (high-intensity outreach and low-intensity mailing intervention) were compared to a group of women who received usual care. MEASURES: Costs were captured via a group discussion of costs, accounting records, sampling of staff time logs, and estimation of costs and task times. Effectiveness was measured as the proportion of women in each intervention arm who reported receiving a Pap smear since the trial began. Cost-effectiveness was calculated as the incremental cost of screening each additional woman between an intervention arm and the control arm. RESULTS: A greater percentage of women who received the outreach intervention had a Pap test than women who received mailed materials or women who were in the usual care arm. The intent-to-treat cost for each additional woman to be screened for a Pap test was $415 in the Outreach arm and $676 for the Direct Mailing arm. The outreach worker intervention, though more expensive overall, was more cost-effective than the mailing intervention. CONCLUSIONS: Outreach intervention is cost-effective for sponsors and should be considered as a strategy to motivate Chinese women living in North America to seek cervical cancer screening.

Predisposing, reinforcing and enabling factors associated with hepatitis B testing in Chinese Canadians in British Columbia.

BACKGROUND: Liver cancer, a significant health problem in Chinese, can be controlled through HBV blood testing, vaccination, and community education about HBV. The PRECEDE framework has been very helpful in identifying factors associated with health practices. OBJECTIVES: The objective was to identify factors associated with HBV testing in Chinese Canadians, using the PRECEDE framework. METHODS: Five hundred and thirty-three randomly selected Chinese Canadian adults were interviewed about HBV blood testing practices. Factors were grouped as predisposing, reinforcing and enabling. RESULTS: Fifty-five percent had received HBV blood testing. Several predisposing factors, all reinforcing factors and one enabling factor were associated with HBV testing in bivariate analysis. A physician's recommendation for testing was the strongest factor associated with testing in multiple logistic regression analysis (OR=4.4, p<0.0001). INTERPRETATION: Many Chinese Canadian adults in Vancouver have not been tested for HBV. Continuing educational efforts are needed and the PRECEDE framework can inform the development of health education interventions.

Hepatitis B knowledge, testing and vaccination levels in Chinese immigrants to British Columbia, Canada.

BACKGROUND: Little is known about hepatitis B (HBV) and liver cancer control in Chinese in Canada. Liver cancer, a significant health problem in Asia, is preventable and can be controlled through HBV blood testing, vaccination, and community education about HBV. OBJECTIVE: The overall goal was to increase HBV testing and vaccination in Chinese adult Canadians. The objective was to present findings on HBV testing, vaccination and knowledge in Chinese immigrants. METHODS: 504 randomly selected Chinese adult immigrants residing in Vancouver responded to the survey which examined HBV blood testing and vaccination practices, HBV knowledge levels and socio-demographic characteristics. Face-to-face interviews were conducted in Cantonese, Mandarin, or English. RESULTS: 57% of participants reported that they had received HBV blood testing, 38% had been vaccinated, and 6% were known HBV carriers. There were gender differences, with lower rates of testing and vaccination, and higher chronic carrier rates, among men. Over 80% knew that HBV can be spread by asymptomatic persons and can cause cirrhosis and liver cancer. However, confusion existed about the routes of HBV transmission. INTERPRETATION: A sizeable proportion of Chinese adult immigrants in Vancouver have not been tested or vaccinated for HBV. Knowledge level, especially about routes of HBV transmission, was low. This is a concern, given that chronic HBV infection is the most common cause of liver cancer in Asian North Americans. To improve knowledge, reduce risk of infection and the burden of chronic infection and its sequelae in immigrant populations, continuing educational efforts are needed.

Tobacco knowledge and beliefs in Chinese American men.

BACKGROUND: Chinese American men have relatively high smoking rates. However, there are limited data about the tobacco-related knowledge, attitudes, and beliefs of this racial/ethnic group. METHODS: We conducted a community-based telephone survey in Seattle, Washington during 2004. Households were identified by applying a previously validated list of Chinese last names to an electronic version of the Seattle telephone book. Interviews were completed in Cantonese, Mandarin, or English. Survey items addressed tobacco knowledge, cultural beliefs, and practices. RESULTS: The study sample included 168 Chinese American men. Current, former, and never smoking rates were 22%, 42%, and 36%, respectively. Current smokers were less likely to be proficient in English than never smokers, and were less likely to have a regular doctor than former smokers. They also had lower levels of knowledge about the health effects of tobacco, and were more likely to have traditional Chinese cultural beliefs about tobacco use than non-smokers. CONCLUSION: Tobacco use continues to be a public health problem among Chinese American men. Smoking cessation programs should target men with limited English proficiency and those without a regular source of health care. Educational materials should specifically address the negative health effects of smoking. They should also both acknowledge and address Chinese cultural beliefs about tobacco use.

Hepatitis B knowledge and practices among Chinese immigrants to the United States.

INTRODUCTION: Chinese immigrants to the United States experience high rates of liver cancer. Chronic carriage of hepatitis B virus (HBV) is the most common underlying cause of liver cancer among Chinese Americans. Our objective was to describe Chinese immigrants' hepatitis B knowledge, testing, and vaccination levels. METHODS: A community-based, in-person survey of Chinese men and women was conducted in Seattle during 2005. Our study sample included 395 individuals. RESULTS: Less than one-half (48%) of our study group indicated they had received a hepatitis B blood test, and about one-third (31%) indicated they had been vaccinated against hepatitis B. The proportions of respondents who knew HBV can be spread during childbirth, during sexual intercourse, and by sharing razors were 70%, 54%, and 55%, respectively. Less than one-quarter of the study group knew that HBV cannot be spread by eating food that was prepared by an infected person (23%) and by sharing eating utensils with an infected person (16%). DISCUSSION: Over 50% of our respondents did not recall being tested for HBV. Important knowledge deficits about routes of hepatitis B transmission were identified. Continued efforts should be made to develop and implement hepatitis B educational campaigns for Chinese immigrant communities.

"Heat in their intestine": colorectal cancer prevention beliefs among older Chinese Americans.

OBJECTIVE: Data regarding disease prevention behaviors among Asian-American populations are limited. This study explored the beliefs of older Chinese Americans toward colorectal cancer screening modalities, including fecal occult blood testing (FOBT). DESIGN AND PARTICIPANTS: We conducted 30 semistructured, open-ended, qualitative interviews in Mandarin and Cantonese, focusing on colorectal cancer prevention and health-seeking behavior. Participants were Chinese patients 50-79 years of age recruited from a community clinic in Seattle, Washington. RESULTS: When asked about colorectal cancer prevention, interviewees discussed such concepts as maintenance of positive energy (qi) and spirit (jing shen) and moderation of exercise and diet. Until prompted, participants did not discuss FOBT. Interviewees believed that colorectal cancer was caused by diets high in foods with "heat" (huo qi) or by intestinal toxins from frequent constipation. Participants presumed that FOBT is unnecessary in the absence of symptoms. CONCLUSIONS: Patients in our study expressed beliefs about health promotion and causes of colorectal cancer that differed from Western biomedical concepts. Failure to recognize these different beliefs may create inadvertent confusion among elderly Chinese-American patients. Health promotion programs to increase colorectal cancer screening must incorporate these concepts to improve cultural relevance among Chinese-American patients.

Colorectal cancer among Asians and Pacific Islanders in the U.S.: survival disadvantage for the foreign-born.

BACKGROUND: Asian Americans and Pacific Islanders (AAPI) have better colorectal cancer survival than other racial populations. However, immigrants face challenges that may place them at higher risk for late diagnosis and death. METHODS: To compare survival between the foreign- and U.S.-born, we identified 17,302 AAPI colorectal cancer patients between 1973 and 1998 from the Surveillance, Epidemiology, and End-Results (SEER) Program. Patients were categorized as foreign-born or U.S.-born using multiple imputation methods. RESULTS: Foreign birth was associated with higher risk for death from any cause (hazard ratio [HR] 1.29; 95% CI 1.23-1.36) and with modestly higher risk after adjustment for selected demographic characteristics (HR 1.13; 95% CI 1.05-1.21) and registry site (HR 1.05; 95% CI 0.98-1.14). Although foreign-born AAPI were more likely to present later, additional adjustment for cancer stage reduced but did not eliminate their higher risk of death (HR 1.09; 95% CI 1.01-1.18) CONCLUSIONS: Compared to the U.S.-born, foreign-born AAPI have poorer survival following colorectal cancer diagnosis. Future investigation of the care processes after diagnosis may be important in understanding these differences.

Cancer preventive screening: a cross-border comparison of United States and Canadian Chinese women.

OBJECTIVE: To compare screening mammography and Pap testing among Chinese women in Seattle, Washington to Vancouver, and British Columbia. METHODS: Using community-based sampling methods, trilingual female interviewers surveyed Chinese women in Seattle and Vancouver. Multiple preventive health behaviors and health care access variables were assessed. Mammography analysis included 409 women aged 50-74 years. Pap testing analysis included 973 women aged 20-69 years. Main outcome measures were ever use and use in the last 2 years of screening mammography and Pap testing. RESULTS: Chinese women in Vancouver were younger, more educated and fluent in English. Unadjusted rates of mammography and Pap testing were similar between the two cities. Provider type was consistently associated with screening in both cities; female providers had the highest rates and Chinese male providers the lowest. Adjusted logistic regression analysis demonstrated similar mammography use in the two cities. However, for Pap testing, women in Seattle had higher odds of screening compared to Vancouver. CONCLUSION: Despite universal health care coverage and baseline characteristics typically associated with greater utilization of preventive screening services, Chinese women in Vancouver did not have higher rates of screening mammography and Pap testing compared to Chinese women in Seattle.

Screening mammography among Chinese Canadian women.

BACKGROUND: Though breast cancer is the most common malignancy among Chinese women, screening mammography is underutilized. This study examined barriers and facilitators of screening mammography among Chinese Canadian women. METHODS: Using community-based sampling, Chinese women in British Columbia were interviewed in 1999 about multiple preventive health behaviours. We included 213 women in the mammography analysis; main outcome measures were ever having a mammogram and routine mammography. RESULTS: Seventy-five percent of women 50 to 79 years old reported ever having had a mammogram, and 53% had two or more mammograms within the last five years. Receiving a recommendation for a mammogram from medical personnel or from a family member, and believing that cancer cannot be prevented by faith were independently associated with both screening outcomes. CONCLUSIONS: A multifaceted approach to screening mammography promotion in Chinese Canadian women is suggested. Interventions that include education of and by medical providers and family members should be considered.