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1.  Predictors of recruited melanoma families into a behavioral intervention project 
Contemporary clinical trials  2011;33(1):85-92.
Examination of families represents an important priority in health research. In this paper we report on individual and family-level factors associated with enrollment in a cancer prevention research project. We approached families affected by melanoma for possible participation in a randomized controlled trial of a web-based communication and support intervention.
We recruited three family members per family for assessment – the melanoma case, a first-degree relative (FDR), and a relative who is a parent of a child age 18 or younger. Recruitment involved three steps: requesting the physician’s consent to approach the melanoma case, approaching the case to request their participation and family contact information, and they approaching the FDRs and parents.
Of the 1380 families approached, 313 were enrolled, 263 were excluded because we could not find or contact a family member (FDR or parent), 331 did not have eligible family members, and 473 refused. The most frequently noted reason for refusal was being too busy or having no time. The primary predictors of participation for cases, FDRs, and parents included higher educational attainment (OR’s=1.5–2.15); FDRs were more likely to enroll if they were female (OR=1.77), parents were more likely to enroll if the case had been diagnosed more recently(OR=3.3), if the parent was partnered (OR=4.37), and if the parent lived in the same city as the case(2.88).
The results can provide information on the potential generalizability of family recruitment.
PMCID: PMC4159354  PMID: 22001361
Recruitment; Family; Response rates; Behavioral intervention; Melanoma
2.  Adaptation of an evidence-based intervention to promote colorectal cancer screening: a quasi-experimental study 
To accelerate the translation of research findings into practice for underserved populations, we investigated the adaptation of an evidence-based intervention (EBI), designed to increase colorectal cancer (CRC) screening in one limited English-proficient (LEP) population (Chinese), for another LEP group (Vietnamese) with overlapping cultural and health beliefs.
Guided by Diffusion of Innovations Theory, we adapted the EBI to achieve greater reach. Core elements of the adapted intervention included: small media (a DVD and pamphlet) translated into Vietnamese from Chinese; medical assistants distributing the small media instead of a health educator; and presentations on CRC screening to the medical assistants. A quasi-experimental study examined CRC screening adherence among eligible Vietnamese patients at the intervention and control clinics, before and after the 24-month intervention. The proportion of the adherence was assessed using generalized linear mixed models that account for clustering under primary care providers and also within-patient correlation between baseline and follow up.
Our study included two cross-sectional samples: 1,016 at baseline (604 in the intervention clinic and 412 in the control clinic) and 1,260 post-intervention (746 in the intervention and 514 in the control clinic), including appreciable overlaps between the two time points. Pre-post change in CRC screening over time, expressed as an odds ratio (OR) of CRC screening adherence by time, showed a marginally-significant greater increase in CRC screening adherence at the intervention clinic compared to the control clinic (the ratio of the two ORs = 1.42; 95% CI 0.95, 2.15). In the sample of patients who were non-adherent to CRC screening at baseline, compared to the control clinic, the intervention clinic had marginally-significant greater increase in FOBT (adjusted OR = 1.77; 95% CI 0.98, 3.18) and a statistically-significantly greater increase in CRC screening adherence (adjusted OR = 1.70; 95% CI 1.05, 2.75).
Theoretically guided adaptations of EBIs may accelerate the translation of research into practice. Adaptation has the potential to mitigate health disparities for hard-to-reach populations in a timely manner.
PMCID: PMC4226971  PMID: 24989083
Adaptation; Implementation; Evidence-based intervention
3.  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
4.  Using a family systems approach to investigate cancer risk communication within melanoma families 
Psycho-oncology  2010;19(10):1102-1111.
The family provides an important communication nexus for information and support exchange about family cancer history, and adoption of family-wide cancer risk reduction strategies. The goals of this study were to: 1) use the family systems theory to identify characteristics of this sample of families at increased risk of developing melanoma and 2) to relate familial characteristics to the frequency and style of familial risk communication.
Participants were first-degree relatives (n=313) of melanoma patients, recruited into a family web-based intervention study. We used multivariable logistic regression models to analyze the association between family functioning and family communication.
Most participants were female (60%), with an average age of 51 years. Fifty percent of participants reported that they spoke to their relatives about melanoma risk and people were more likely to speak to their female family members. Familial adaptation, cohesion, coping, and health beliefs were strongly associated with an open style of risk communication within families. None were associated with a blocked style of risk communication. Only cohesion and adaptation were associated with the amount of risk communication that occurred within families.
Overall, individuals who came from families that were more highly cohesive, adaptable, and shared strong beliefs about melanoma risk were more likely to communicate openly about melanoma. The fact that this association was not consistent across blocked communication and communication frequency highlights the multifaceted nature of this process. Future research should focus on the interplay between different facets of communication.
PMCID: PMC2888971  PMID: 20119933
5.  Possible socioeconomic and ethnic disparities in quality of life in a cohort of breast cancer survivors 
This paper describes the ethnic and socioeconomic correlates of psychosocial functioning in a cohort of long-term nonrecurring breast cancer survivors and determines the contribution of ongoing difficulties, including symptoms and concerns about cancer, to the ethnic and socioeconomic differences in functioning levels.
Participants (n=804) in this study were women from the Health, Eating, Activity, and Lifestyle (HEAL) Study, a population-based, multicenter, multiethnic, prospective study of women newly diagnosed with in situ or Stages I to IIIA breast cancer. Measurements occurred at three timepoints following diagnosis (average 6.1 months following diagnosis, at approximately 30.5 months post diagnosis, at approximately 40.6 months post diagnosis). Outcomes included standardized measures of functioning (MOS SF-36).
Overall, these long-term survivors reported values on two physical function subscales of the SF-36 slightly lower than population norms. Black women reported statistically significantly lower physical functioning scores (p=0.01), compared with White and Hispanic women, but higher mental health scores (p<0.01) compared with White and Hispanic women. In the final adjusted model, race was significantly related to physical functioning, with Black participants and participants in the “Other” ethnic category reporting poorer functioning compared to the White referent group (p<0.01, 0.05). Not working outside the home, being retired or disabled and being unemployed (on leave, looking for work) were associated with poorer physical functioning compared to currently working (both p<0.01).
These data indicate that race/ethnicity influences psychosocial functioning in breast cancer survivors and can be used to identify need for targeted interventions to improve functioning.
PMCID: PMC2999962  PMID: 17260096
6.  Psychometric evaluation of the Brief Cancer Impact Assessment among breast cancer survivors 
Oncology  2006;70(3):190-202.
The increasing number of cancer survivors brings greater attention to the biopsychosocial impact of surviving cancer. Instruments exist that measure quality of life (QOL), symptoms, and specific types of functioning after cancer; however, a reliable and valid assessment of the perceived impact of cancer on the life plans and activities of cancer survivors has been missing. This study evaluated the psychometric properties of the 16-item Brief Cancer Impact Assessment (BCIA).
Factor analysis with Promax oblique rotation established the factor structure of the BCIA in 783 ethnically-diverse breast cancer survivors, 2+ years post-diagnosis. Construct validity was assessed by comparing factor-based scale means by demographic and treatment characteristics, and correlating scales with psychosocial and health-related QOL scales.
Factor analysis revealed four factors measuring the impact of cancer on caregiving and finances, exercise and diet behaviors, social and emotional functioning, and religiosity. Scale scores differed by demographic and treatment characteristics according to expectations, and the pattern of correlations with psychosocial and health-related QOL generally supported the construct validity of the scales.
Including the BCIA with measures of QOL, symptoms, and functioning will allow researchers to gain a more comprehensive assessment of the biopsychosocial impact of cancer in survivors.
PMCID: PMC2996238  PMID: 16809938
cancer survivors; psychometric testing; impact of cancer; quality of life; factor analysis
7.  Psychometric properties of a tool for measuring hormone-related symptoms in breast cancer survivors 
Psycho-oncology  2006;15(11):985-1000.
Hormone-related symptoms are common in breast cancer survivors and many aspects of these symptoms are currently under study. Reliable and valid assessment tools are needed to successfully study hormone-related symptoms in breast cancer survivors; however, no gold standard currently exists for measuring these symptoms. This study evaluated the psychometric properties of a shortened version of the Breast Cancer Prevention Trial (BCPT) symptom checklist in a sample of 803 breast cancer survivors. Principal factor analysis with Promax oblique rotation revealed a five-factor structure, identifying five separate hormone-related symptoms scales: vasomotor symptoms, urinary incontinence, cognitive/mood changes, vaginal symptoms, and weight gain/appearance concern. Hormone-related symptom scale scores differed by demographic and clinical characteristics according to expectations, suggesting that these five scales from the shortened BCPT checklist are reasonably reliable and valid. Symptom scale scores were only weakly correlated with health-related quality of life scores; however, the pattern of results generally supported the validity of the symptom scales. This study adds to the evidence that breast cancer survivors experience a significant number of hormone-related symptoms. Future clinical trials and quality of life and symptom management intervention studies would benefit from accurate assessment of hormone-related symptoms with the five scales from the shortened BCPT checklist.
PMCID: PMC2996243  PMID: 16470891
8.  Interest in Genetic Testing Among Affected Men from Hereditary Prostate Cancer (HPC) Families and their Unaffected Male Relatives 
The objective of this study was to evaluate potential sociodemographic, medical, psychosocial, and behavioral correlates of interest in genetic testing in men from hereditary prostate cancer families (HPC).
Family members affected with prostate cancer (n=559) and their unaffected male relatives (n=370) completed a mailed survey. Multivariable logistic regression models were used to examine the association between potential correlates and interest in genetic testing for prostate cancer.
Forty-five percent of affected and 56% of unaffected men reported that they definitely would take a genetic test for prostate cancer. More affected men reported high levels of familiarity with genetic testing than unaffected men (46% vs. 25%). There were several variables that were significantly correlated with interest in either affected or unaffected men but only age and familiarity with genetics were significant in both groups. After controlling for confounding variables, only familiarity remained a significant correlate in both groups.
The contrast between low levels of familiarity with genetics and high test interest among unaffected men highlights the need for increased educational efforts targeting HPC families. Overall, results illuminated several novel characteristics of men from HPC families that should be considered when developing future informed consent procedures or educational materials for prostate cancer genetic testing.
PMCID: PMC2683189  PMID: 19346959
Prostate cancer; family; hereditary; genetic test; psychosocial
9.  Employer Adoption of Evidence-Based Chronic Disease Prevention Practices: A Pilot Study 
Preventing Chronic Disease  2008;5(3):A92.
We conducted a pilot test of American Cancer Society Workplace Solutions, an intervention that takes a marketing approach to increasing employers' adoption of evidence-based practices to prevent and control chronic diseases among their employees.
We delivered the intervention and assessed the changes in practices of 8 large employers in the Pacific Northwest.
Workplace Solutions recommends 15 employer practices in 5 categories: 1) health insurance benefits, 2) policies, 3) workplace programs, 4) health-promoting communication, and 5) tracking of employee health behaviors to measure progress. The intervention includes 4 meetings with employers over 2 months and begins with a questionnaire-based assessment of employer practices. Tailored recommendations follow, along with practice-specific implementation assistance on requested topics. We tested the intervention in a before–after study without a comparison group.
The employers ranged in size from 7500 to 115,522 employees and included private companies and public employers. Seven of the eight employers implemented more of the recommended practices at follow-up (an average of 13 months after the intervention) than at baseline. Overall, implementation of the practices increased from 38% at baseline to 61% at follow-up (P = .02).
Workplace Solutions is a promising new approach to bringing evidence-based best practices for preventing chronic disease to large numbers of adults.
PMCID: PMC2483563  PMID: 18558042
10.  Mammography Screening among Chinese-American Women 
Cancer  2003;97(5):1293-1302.
Breast carcinoma is the most common major malignancy among several Asian-American populations. This study surveyed mammography screening knowledge and practices among Chinese-American women.
In 1999, the authors conducted a cross-sectional, community-based survey in Seattle, Washington. Bilingual and bicultural interviewers administered surveys in Mandarin, Cantonese, or English at participants’ homes.
The survey cooperation rate (responses among reachable and eligible households) was 72% with 350 eligible women (age ≥ 40 years with no prior history of breast carcinoma or double mastectomy). Seventy-four percent of women reported prior mammography screening, and 61% of women reported screening in the last 2 years. In multivariate analysis, a strong association was found between mammography screening and recommendations by physicians and nurses (prior screening: odds ratio [OR], 16.0; 95% confidence interval [95% CI], 7.8–35.0; recent screening: OR, 7.0; 95% CI, 3.8–13.6). This finding applied to both recent immigrants (< 15 years in the U.S.) and earlier immigrants (≥ 15 years in the U.S.). Thirty-two percent of women reported that the best way to detect breast carcinoma was a modality other than mammogram.
The authors recommend a multifaceted approach to increase mammography screening by Chinese-American women: recommendations from the provider plus targeted education to address the effectiveness of screening mammography compared with breast self examination and clinical breast examination.
PMCID: PMC1618781  PMID: 12599238
mammography; screening; Asian; Chinese
Journal of community health  2003;28(1):41-57.
Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.
PMCID: PMC1618780  PMID: 12570172
cervix neoplasms; Chinese Americans; risk factors
12.  Pap Testing Stages of Adoption among Cambodian Immigrants 
We examined levels of Pap testing and factors associated with screening participation among Cambodian refugees.
A community-based, in-person survey was conducted in Seattle during late 1997 and early 1998. Interviews were completed by 413 women; the estimated response rate was 73%. We classified respondents into four Pap testing stages of adoption: precontemplation/contemplation (never screened), relapse (ever screened but did not plan to be screened in the future), action (ever screened and planned to be screened in the future), and maintenance (recently screened and planned to be screened in the future). Bivariate and multivariate techniques were used to examine various factors.
About one-quarter (24%) of the respondents has never been screened, and a further 22% had been screened but did not plan to obtain Pap tests in the future. Fifteen percent were in the action stage and 39% were in the maintenance stage. The following factors were independently associated with cervical cancer screening stages: previous physician recommendation; younger age; beliefs about Pap testing for post-menopausal women, screening for sexually inactive women, and regular checkups; provider ethnicity; prenatal care in the US; and problems finding interpreters.
Our findings confirm low Pap testing rates among Cambodian immigrants, and suggest that targeted interventions should be multifaceted.
PMCID: PMC1592338  PMID: 11567513
13.  Breast cancer screening: stages of adoption among Cambodian American women 
Little information is available on the breast cancer screening behavior of Cambodian American women.
We identified households from multiple sources using Cambodian surnames and conducted a cross-sectional survey, administered by bilingual and bicultural interviewers. Breast cancer screening stages of adoption were examined based on concepts from the transtheoretical model of behavioral change.
Our response rate was 73% (398 women in clinical breast exam (CBE) analysis, and 248 in mammography analysis) with approximately 25% each in the maintenance stage. We found significant associations between screening stage with physician characteristics. Asian American female physician increased the likelihood of being in the maintenance stage (CBE, OR = 10.1, 95% CI 2.8–37.1; mammogram, OR = 74.7, 95% CI 8.3–674.6), compared to Asian American male physician with precontemplation/contemplation stage as our referent outcome.
Results from this study support the need to promote regular breast cancer screening among Cambodian American women. © 2002 International Society for Preventive Oncology. Published by Elsevier Science Ltd. All rights reserved.
PMCID: PMC1592336  PMID: 12088201
Breast cancer; Screening; Asian; Stages of adoption
14.  Evaluation of an outreach intervention to promote cervical cancer screening among Cambodian American women 
Cancer detection and prevention  2002;26(4):320-327.
Southeast Asian women have low levels of Papanicolaou (Pap) testing participation. We conducted a group-randomized controlled trial to evaluate a cervical cancer screening intervention program targeting Seattle’s Cambodian refugee community.
Women who completed a baseline, community-based survey were eligible for the trial. Neighborhoods were the unit of randomization. Three hundred and seventy survey participants living in 17 neighborhoods were randomized to intervention or control status. Intervention group women received home visits by outreach workers and were invited to group meetings in neighborhood settings. The primary outcome measure was self-reported Pap testing in the year prior to completing a follow-up survey.
The proportion of women in the intervention group reporting recent cervical cancer screening increased from 44% at baseline to 61% at follow-up (+17%). The corresponding proportions among the control group were 51 and 62% (+11%). These temporal increases were statistically significant in both the intervention (P < 0.001) and control (P = 0.027) groups.
This study was unable to document an increase in Pap testing use specifically in the neighborhood-based outreach intervention group; rather, we found an increase in both intervention and control groups. A general awareness of the project among women and their health care providers as well as other ongoing cervical cancer screening promotional efforts may all have contributed to increases in Pap testing rates.
PMCID: PMC1592335  PMID: 12430637
Cambodian Americans; Pap testing; Outreach
15.  Cervical cancer screening among Chinese Americans 
Cancer detection and prevention  2002;26(2):139-145.
Study purpose
Chinese women in North America have high rates of invasive cervical cancer and low levels of Papanicolaou (Pap) testing use. This study examined Pap testing barriers and facilitators among Chinese American women.
Basic procedures
A community-based, in-person survey of Chinese women was conducted in Seattle, Washington during 1999. Four hundred and thirty-two women in the 20–79 years age-group were included in this analysis. The main outcome measures were a history of at least one previous Pap smear and Pap testing within the last 2 years.
Main findings
Nineteen percent of the respondents had never received cervical cancer screening and 36% had not been screened in the previous 2 years. Eight characteristics were independently associated with a history of at least one Pap smear: being married, thinking Pap testing is necessary for sexually inactive women, lack of concerns about embarrassment or cancer being discovered, having received a physician or family recommendation, having obtained family planning services in North America, and having a regular provider. The following characteristics were independently associated with recent screening: thinking Pap testing is necessary for sexually inactive women, lack of concern about embarrassment, having received a physician recommendation, having obtained obstetric services in North America, and having a regular provider.
Principal conclusions
Pap testing levels among the study respondents were well below the National Cancer Institute’s Year 2000 goals. The findings suggest that cervical cancer control interventions for Chinese are more likely to be effective if they are multifaceted. © 2002 International Society for Preventive Oncology. Published by Elsevier Science Ltd. All rights reserved.
PMCID: PMC1592328  PMID: 12102148
Chinese Americans; Cervical cancer; Papanicolaou testing
16.  A Randomized Controlled Trial of Interventions to Promote Cervical Cancer Screening Among Chinese Women in North America 
North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.
Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants’ Pap testing behavior. All statistical tests were two-sided.
A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P = .03 for direct mail versus control, and P = .02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.
Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.
PMCID: PMC1592333  PMID: 11983755
Journal of community health  2002;27(3):151-163.
Southeast Asians have higher liver cancer rates than any other racial/ethnic group in the US. Approximately 80 percent of liver cancers are etiologically associated with hepatitis B virus (HBV) infection which is endemic in Southeast Asia. An in-person survey of Cambodian women (n = 320) was conducted in Seattle, Washington, during 1999. The questionnaire included items about HBV knowledge, beliefs, and practices. Prior to being provided with a description of the disease, only about one-half (56 percent) of our respondents had heard of HBV infection. Less than one-quarter (23 percent) of the study group thought that asymptomatic individuals can transmit the disease to others. Most thought that HBV infection can cause liver cancer (54 percent) and death (72 percent). However, a minority thought that infection can be lifelong (24 percent) and incurable (15 percent). Only 38 percent reported they had been serologically tested for HBV. Finally, of those who had been tested and thought they were susceptible, two-thirds (67 percent) had not been vaccinated. Lower levels of education were associated with lower levels of HBV knowledge and serologic testing. Our findings suggest that Cambodian immigrants have low levels of HBV knowledge, serologic testing, and vaccination; and demonstrate a need for targeted educational interventions aimed at reducing HBV-related liver cancer mortality among Southeast Asian communities.
PMCID: PMC1592329  PMID: 12027266
hepatitis B; liver cancer; Cambodian Americans

Results 1-17 (17)