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1.  Strategies and Opportunities to STOP Colon Cancer in Priority Populations: Design of a Cluster-Randomized Pragmatic Trial 
Contemporary clinical trials  2014;38(2):344-349.
Colorectal cancer is the second-leading cause of cancer deaths in the United States. The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) in Priority Populations study is a pragmatic trial and a collaboration between two research institutions and a network of more than 200 safety net clinics. The study will assess effectiveness of a systems-based intervention designed to improve rates of colorectal-cancer screening using fecal immunochemical testing (FIT) in federally qualified health centers in Oregon and Northern California.
Material and Methods
STOP CRC is a cluster-randomized comparative-effectiveness pragmatic trial enrolling 26 clinics. Clinics will be randomized to one of two arms. Clinics in the intervention arm (1) will use an automated, data-driven, electronic health record-embedded program to identify patients due for colorectal screening and mail FIT kits (with pictographic instructions) to them; (2) will conduct an improvement process (e.g. Plan-Do-Study-Act) to enhance the adoption, reach, and effectiveness of the program. Clinics in the control arm will provide opportunistic colorectal-cancer screening to patients at clinic visits. The primary outcomes are: proportion of age– and screening-eligible patients completing a FIT within 12 months; and cost, cost-effectiveness, and return on investment of the intervention.
This large-scale pragmatic trial will leverage electronic health record information and existing clinic staff to enroll a broad range of patients, including many with historically low colorectal-cancer screening rates. If successful, the program will provide a model for a cost-effective and scalable method to raise colorectal-cancer screening rates.
PMCID: PMC4226652  PMID: 24937017
Colorectal cancer screening; fecal immunochemical test; pragmatic study; cluster-randomized study
2.  Navigating the Murky Waters of Colorectal Cancer Screening and Health Reform 
American journal of public health  2014;104(6):982-986.
The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT).
People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers).
Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing.
PMCID: PMC4062021  PMID: 24825195
3.  Advantages of Wordless Instructions on how to Complete a Fecal Immunochemical Test: Lessons from Patient Advisory Council Members of a Federally Qualified Health Center 
Some patients face difficulty understanding Instructions for completing the fecal immunochemical test (FIT), a self-administered test to screen for colorectal cancer. We sought to develop and test low-literacy instructions for completing the FIT. Working in partnership with a Latino-serving Federally Qualified Health Center (FQHC) in the Portland Metro area, we developed and tested low literacy instructions for completing the FIT; the instructions contained 7 words [Mail within 3 days; Devolver dentro de 3 dias]. We conducted focus groups of Spanish-speaking patients on the advisory council of our partnering FQHC organization, and we gathered feedback from the project’s advisory board members and clinic staff. We mailed a FIT kit to each patient, along with either (a) instructions written in English and Spanish, consisting of 415 words; or (b) low-literacy “wordless” instructions. We asked patients to complete the test before providing feedback. Our qualitative assessment showed that the wordless instructions were preferred over instructions consisting of words. Wordless instructions might aid efforts to raise the rates of colorectal cancer screening among low-literacy and non-English-speaking populations.
PMCID: PMC3946071  PMID: 24057692
4.  Variability in the Take-Home Pathway: Farmworkers and Non-farmworkers and their Children 
Organophosphate pesticides (OPs) are related to ill health among adults including farmworkers who are exposed to OPs as part of their regular work. Children of both farmworkers and non-farmworkers in agricultural communities may also be affected by pesticide exposure.
Study groups of 100 farmworkers with a referent child (aged 2 to 6 years) and 100 non-farmworkers with a referent child were recruited to participate in three data collection periods over the course of a year. At each collection, participants provided three urine samples within 5 days, and homes and vehicles were vacuumed to collect pesticide residues in dust.
In thinning and harvest seasons, farmworkers and their children had higher dimethyl urinary metabolites than non-farmworkers and their children. During the non-spray season, the urinary metabolites levels decreased among farmworkers to a level comparable to non-farmworkers. Farmworkers consistently had higher pesticide residues in their home and vehicle dust.
Differences exist between farmworkers and non-farmworkers in urinary metabolites and the differences extended throughout the agricultural seasons. OP metabolites are seen at much higher levels for farmworkers and their children than non-farmworkers and their children during agricultural seasons when OPs are in use. These metabolite levels were significantly higher than the nationwide NHANES IV survey and up to 10 fold higher than other rural agricultural studies.
PMCID: PMC4141015  PMID: 24594649
organophosphate pesticides; child exposure/health; population based studies; environmental monitoring
5.  Reasons for non-response to a direct-mailed FIT kit program: lessons learned from a pragmatic colorectal-cancer screening study in a federally sponsored health center 
Colorectal cancer screening rates are below optimal. As part of a pilot clinic-based pragmatic study aiming to raise rates of colorectal-cancer screening, we explored patients’ reasons for not responding to a direct-mailed screening invitation. We conducted telephone interviews with patients who were mailed a fecal immunochemical test (FIT) but who did not return it to the lab. Interviews were audio-recorded, transcribed, and coded for thematic analysis. We met our goal of 20 interviews (10 in English and 10 Spanish; 75 % female). Reasons for not completing tests were fear of results or cost of follow-up colonoscopy (n = 9); not having received the test in the mail (n = 7); concerns about mailing fecal matter or that test results could be mixed up (n = 6); and being busy or forgetful (n = 4). Efforts to improve uptake of colorectal cancer screening in a direct-mailed program ought to address concerns identified in our study.
Electronic supplementary material
The online version of this article (doi:10.1007/s13142-014-0276-x) contains supplementary material, which is available to authorized users.
PMCID: PMC4332898  PMID: 25729454
Colorectal cancer screening; Direct-mailed fecal testing; Federally qualified health centers; Implementation; Pragmatic research; Qualitative interviews
6.  “BeneFITs” to Increase Colorectal Cancer Screening in Priority Populations 
JAMA internal medicine  2014;174(8):1242-1243.
PMCID: PMC4217574  PMID: 24934255
8.  Using an Automated Data-driven, EHR-Embedded Program for Mailing FIT kits: Lessons from the STOP CRC Pilot Study 
The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) study is collaboration among two research institutions and health-systems partners. The main study, scheduled to begin in 2014, will assess effectiveness of an intervention program using electronic health record (EHR) clinical decision support (CDS) tools to improve rates of colorectal-cancer screening in federally qualified health centers (FQHCs). Very few studies, and no large studies, aimed at raising CRC screening rates have utilized an EHR-embedded system.
Study design
We piloted the use of an EHR-embedded real-time patient registry reporting tool in a pilot study undertaken prior to beginning our main CRC screening study. The pilot study goal was to assess feasibility and effectiveness of two clinic-based approaches to raising rates of colorectal cancer screening among selected patients aged 50–74 who were not up-to-date with colorectal-cancer screening guidelines. We used work sessions and qualitative interviews with clinic personnel to assess performance of the tool, as well as to identify specific elements of the tool’s functionality needing refinement.
Two critical elements of the EHR tool allowed us to mail FIT kits efficiently to appropriate patients: (1) having a direct interface with the laboratory that processed the FITs, thus allowing for real-time updates to the registry; and (2) being able to place lab orders from a list of selected patients. We identified the following elements that needed refining: the use of Health Maintenance (EHR function for tracking screening eligibility and due dates incorporating STOP CRC inclusion and exclusion criteria), and the development of report templates for identifying patients eligible for each step.
We found that most elements of our EHR-embedded program worked well and that specific refinement may improve the accuracy of identifying patients at each step. Our findings can inform future efforts to build EHR-embedded CDS tools for preventive services.
PMCID: PMC4233714  PMID: 25411657
Electronic health record; Colorectal cancer screening; Reporting workbench; Patient registry; Clinical decision support; Fecal immunochemical (FIT) kit
9.  Cancer Screening at a Federally Qualified Health Center: A qualitative study on organizational challenges in the era of health care reform 
Federally Qualified Health Centers (FQHCs) serve uninsured and minority populations, who have low cancer screening rates. The patient-centered medical home (PCMH) model aims to provide comprehensive preventive services, including cancer screening, to these populations. Little is known about organizational factors influencing the delivery of cancer screening in this context.
We conducted 18 semi-structured interviews with clinic personnel at four FQHC clinics in Washington State. All interviews were recorded and transcribed verbatim and analyzed by two bilingual coders to identify salient themes.
We found that screening on-site, scheduling separate visits for preventive care, and having non-provider staff recommend and schedule screening services facilitated the delivery of cancer screening. We found work overload to be a barrier to screening.
To successfully implement screening strategies within the PCMH model, FQHCs must enhance facilitators and address organizational gaps in their cancer screening processes.
PMCID: PMC3530661  PMID: 22878911
cancer prevention; cancer screening; Latinos; uninsured; primary care medical home; organizational change
10.  Utilizing Pyrosequencing and Quantitative PCR to Characterize Fungal Populations among House Dust Samples 
Molecular techniques are replacing culturing and counting methods in quantifying indoor fungal contamination. Pyrosequencing offers the possibility of identifying unexpected indoor fungi. In this study, 50 house dust samples were collected from homes in the Yakima Valley, WA. Each sample was analyzed by quantitative PCR (QPCR) for 36 common fungi and by fungal tag-encoded flexible (FLX) amplicon pyrosequencing (fTEFAP) for these and additional fungi. Only 24 of the samples yielded amplified results using fTEFAP but QPCR successfully amplified all 50 samples. Over 450 fungal species were detected by fTEFAP but most were rare. Twenty-two fungi were found by fTEFAP to occur with at least an average of ≥ 0.5% relative occurrence. Many of these fungi seem to be associated with plants, soil or human skin. Combining fTEFAP and QPCR can enhance studies of fungal contamination in homes.
PMCID: PMC4079115  PMID: 22767010
11.  Evaluation of a Radionovela to Promote HPV Vaccine Awareness and Knowledge Among Hispanic Parents 
Journal of community health  2011;36(6):957-965.
Hispanic women have more than a 1.5-fold increased cervical cancer incidence and mortality compared to non-Hispanic white women in the United States. The Centers for Disease Control recommends the HPV vaccine for females at ages 11 and 12 years, though it is approved for females aged 9–26 to protect against the primary types of high-risk HPV (HPV-16 and HPV-18) that cause approximately 70% of cervical cancer cases. Few culturally-tailored Spanish HPV vaccine awareness programs have been developed. This study evaluates the efficacy of a Spanish radionovela as an educational tool. Rural Hispanic parents of daughters aged 9–17 (n = 88; 78 mothers and 10 fathers) were randomized to listen to the HPV vaccine radionovela or to another public service announcement. Participants completed a 30 min pretest posttest questionnaire. Parents who listened to the HPV radionovela (intervention group) scored higher on six knowledge and belief items. They were more likely to confirm that HPV is a common infection (70% vs. 48%, P = .002), to deny that women are able to detect HPV (53% vs. 31%, P = .003), to know vaccine age recommendations (87% vs. 68%, P = .003), and to confirm multiple doses (48% vs. 26%, P = .03) than control group parents. The HPV vaccine radionovela improved HPV and HPV vaccine knowledge and attitudes. Radionovela health education may be an efficacious strategy to increase HPV vaccine awareness among Hispanic parents.
PMCID: PMC4065612  PMID: 21452030
Rural Hispanic parents; HPV vaccine education; Cervical cancer prevention; Efficacy evaluation
12.  Having a Diagnosis of Diabetes Is Not Associated With General Diabetes Knowledge in Rural Hispanics 
The prevalence of diabetes among Hispanics in Washington State is 30% greater than it is for non-Hispanic Whites. Hispanics also have higher rates of diabetes-related complication and mortality due to the disease. Although interventions have been developed for the Hispanic community, studies in rural settings are limited. To address this we conducted a study to identify factors associated with general diabetes knowledge in a rural Hispanic population.
This study was conducted as part of a larger project in partnership with a local community hospital in Washington State’s Lower Yakima Valley. Diabetes knowledge was assessed as part of a screening survey using 5-statements selected from the Diabetes Knowledge Questionnaire. Men and women (N=1297) between the ages of 18–92 attending community-oriented events took part in the survey. Gender, education, age, birthplace, diabetic status and family history of diabetes were tested as predictors of diabetes knowledge.
Overall, general knowledge was high with 71–84% of participants responding correctly to 4 of 5 statements, while only 17% of participants responded correctly to a 5th statement. Although, no variable was associated with all statements, family history, gender and education were most frequently associated with knowledge. Diabetic status, age, and birthplace were less often or not associated with the knowledge statements.
Contrary to expectations having a diagnosis of diabetes was not among the factors most frequently associated with diabetes knowledge. Future research should investigate the roles of family history, gender and diabetic status as conduits of diabetes education among rural Hispanics.
PMCID: PMC4022479  PMID: 21029169
diabetes; health promotion; Hispanic; rural; social determinants of health
13.  Strategies for Increasing Mammography Screening in Primary Care in Chile: Results of a Randomized Clinical Trial 
Breast cancer is the cancer with the highest incidence among women in Chile and in many Latin American countries. Breast cancer screening has very low compliance among Chilean women.
We compare the effects on mammography screening rates of standard care, of a low intensity intervention based on mail contact, and of a high intensity intervention based on mail plus telephone or personal contact. A random sample of 500 women 50 to 70 years registered at a community clinic in Santiago who had not had a mammogram in the past two years were randomly assigned to one of the three intervention groups. Six months after randomization, participants were re-evaluated for their compliance with mammography screening. The outcome was measured by self report and by electronic clinical records. An intention to treat model was used to analyze the results.
Between 92% and 93% of participants completed the study. Based on electronic records, mammography screening rates increased significantly from 6% in the control group to 51.8% in the low intensity group, and 70.1% in the high intensity group. About 14% of participants in each group received opportunistic advice, 100% of participants in the low and high intensity groups received the mail contact, and 50% in the high intensity group received a telephone or personal contact.
A primary care intervention based on mail or brief personal contact could significantly improve mammogram screening rates.
A relatively simple intervention could have a strong impact in breast cancer prevention in underserved communities.
PMCID: PMC3985495  PMID: 20826832
14.  Seasonal Variation in Fruit and Vegetable Consumption in a Rural Agricultural Community 
Seasonal variation in fruit and vegetable consumption has been documented in a limited number of previous investigations and is important for the design of epidemiologic investigations and in the evaluation of intervention programs.
This study investigates fruit and vegetable consumption behaviors among Hispanic farmworkers and non-farmworkers in a rural agricultural community.
A larger study recruited 101 farmworker families and 100 non-farmworker families from the Yakima Valley in Washington State between December 2004 and October 2005. All families were Hispanic. An in-person administered questionnaire collected information on consumption of locally-grown fruits and vegetables and sources of obtaining fruits and vegetables. Data on dietary intake asked whether or not the respondent had consumed a given fruit or vegetable in the past month. Data were collected longitudinally coinciding with three agricultural seasons: thinning (June–July); harvest (September–October); and, non-spray (December–January).
Statistical analyses performed
Generalized estimating equations were used to test for statistical significance between proportions of the population who consumed a given fruit or vegetable across agricultural seasons. Multivariable logistic regression was performed and corresponding odds ratios and 95% confidence intervals are reported.
The proportion of respondents who ate apples, pears, plums, peaches, apricots, peppers, corn, and cucumbers was highest in the fall harvest season, whereas the proportions of those who ate cherries and asparagus were highest in the summer thinning season. Compared to non-farmworkers, a higher proportion of farmworkers reported having eaten peaches, apricots, cherries, green beans, carrots, peppers, corn, pumpkin, squash, and onions, in the past month.
Epidemiologic investigations and public health interventions that examine the consumption of fruits and vegetables ought to consider the seasonal variation in consumption patterns, especially in agricultural communities.
PMCID: PMC3983846  PMID: 19103322
fruit and vegetable consumption; agricultural season; Hispanic
15.  A systematic review of special events to promote breast, cervical and colorectal cancer screening in the United States 
BMC Public Health  2014;14:274.
Special events are common community-based strategies for health promotion. This paper presents findings from a systematic literature review on the impact of special events to promote breast, cervical or colorectal cancer education and screening.
Articles in English that focused on special events involving breast, cervical, and/or colorectal cancer conducted in the U.S. and published between January 1990 and December 2011 were identified from seven databases: Ovid, Web of Science, CINAHL, PsycINFO, Sociological Abstract, Cochrane Libraries, and EconLit. Study inclusion and data extraction were independently validated by two researchers.
Of the 20 articles selected for screening out of 1,409, ten articles on special events reported outcome data. Five types of special events were found: health fairs, parties, cultural events, special days, and plays. Many focused on breast cancer only, or in combination with other cancers. Reach ranged from 50–1732 participants. All special events used at least one evidence-based strategy suggested by the Community Guide to Preventive Services, such as small media, one-on-one education, and reducing structural barriers. For cancer screening as an outcome of the events, mammography screening rates ranged from 4.8% to 88%, Pap testing was 3.9%, and clinical breast exams ranged from 9.1% to 100%. For colorectal screening, FOBT ranged from 29.4% to 76%, and sigmoidoscopy was 100% at one event. Outcome measures included intentions to get screened, scheduled appointments, uptake of clinical exams, and participation in cancer screening.
Special events found in the review varied and used evidence-based strategies. Screening data suggest that some special events can lead to increases in cancer screening, especially if they provide onsite screening services. However, there is insufficient evidence to demonstrate that special events are effective in increasing cancer screening. The heterogeneity of populations served, event activities, outcome variables assessed, and the reliance on self-report to measure screening limit conclusions. This study highlights the need for further research to determine the effectiveness of special events to increase cancer screening.
PMCID: PMC3987802  PMID: 24661503
Cancer screening; Early detection of cancer; Health promotion; Community health education; Breast neoplasms; Cervical neoplasms; Colorectal neoplasms
16.  Racial/ethnic differences in use and duration of adjuvant hormonal therapy for breast cancer in the Women’s Health Initiative 
Five-year breast cancer survival rates are lower among Hispanic and African American women than among Non-Hispanic White (NHW) women. Differences in breast cancer treatment likely play a role. Adjuvant hormonal therapies increase overall survival among women with hormone receptor-positive breast cancer.
We examined racial/ethnic differences in use and duration of adjuvant hormonal therapy among 3,588 postmenopausal women enrolled in the Women’s Health Initiative (WHI) Extension Study. Women diagnosed with hormone receptor-positive localized or regional stage breast cancer after study enrollment were surveyed between September 2009 and August 2010 and asked to recall prior use and duration of adjuvant hormonal breast cancer therapy. Odds ratios [OR] comparing self-reported use and duration by race/ethnicity (Hispanic, African American, Asian/Pacific Islander vs. NHW) were estimated using multivariable-adjusted logistic regression.
Of the 3,588 women diagnosed from 1994–2009; 3,039 (85%) reported any use of adjuvant hormonal therapy and 67% of women reporting ever-use who were diagnosed prior to 2005 reported using adjuvant hormonal therapy for the optimal duration of ≥5 years. In adjusted analysis, no statistically significant differences in use or duration by race/ethnicity were observed.
This study did not find significant differences in use or duration of use of adjuvant hormonal therapy by race/ethnicity.
Findings should be confirmed in other population-based samples and potential reasons for discontinuation of therapy across all racial/ethnic groups should be explored.
PMCID: PMC3596451  PMID: 23275187
postmenopausal breast cancer; adjuvant hormonal therapy; racial/ethnic disparities
17.  Strategies and opportunities to STOP colon cancer in priority populations: pragmatic pilot study design and outcomes 
BMC Cancer  2014;14:55.
Colorectal-cancer is a leading cause of cancer death in the United States, and Latinos have particularly low rates of screening. Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) is a partnership among two research institutions and a network of safety net clinics to promote colorectal cancer screening among populations served by these clinics. This paper reports on results of a pilot study conducted in a safety net organization that serves primarily Latinos.
The study assessed two clinic-based approaches to raise rates of colorectal-cancer screening among selected age-eligible patients not up-to-date with colorectal-cancer screening guidelines. One clinic each was assigned to: (1) an automated data-driven Electronic Health Record (EHR)-embedded program for mailing Fecal Immunochemical Test (FIT) kits (Auto Intervention); or (2) a higher-intensity program consisting of a mailed FIT kit plus linguistically and culturally tailored interventions delivered at the clinic level (Auto Plus Intervention). A third clinic within the safety-net organization was selected to serve as a passive control (Usual Care). Two simple measurements of feasibility were: 1) ability to use real-time EHR data to identify patients eligible for each intervention step, and 2) ability to offer affordable testing and follow-up care for uninsured patients.
The study was successful at both measurements of feasibility. A total of 112 patients in the Auto clinic and 101 in the Auto Plus clinic met study inclusion criteria and were mailed an introductory letter. Reach was high for the mailed component (92.5% of kits were successfully mailed), and moderate for the telephone component (53% of calls were successful completed). After exclusions for invalid address and other factors, 206 (109 in the Auto clinic and 97 in the Auto Plus clinic) were mailed a FIT kit. At 6 months, fecal test completion rates were higher in the Auto (39.3%) and Auto Plus (36.6%) clinics compared to the usual-care clinic (1.1%).
Findings showed that the trial interventions delivered in a safety-net setting were both feasible and raised rates of colorectal-cancer screening, compared to usual care. Findings from this pilot will inform a larger pragmatic study involving multiple clinics.
Trial registration NCT01742065
PMCID: PMC3936821  PMID: 24571550
Colorectal cancer screening; Fecal testing; Latinos; Hispanics; Safety net clinic; Federally qualified health center; Pragmatic study
18.  Do workplace and home protective practices protect farm workers? Findings from the For Healthy Kids Study 
To assess associations of protective workplace and home practices to pesticide exposure levels.
Using data from orchard workers in the Yakima Valley, Washington, we examined associations of workplace and home protective practices to (1) urinary metabolite concentrations of dimethylthiophosphate (DMTP) in adults and children aged 2–6; and (2) azinphos-methyl levels in house and vehicle dust.
Data were from 95 orchard workers and 94 children. Contrary to expectation, adult farm workers who wore boots or washed hands using hand sanitizer had higher concentrations of DMTP than those who did not. Children who attended daycare had higher DMTP concentrations than children who did not.
Few workplace or home practices were associated with pesticide exposure levels; workers who used hand sanitizer had higher concentrations of DMTP, as did children who attended daycare.
PMCID: PMC3866960  PMID: 22772953
Pesticides; agriculture; United States Environmental Protection Agency Worker Protection Standard; home practices; workplace practices
19.  Issues in Biomedical Research: What Do Hispanics Think? 
To examine barriers and facilitators of biomedical research participation among Hispanics in a rural community in Washington State.
Questionnaires addressed socio-demographics, health care access, and barriers and facilitators of participation in biomedical studies. This is a descriptive analysis of the findings.
Barriers include the need to care for family members (82%), fear of having to pay for research treatments (74%), cultural beliefs (65%), lack of time (75%) and trust (71%), and the degree of hassle (73%). Facilitators include having a friend/relative with the disease being researched (80%) and monetary compensation (73%).
Researchers should be mindful of these facilitators and barriers when recruiting for biomedical research studies.
PMCID: PMC3860276  PMID: 22943104
biomedical research; Hispanic; research ethics; recruitment
20.  Physical Activity among Cambodian Americans: An Exploratory Study 
Journal of community health  2012;37(5):1040-1048.
Available data indicate that Asian Americans as a group have lower levels of physical activity than non-Latino whites. However, few studies have focused on physical activity among Asian American sub-groups. Our objectives were to describe levels of physical activity, as well as individual and environmental correlates of physical activity among Cambodian Americans.
We conducted a telephone survey of Cambodians living in three geographic areas (Central California, Northern California, and the Pacific Northwest) during 2010. Physical activity levels were assessed using the International Physical Activity Questionnaire (IPAQ) short version. Survey items addressed demographic characteristics, knowledge about the health benefits of physical activity, social norms and supports with respect to physical activity, the availability of neighbourhood recreational facilities, and neighbourhood characteristics.
Our study group included 222 individuals. Only 12% of the study group reported low levels of physical activity, 40% reported moderate levels, and 48% reported high levels. Physical activity was strongly associated with the availability of neighborhood recreational facilities such as parks, but not with neighborhood characteristics such as heavy traffic.
Our results suggest that a majority of Cambodian Americans are adherent to current physical activity guidelines. Neighborhood recreational facilities that provide opportunities for leisure-time physical activity are associated with higher levels of physical activity in Cambodian communities. Future research should assess the reliability and validity of the IPAQ in a Cambodian American study group.
PMCID: PMC3437005  PMID: 22183889
Cambodian Americans; Physical activity
21.  Racial and Ethnic Differences in Adjuvant Hormonal Therapy Use 
Journal of Women's Health  2012;21(9):950-958.
In the United States, 5-year breast cancer survival is highest among Asian American women, followed by non-Hispanic white, Hispanic, and African American women. Breast cancer treatment disparities may play a role. We examined racial/ethnic differences in adjuvant hormonal therapy use among women aged 18–64 years, diagnosed with hormone receptor-positive breast cancer, using data collected by the Northern California Breast Cancer Family Registry (NC-BCFR), and explored changes in use over time.
Odds ratios (OR) comparing self-reported ever-use by race/ethnicity (African American, Hispanic, non-Hispanic white vs. Asian American) were estimated using multivariable adjusted logistic regression. Analyses were stratified by recruitment phase (phase I, diagnosed January 1995–September 1998, phase II, diagnosed October 1998–April 2003) and genetic susceptibility, as cases with increased genetic susceptibility were oversampled.
Among 1385 women (731 phase I, 654 phase II), no significant racial/ethnic differences in use were observed among phase I or phase II cases. However, among phase I cases with no susceptibility indicators, African American and non-Hispanic white women were less likely than Asian American women to use hormonal therapy (OR 0.20, 95% confidence interval [CI]0.06–0.60; OR 0.40, CI 0.17–0.94, respectively). No racial/ethnic differences in use were observed among women with 1+ susceptibility indicators from either recruitment phase.
Racial/ethnic differences in adjuvant hormonal therapy use were limited to earlier diagnosis years (phase I) and were attenuated over time. Findings should be confirmed in other populations but indicate that in this population, treatment disparities between African American and Asian American women narrowed over time as adjuvant hormonal treatments became more commonly prescribed.
PMCID: PMC3430474  PMID: 22731764
22.  Recruiting underrepresented groups into the Carbohydrates and Related Biomarkers (CARB) cancer prevention feeding study 
Contemporary clinical trials  2012;33(4):641-646.
Using data from a randomized, controlled feeding study, which aimed to recruit 88 participants (including 22 Hispanics and 22 African Americans), we examined strategies for recruiting individuals from underrepresented groups into research trials. Study eligibility criteria included participants who 1) were 18–45 years old; 2) had a body mass index (BMI) >18 < 24.9 or BMI > 28.0 <40.0; 3); had no preexisting health conditions; 4) were non-smoking; 5) had normal fasting blood glucose level (< 100 mg/dL); and 6) spoke English. Participants were recruited using two overarching methods: media-based strategies (flyers and posters, email announcements, announcements in local and campus newspapers, and the Internet) and in-person strategies (presentations in university classes and community events). Participants were enrolled March 2006–March 2009. We present the numbers of individuals requesting study information, completing pre-enrollment screening questionnaires, and enrolling in the study. A total of 1036 individuals requested study information, and 396 completed a pre-enrollment screening questionnaire; 90 enrolled in the study (22 Hispanics and 18 African Americans). Among enrolled participants, in-person recruitment strategies were reported by 39% of African Americans, 73% of Hispanics, and 30% of non-Hispanic Whites (P <0.001). In-person recruitment strategies were successful among Hispanics. Mass media recruitment strategies were successful among non-Hispanic Whites but enlisted relatively few Hispanic participants. Both strategies recruited nearly equal percentages of African Americans. These data suggest that different strategies are needed to effectively recruit racial/ethnic population subgroups into intervention studies.
PMCID: PMC3516589  PMID: 22504222
Patient recruitment; carbohydrate metabolism; Hispanic American; African American
23.  Glycemic load effect on fasting and post-prandial serum glucose, insulin, IGF-1 and IGFBP-3 in a randomized, controlled feeding study 
European journal of clinical nutrition  2012;66(10):1146-1152.
The effect of a low glycemic load (GL) diet on insulin-like growth factor-1 (IGF-1) concentration is still unknown but may contribute to lower chronic disease risk. We aimed to assess the impact of GL on concentrations of IGF-1 and IGFBP-3.
We conducted a randomized, controlled crossover feeding trial in 84 overweight-obese and normal weight healthy individuals using two 28-day weight-maintaining high- and low-GL diets. Measures were fasting and post-prandial concentrations of insulin, glucose, IGF-1 and IGFBP-3. 20 participants completed post-prandial testing by consuming a test breakfast at the end of each feeding period. We used paired t-tests for diet-component and linear mixed models for biomarker analyses.
The 28-day low-GL diet led to 4% lower fasting concentrations of IGF-1 (10.6 ng/mL, p=0.04) and a 4% lower ratio of IGF-1/IGFBP-3 (0.24, p=0.01) compared to the high-GL diet. The low-GL test breakfast led to 43% and 27% lower mean post-prandial glucose and insulin responses, respectively; mean incremental areas under the curve for glucose and insulin, respectively, were 64.3±21.8 (mmol/L/240min) (p<0.01) and 2253±539 (μU/mL/240min) (p<0.01) lower following the low- compared to the high-GL test meal. There was no effect of GL on mean HOMA-IR or on mean integrated post-prandial concentrations of glucose-adjusted insulin, IGF-1 or IGFBP-3. We did not observe modification of the dietary effect by adiposity.
Low-GL diets resulted in 43% and 27% lower post-prandial responses of glucose and insulin, respectively, and modestly lower fasting IGF-1 concentrations. Further intervention studies are needed to weigh the impact of dietary GL on risk for chronic disease.
PMCID: PMC3463643  PMID: 22892437
Adiposity; Glycemic Index; Insulin Resistance; Insulin-Like Growth Factor I; Insulin-Like Growth Factor Binding Protein 3; Randomized Controlled Trial [Publication Type]
25.  Strategies for Diversifying the Pool of Graduate Students in Biomedical Sciences 
As part of our National Cancer Institute–sponsored partnership between New Mexico State University and the Fred Hutchinson Cancer Research Center, we implemented the Cancer Research Internship for Undergraduate Students to expand the pipeline of underrepresented students who can conduct cancer-related research. A total of 21 students participated in the program from 2008 to 2011. Students were generally of senior standing (47%), female (90%), and Hispanic (85%). We present a logic model to describe the short-term, medium-term, and long-term outputs of the program. Comparisons of pre- and post-internship surveys showed significant improvements in short-term outputs including interest (p<0.001) and motivation (p<0.001) to attend graduate school, as well as preparedness to conduct research (p=0.01) and write a personal statement (p=0.04). Thirteen students were successfully tracked, and of the 9 who had earned a bachelor’s degree, 6 were admitted into a graduate program (67%), and 4 of these programs were in the biomedical sciences.
PMCID: PMC3516588  PMID: 22576869
undergraduate training program; internship; minority students

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