Sociocultural Barriers to Lung Cancer Screening Among Korean Immigrant Men.

Lung cancer is a commonly occurring cancer among Korean American men. Korean Americans have lower rates of cancer screening participation than other Asian American sub-groups. However, little is known about factors that influence the cancer screening behavior of Korean immigrants. The purpose of this study was to explore facilitators of and barriers to lung cancer screening (i.e., low dose CT of the chest) among Korean immigrant men, using qualitative individual interviews and focus groups. A convenience sample of 24 Korean men who were immigrants, Washington State residents, able to speak Korean, aged 55-79, and eligible for lung cancer screening (based on current guidelines) were recruited from Korean churches and senior centers. Five focus groups (that included between two and five men) and nine individual interviews were conducted. Content analysis was used to analyze the qualitative data. Facilitators of lung cancer screening included perceptions about positive aspects of the health care system in South Korea, recommendations from others (physicians, family members, and community organizations), existing health problems and respiratory symptoms, interest in health, and the health consequences of aging. Barriers included costs of health care in the US, lack of time, lack of knowledge (about lung cancer and screening), attitudes about prevention, and lack of physician recommendation. This study adds new knowledge to a field where little information is available. It also lays the groundwork for developing culturally relevant lung cancer screening interventions for Korean Americans and the health care providers who serve them.

Perceptions of under and overutilization of cervical cancer screening services at Latino-serving community health centers.

We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (FQHCs) about patients' utilization of screening services for cervical cancer. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving FQHCs in Oregon. The clinic personnel we interviewed observed both under and overutilization of cervical cancer screening services. Clinic personnel estimated that 20-60 % of eligible patients were underscreened for cervical cancer, with 30 % the most commonly cited percentage. Underscreening was thought to occur among low-income, underinsured, and undocumented patients. Overscreening for cervical cancer was estimated to occur in 10-50 % of eligible patients, with 10 % the most frequently cited proportion. Overscreening was thought to occur among women younger than age 21 and women with a recent pregnancy. Our findings may inform future efforts to promote guideline-appropriate cancer screening and coordinated follow-up care.

Lactation from the inside out: Maternal homeorhetic gastrointestinal adaptations regulating energy and nutrient flow into milk production.

Lactation invokes homeorhetic processes to ramp up and supply milk synthesis components to fulfil nutritional, immunological and microbiological requirements of developing offspring, overseen by complex neuroendocrine networks. The maternal gut meets these intense metabolic demands, supported by hyperphagia and rapid adjustments to process larger food quantities. Enteroplasticity describes an inherent ability of the gastrointestinal tract to harness metabolic and structural adaptations that increase nutrient absorption. Most shifts in response to increased demands are transitory and by secreting milk, the continuous energetic drain out of the maternal body avoids development of pathological metabolic diseases. Lactation has various positive benefits for long-term maternal health but many females do not lactate for long post pregnancy and younger women are increasingly pre-disposed to excessive body mass and/or metabolic complications prior to reproducing. Inadvertently invoking intestinal adaptations to harvest and store excess nutrients has negative health implications with increased risks for both mother and offspring.

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.

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 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.

Conjugated equine estrogens and colorectal cancer incidence and survival: the Women's Health Initiative randomized clinical trial.

BACKGROUND: In separate Women's Health Initiative randomized trials, combined hormone therapy with estrogen plus progestin reduced colorectal cancer incidence but estrogen alone in women with hysterectomy did not. We now analyze features of the colorectal cancers that developed and examine the survival of women following colorectal cancer diagnosis in the latter trial. PARTICIPANTS AND METHODS: 10,739 postmenopausal women who were 50 to 79 years of age and had undergone hysterectomy were randomized to conjugated equine estrogens (0.625 mg/d) or matching placebo. Colorectal cancer incidence was a component of the monitoring global index of the study but was not a primary study endpoint. Colorectal cancers were verified by central medical record and pathology report review. Bowel exam frequency was not protocol defined, but information on their use was collected. RESULTS: After a median 7.1 years, there were 58 invasive colorectal cancers in the hormone group and 53 in the placebo group [hazard ratio, 1.12; 95% confidence interval (95% CI), 0.77-1.63]. Tumor size, stage, and grade were comparable in the two randomization groups. Bowel exam frequency was also comparable in the two groups. The cumulative mortality following colorectal cancer diagnosis among women in the conjugated equine estrogen group was 34% compared with 30% in the placebo group (hazard ratio, 1.34; 95% CI, 0.58-3.19). CONCLUSIONS: In contrast to the preponderance of observational studies, conjugated equine estrogens in a randomized clinical trial did not reduce colorectal cancer incidence nor improve survival after diagnosis.

Development of intervention materials for individuals with limited English proficiency: lessons learned from "Colorectal Cancer Screening in Chinese Americans".

BACKGROUND: According to recent US census data, 52 million people reported speaking a language other than English at home, and almost 45% of this population reported limited English proficiency (LEP). Colorectal cancer (CRC) ranks among the top 3 most common cancers for several Asian ethnic groups, yet screening remains underutilized by Asian Americans. OBJECTIVES: This article describes the development of culturally and linguistically appropriate intervention materials for individuals with LEP. We discuss lessons learned from this research and implications for the translation of research into practice. METHODS: The Health Behavior Framework served as the conceptual model for this study, and qualitative findings guided the development of our intervention materials (a video and pamphlet). To recommend Western preventive behaviors, the research team bridged the gap between Western and Chinese values and beliefs by devoting particular attention to: (1) the target population's sociocultural values and health beliefs; and (2) unique linguistic features of the Chinese language. RESULTS: Key lessons learned from this study include the importance of: (1) a conceptual framework to guide intervention development; (2) incorporating sociocultural values and health beliefs into the intervention; (3) addressing and capitalizing on complex linguistics issues; (4) using qualitative methodology in cross-cultural research; and (5) contributions from a multicultural and multilingual research team. Other lessons relate to the translation of research findings into practice. We surmise that lessons learned from this study may be pertinent to the promotion of CRC screening among other patient groups with LEP and applicable to additional cancer screening tests.

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.

Within and between day repeatability of the incremental shuttle walking test in patients with thoracic cancer.

BACKGROUND: Breathlessness is common in patients with thoracic cancer but difficult to manage. The Incremental Shuttle Walking Test (ISWT) can help assess new treatments, but its repeatability has not been described in this group. AIM: To examine within and between day repeatability of the ISWT in this setting. METHODS: Patients with incurable thoracic cancer were recruited from outpatient clinics at a University Hospital. Two ISWTs were completed one hour apart on two consecutive days, with the first test for familiarization purposes only. Repeatability of distance walked was examined using Bland and Altman plots and assessed as the single determination (within subject) standard deviation of the difference between tests and its 95% range. RESULTS: Forty-one patients participated and completed all tests. Mean (SD) distance walked was 333 (134), 349 (129) and 353 (130) m over the three tests, with the mean difference significantly different from zero between days (16 m, 95% CI 8-24 m, P = 0.043) but not within days (5 m, 95% CI -2 to 12 m, P = 0.47). Within and between day single determination SD and 95% ranges were 30 (-31 to 91) m and 36 (-37 to 109) m respectively. CONCLUSIONS: These data help inform the design of studies making use of the ISWT and the interpretation of their findings.

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.

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.

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.

"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.

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.