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1.  Evaluating the Training of Filipino American Community Health Advisors to Disseminate Colorectal Cancer Screening 
Journal of community health  2012;37(6):1218-1225.
Community health advisor-led interventions are associated with improved health promotion behaviors, such as cancer screening, but the process of training community health advisors is rarely described and evaluated. We trained 91 Filipino Americans from 19 organizations to conduct small-group sessions with members of their organizations to promote colorectal cancer screening. Community health advisors completed brief pre- and post-training surveys that included knowledge of colorectal cancer screening guidelines (4 items), perceived self-efficacy of performing specific tasks (15-item scale, Cronbach’s alpha >.90) and satisfaction with the training itself (5 items). Community health advisors had high levels of knowledge and self-efficacy at pre-training, but levels increased significantly immediately after the 6-hour training (percent of knowledge items answered correctly: 63% to 94%; self-efficacy: 8.2 to 8.9 on a 10 point scale, both p<.001). Correlates of self-efficacy at pre- and post-test were high educational attainment, health care background, high level of participation in the organization, being perceived by others as a leader, and frequent participation in research activities in the past. Consistent evaluation measuring similar constructs across studies may help to standardize the quality of the training, and may improve the implementation of community health advisor-led programs.
PMCID: PMC3383892  PMID: 22430865
lay health educator; community health educator; evaluation of training; self-efficacy; knowledge; satisfaction
2.  Health Risk Behaviors among Five Asian American Subgroups in California: Identifying Intervention Priorities 
This analysis assessed the prevalence of excess body weight, physical inactivity and alcohol and tobacco use in Asian American subgroups. Using 2005 California Health Interview Survey data, we estimated the prevalence of body mass index (BMI) categories using both standard and World Health Organization-proposed Asian-specific categories, physical inactivity, and alcohol and tobacco use for Chinese (n=1285), Japanese (n=421), Korean (n=620), Filipino (n=659) and Vietnamese (n=480) Americans in California. About 80% of Japanese and Filipino American men and 70% of Korean American men were “increased/high risk” by Asian-specific BMI categories. Most Asian American subgroups were more likely to walk for transportation than non-Hispanic whites, but less likely to report other physical activities. Highest smoking and binge drinking prevalences were among Korean, Vietnamese and Filipino American men and Japanese and Korean American women. These results suggest risk profiles for each Asian American subgroup to consider when setting priorities for health promotion programs.
PMCID: PMC3298627  PMID: 22089979
Asian American subgroups; California Health Interview Survey; Body Mass Index; Health risk behaviors
3.  Behavioral mediators of colorectal cancer screening in a randomized controlled intervention trial 
Preventive medicine  2010;52(2):167-173.
Understanding mediators for behavioral change is important for the optimization of intervention strategies. This report examines mediators of change in the context of a randomized controlled intervention trial (Los Angeles, 2004–2009) that successfully increased colorectal cancer (CRC) screening among Filipino Americans.
The intervention, based on the Health Behavior Framework, targeted knowledge/awareness of CRC screening, communication with health care provider, health beliefs, social support and barriers to CRC screening. Health Behavior Framework variables were assessed at baseline and 6 month follow-up (N=432). Variables targeted for change were tested as potential mediators of the primary outcome, self-reported receipt of CRC screening during the follow-up period, which was previously found to have increased significantly among intervention participants.
Consistent with the Health Behavior Framework, knowledge/awareness of CRC screening and patient-provider communication mediated receipt of screening. Increase in knowledge/awareness of CRC screening accounted for 13% (95% confidence interval 2%–24%) of the total intervention effect size while patient-provider communication accounted for 20% (5%–36%). Combined, these two variables accounted for 28% (10%–46%) of the total effect size.
Examining the roles of potential mediators in intervention trials may help identify constructs to target in order to enhance the effectiveness of interventions to increase screening.
PMCID: PMC3075444  PMID: 21111754
colorectal cancer; cancer screening; immigrants; intervention trial; mediation
4.  Results of a Community-based Randomized Trial to Increase Colorectal Cancer Screening among Filipino Americans 
American journal of public health  2010;100(11):2228-2234.
Low CRC screening rates among Asian Americans are contributing to late stage at diagnosis and poor survival outcomes compared to Non-Hispanic whites. We conducted one of the first community-based trials to increase CRC screening in an Asian American population.
Filipino Americans (N=548) non-adherent to CRC screening guidelines were randomized into two multi-component intervention arms that included a small-group CRC education session with or without distribution of free FOBT kits or a control condition (small-group education promoting physical activity).
Based on intent-to-treat analysis, self-reported CRC screening rates during the 6 month follow-up period were 30%, 25% and 9% for participants assigned to intervention with FOBT kit, intervention without FOBT kit, and the control condition, respectively. Participants randomized to either of the two intervention arms were significantly more likely to report screening at follow-up than control group assignees (odds ratios 4.9 and 3.7 compared to control, both p<.001).
A multi-component intervention that includes an educational group session in a community setting can significantly increase CRC screening in Filipino Americans, even when no free FOBT kits are distributed.
PMCID: PMC2951922  PMID: 20864724
5.  Results of a randomized controlled trial testing the efficacy of a culturally-targeted and a generic video on mammography screening among Chinese-American immigrants 
Research comparing the effects of culturally-targeted and generic but linguistically appropriate intervention programs is limited. We conducted a randomized controlled trial comparing the efficacy of a culturally-targeted video, a generic video, and a fact sheet (control) in promoting mammography screening among Chinese-American immigrants.
We randomized 664 Chinese-American women from the Washington, DC and New York City areas who were >40 years and non-adherent to annual mammography screening guidelines to three study arms (each with ~221 women). The outcome was self-reported mammography screening six months post intervention. Measures of knowledge, Eastern cultural views, and health beliefs were administered before and after the intervention.
The culturally-targeted video, the generic video, and the fact sheet increased mammography utilization by 40.3%, 38.5%, and 31.1% from baseline, respectively. A significant intervention effect was observed only in one subgroup: The culturally-targeted video significantly increased mammography screening among low-acculturated women over the fact sheet (OR=1.70, 95% CI=1.04, 2.78). Overall, women who obtained a mammogram during the follow-up period reported significantly fewer barriers to screening after intervention than those who had not obtained screening. Both of the video groups reported fewer barriers after intervention than the control group.
Both theoretically-guided videos increased the likelihood of mammography use to a similar extent. Cultural targeting was only effective for low-acculturated women. Both videos reduced perceived barriers to screening and consequently increased screening behavior.
The results of this study provide empirical evidence on the efficacy of cultural targeting for minority immigrants.
PMCID: PMC3542829  PMID: 22971901
Cultural targeting; Video intervention; Mammography screening; Chinese Americans; Randomized controlled trial
6.  An Experimental Test of the Effect of Incentives on Recruitment of Ethnically Diverse Colorectal Cancer Cases and Their First-Degree Relatives into a Research Study 
Optimizing participant response rates is important for obtaining representative samples and the timely completion of studies. It is a common practice to use participant incentives to boost response rates, but few studies have systematically examined their effectiveness, particularly among minority groups.
We experimentally tested three incentive strategies for their effectiveness in improving response rates among colorectal cancer cases (N=3,816) and their relatives (N=2,353). A 2×2×2 factorial design compared (1) registered versus first class mail, (2) $5 cash with the initial mailing (yes/no), and (3) $20promise (yes/no) upon completion of the information form (for cases) or $10 promise (yes/no) upon completion of the baseline survey (for relatives). Outcome measures were provision of contact information on first-degree relatives for cases and completion of the baseline survey for relatives.
The response rate among cases was low in all ethnic groups (28 – 37%) and incentive strategies did not have an effect. Among relatives, the overall baseline survey response rate was 71%, ranging from 66% among Asians to 76% among Whites. Modest absolute increases were observed for payment schedules that included a $5 cash enclosure with the initial mailing in the total sample (OR 1.65 and 1.47) and among Latinos (OR 1.94 and 1.74) but not among Asians (OR 1.61 and 1.55) or African Americans (OR 1.19 and 1.02). Response rates were not influenced by registered versus first-class mailing.
The effects of incentives in this study were modest with some suggestion of differences by ethnic group and type of incentive.
PMCID: PMC2759859  PMID: 19755646
randomized trial; effect of incentives; Asian American; Latino; African American
7.  Disparities in Receipt of FOBT versus Endoscopy among Filipino American Immigrants 
This report examines disparities associated with the type of colorectal screening test, fecal occult blood test (FOBT) versus endoscopy, within a particular racial/ethnic group, Filipino American immigrants.
Between July 2005 and October 2006, Filipino Americans age 50-75 from 31 community organizations in Los Angeles completed a 15-minute survey in English (65%) or Filipino (35%).
Of the 487 respondents included in this analysis, 257 (53%) had never received any type of colorectal cancer (CRC) screening. Among the 230 subjects who had ever received a routine screening test, 78 had FOBT only (16% of the total sample) and 152 had endoscopy with or without FOBT (31% of the total sample). After controlling for access to care and key demographic variables in a multivariate analysis, only two characteristics distinguished between respondents who had FOBT only versus those who had endoscopy: acculturation, assessed by percent lifetime in the U.S. and language of interview, and income.
Our data suggest a two tier system, FOBT for less acculturated Filipino Americans with lower income versus endoscopy for Filipino immigrants with higher levels of acculturation and income. The disparity persists after adjusting for access to care. Instead of treating minority groups as monolithic, differences within groups need to be examined so that interventions can be appropriately targeted.
PMCID: PMC2852182  PMID: 18708385
colorectal cancer screening; fecal occult blood test; endoscopy; Filipino American immigrants
8.  Trends in Colorectal Cancer Screening Utilization among Ethnic Groups in California: Are We Closing the Gap? 
Given the low prevalence of and racial/ethnic disparities in colorectal cancer (CRC) screening, it is important to monitor whether prevalence and disparities are increasing or decreasing over time.
We estimated the prevalence of CRC screening by year (2001, 2003 and 2005), modality (endoscopy, fecal occult blood test, either) and recency (ever had, up-to-date) for the California population as a whole, major racial/ethnic groups (White, Black, Latino, Asian), and selected Asian subgroups (Chinese, Filipino, Japanese, Korean, Vietnamese) using data from the California Health Interview Survey. All prevalence estimates were age- and gender-standardized.
Between 2001 and 2005, prevalence of up-to-date screening increased significantly among Whites and Latinos but not among Blacks and Asian Americans. Screening prevalence varied substantially among Asian subgroups, with Korean, Filipino and Vietnamese Americans having the lowest prevalence. Korean Americans were the only group in the analysis with a significant decline in screening prevalence between 2001 and 2005. The gap between the highest and lowest up-to-date screening prevalence using any screening modality, exhibited by Japanese and Korean Americans, increased from 18% in 2001 to 30% in 2005.
Findings suggest that we need to intensify efforts to increase colorectal cancer screening, especially among Korean Americans but also among Filipinos, Vietnamese and Latinos.
PMCID: PMC2745842  PMID: 19273482
colorectal cancer screening; ethnic disparities; Asian subgroups; California Health Interview Survey
9.  Comparing Perceived and Test-Based Knowledge of Cancer Risk and Prevention among Hispanic and African Americans: An Example of Community Participatory Research 
Ethnicity & disease  2013;23(2):210-216.
Most theoretical formulations acknowledge that knowledge and awareness of cancer screening and prevention recommendations significantly influence health behaviors. This study compares perceived knowledge of cancer prevention and screening with test-based knowledge in a community sample. We also examine demographic variables and self-reported cancer screening and prevention behaviors as correlates of both knowledge scores, and consider whether cancer related knowledge can be accurately assessed using just a few, simple questions in a short and easy-to-complete survey.
We used a community-partnered participatory research approach to develop our study aims and a survey. The study sample was composed of 180 predominantly African American and Hispanic community individuals who participated in a full-day cancer prevention and screening promotion conference in South Los Angeles, California, on July 2011. Participants completed a self-administered survey in English or Spanish at the beginning of the conference.
Our data indicate that perceived and test-based knowledge scores are only moderately correlated. Perceived knowledge score shows a stronger association with demographic characteristics and other cancer related variables than the test-based score. Thirteen out of twenty variables that are examined in our study showed a statistically significant correlation with the perceived knowledge score, however, only four variables demonstrated a statistically significant correlation with the test-based knowledge score.
Perceived knowledge of cancer prevention and screening was assessed with fewer items than test-based knowledge. Thus, using this assessment could potentially reduce respondent burden. However, our data demonstrate that perceived and test-based knowledge are separate constructs.
PMCID: PMC3747224  PMID: 23530303
Cancer; Knowledge; Minority; Prevention; Screening
Journal of community health  2005;30(3):167-179.
Recruitment and retention of subjects in cancer prevention, screening, and treatment trials is challenging, especially if subjects are low-income, from minority groups or immigrants with limited English fluency. This article describes our experiences in recruiting 530 female Filipino–American immigrants at community based organizations and churches for a randomized trial that assessed the effect of a small group educational session on breast and cervical cancer screening. We found that a personal invitation from either a female project liaison, a friend, or the Filipino project director were all successful strategies that resulted in over 80% attendance at an educational session that was offered as part of the study. Although non-attendees did not differ from attendees in demographic characteristics, they expressed significantly more barriers to participating in a health study. Attendance at the group session was a significant predictor of retention in the study. We were able to conduct telephone follow-up surveys among 88% of enrollees at 12 month follow-up and 76% at 24 month follow-up. Results and implications are discussed in the hope that they may facilitate future participation of Filipinos and other Asian immigrants in research.
PMCID: PMC1810967  PMID: 15847243
recruitment and retention strategies; Filipino–American immigrants; cancer screening study
11.  Drinking Patterns Among Korean Adults: Results of the 2009 Korean Community Health Survey 
In Korea, the proportion of deaths due to alcohol is estimated at 8.9%, far exceeding the global estimate of 3.8%. Therefore, this study was performed to examine the factors associated with low-risk, moderate-risk, and high-risk drinking patterns in Korean adults and to identify target populations for prevention and control of alcohol-related diseases and deaths.
We analyzed data from 230 715 Korean adults aged 19 years and older who participated in the 2009 Korean Community Health Survey. Multinomial logistic regression analysis was used to examine associations between socio-demographic and health-related factors and patterns of alcohol use.
A substantially larger proportion of men than women engaged in high risk (21.2% vs. 3.4%) and moderate-risk alcohol use (15.5% vs. 8.2%). In both sexes, moderate- and high-risk uses were associated with younger age, higher income, being currently employed, smoking, being overweight/obese, and good self-rated health.
Given the large proportion of the population that is engaging in moderate- and high-risk drinking and given the social norms that support this behavior, public health policies and campaigns to reduce alcohol consumption targeting the entire population are indicated.
PMCID: PMC3740223  PMID: 23946876
Alcohol drinking; Epidemiology; High-risk drinking; Risk factors; Republic of Korea
12.  Physical Activity Among Older Filipino-American Women 
Women & health  2002;36(1):67-79.
Filipino women (N = 530, mean age 63 years, predominantly low income) were recruited through various community based organizations and churches in Los Angeles County. All women were randomly invited to attend a single group session with a Filipino health educator to discuss breast and cervical cancer screening or the health benefits of exercise. At 3 months after the group session, the exercise assessment tool used in the National Health and Nutrition Examination Survey III was completed by 487 women (92 percent retention rate). This paper describes the pattern of physical activity among older Filipino-American women and a physical activity intervention specifically designed for this group.
PMCID: PMC1618778  PMID: 12215004
Filipino older women; immigrants; physical activity pattern; intervention; randomized design
13.  Intervention tailoring for Chinese American women: comparing the effects of two videos on knowledge, attitudes and intentions to obtain a mammogram 
Health Education Research  2012;27(3):523-536.
This study utilized data from an ongoing randomized controlled trial to compare a culturally tailored video promoting positive attitudes toward mammography among Chinese immigrant women to a linguistically appropriate generic video and print media. Intervention development was guided by the Health Belief Model. Five hundred and ninety-two immigrant Chinese Americans from the metropolitan Washington, DC, and New York City areas completed telephone interviews before and after intervention. Changes in knowledge, Eastern views of health care (fatalism and self-care), health beliefs (perceived susceptibility, severity, benefits and barriers) and screening intentions were measured. Results showed that both videos improved screening knowledge, modified Eastern views of health care, reduced perceived barriers and increased screening intentions relative to print media (all P < 0.05). The generic video increased screening intention twice as much as the cultural video, although subgroup analysis showed the increase was only significant in women aged 50–64 years. Only Eastern views of health care were negatively associated with screening intentions after adjusting for all baseline covariates. These data suggest that a theoretically guided linguistically appropriate video that targets women from various ethnic groups is as efficacious in modifying attitudes toward mammography screening as a video that is exclusively tailored for Chinese immigrant women.
PMCID: PMC3337423  PMID: 22327806
14.  Pilot test of a peer-led small-group video intervention to promote mammography screening among Chinese American immigrants 
Health promotion practice  2010;12(6):887-899.
This study evaluated the feasibility, acceptability and potential effect of a small-group video intervention led by trained Chinese American lay educators who recruited Chinese American women not up to date on mammography screening. Nine lay educators conducted 14 “breast health tea time workshops” in community settings and private homes that started with watching a culturally tailored video promoting screening followed by a question and answer session and distribution of print materials. Many group attendees did not have health insurance or a regular doctor, had low levels of income and were not proficient in English. Forty-four percent of the attendees reported receipt of a mammogram within 6 months after the small-group session with higher odds of screening among women who had lived in the U.S. less than 10% of their lifetime. Four of the educators were very interested in conducting another group session in the next 6 months.
PMCID: PMC2990797  PMID: 20720095
small-group/video intervention; mammography screening; Chinese American women
15.  Alternative approaches to assessing intervention effectiveness in randomized trials: Application in a colorectal cancer screening study 
Cancer causes & control : CCC  2011;22(9):1233-1241.
Previous analysis of a randomized community-based trial of a multi-component intervention to increase colorectal cancer (CRC) screening among Filipino Americans (n=548) found significantly higher screening rates in the two intervention groups compared to the control group, when using intent-to-treat analysis and self-reported screening as the outcome. This report describes more nuanced findings obtained from alternative approaches to assessing intervention effectiveness to inform future intervention implementation.
The effect of the intervention on CRC screening receipt during follow-up was estimated using methods that adjusted for biases due to missing data and self-report, and for different combinations of intervention components. Adjustment for self-report used data from a validation substudy. Effectiveness within demographic subgroups was also examined.
Analyses accounting for self-report bias and missing data supported the effectiveness of the intervention. The intervention was also broadly effective across the demographic characteristics of the sample. Estimates of the intervention effect were highest among participants whose providers received a letter as part of the intervention.
The findings increase confidence that the intervention could be broadly effective at increasing CRC screening in this population. Subgroup analyses and attempts to deconstruct multi-component interventions can provide important information for future intervention development, implementation and dissemination.
PMCID: PMC3148350  PMID: 21678032
colorectal cancer; cancer screening; immigrants; validation of self-report; subgroup analysis
16.  Cluster randomized trials of cancer screening interventions: are appropriate statistical methods being used? 
Contemporary clinical trials  2011;32(4):477-484.
The design and analysis of cluster randomized trials can require more sophistication than individually randomized trials. However, the need for statistical methods that account for the clustered design has not always been appreciated, and past reviews have found widespread deficiencies in methodology and reporting. We reviewed cluster randomized trials of cancer screening interventions published in 1995–2010 to determine whether the use of appropriate statistical methods had increased over time. Literature searches yielded 50 articles reporting outcome analyses of cluster randomized trials of breast, cervix and colorectal cancer screening interventions. Of studies published in 1995–1999, 2000–2002, 2003–2006 and 2007–2010, 55% (6/11), 82% (9/11), 92% (12/13) and 60% (9/15) used appropriate analytic methods, respectively. Results were suggestive of a peak in 2003–2006 (p=.06) followed by a decline in 2007–2010 (p=.08). While the sample of studies was small, these results indicate that many cluster randomized trials of cancer screening interventions have had deficiencies in the application of correct statistical procedures for the outcome analysis, and that increased adoption of appropriate methods in the early and mid-2000’s may not have been sustained.
PMCID: PMC3104062  PMID: 21382513
cluster randomized trials; intraclass correlation coefficient; CONSORT; cancer screening intervention trials
17.  Changes in Risk Perceptions in Relation to Self-Reported Colorectal Cancer Screening among First-Degree Relatives of Colorectal Cancer Cases Enrolled in a Randomized Trial 
This secondary data analysis was conducted to evaluate the applicability of the Risk Reappraisal Hypothesis, which has been proposed to explain the influence of performing a health behavior on perceived risk. Data were collected in the context of a randomized trial which found that an individually tailored, multi-component intervention was successful in increasing colorectal cancer (CRC) screening among first-degree relatives of CRC cases.
The ethnically-diverse study sample (n = 841; 29% Latino, 21% African American, 20% Asian) consisted of adult siblings and children (40–80 years) of CRC cases, identified through the California Cancer Registry. Data were collected at baseline, 6- and 12- month follow-up. Changes in self-reported risk perception (perceived likelihood of developing CRC) were examined over the study period in relation to study condition and screening status.
Greater increases in perceived risk were observed among intervention versus control group participants over the study period, but increases were limited to intervention participants who had not been screened. We also examined trajectories of perceived risk in relation to timing of screening receipt (e.g., before 6 months, 6–12 months, never). Continued upward shifts in risk were observed during the study period among intervention participants not screened during the study. In contrast, participants screened by 6 months displayed a reduction or leveling off in perceived risk between 6 and 12- month follow-up.
Results provide support for the applicability of the Risk Reappraisal Hypothesis within a high risk sample enrolled in a CRC screening promotion trial. Future research is needed to explore the impact of short-term risk reductions on future CRC screening behavior.
PMCID: PMC3201806  PMID: 21744967
Perceived Risk; Colorectal cancer; Cancer screening; Health Behavior; Theory
18.  Population Colorectal Cancer Screening Estimates: Comparing Self-Report to Electronic Health Record Data in California 
Population-based surveys are used to assess colorectal cancer (CRC) screening rates, but may be subject to self-report biases. Clinical data from electronic health records (EHR) are another data source for assessing screening rates and self-report bias; however, use of EHR data for population research is relatively new. We sought to compare CRC screening rates from a self-report survey, the 2007 California Health Interview Survey (CHIS), to EHR data from Palo Alto Medical Foundation (PAMF), a multi-specialty healthcare organization serving three counties in California.
Ever- and up-to-date CRC screening rates were compared between CHIS respondents (N=18,748) and PAMF patients (N=26,283). Both samples were limited to English proficient subjects aged 51–75 with health insurance and a physician visit in the past two years. PAMF rates were age-sex standardized to the CHIS population. Analyses were stratified by racial/ethnic group.
EHR data included PAMF internally completed tests (84%), and patient-reported externally completed tests which were either confirmed (7%) or unconfirmed (9%) by a physician. When excluding unconfirmed tests, PAMF screening rates were 6–14 percentage points lower than CHIS rates, for both ever- and up-to-date CRC screening among Non-Hispanic White, Black, Hispanic/Latino, Chinese, Filipino and Japanese subjects. When including unconfirmed tests, differences in screening rates between the two data sets were minimal.
Comparability of CRC screening rates from survey data and clinic-based EHR data depends on whether or not unconfirmed patient-reported tests in EHR are included. This indicates a need for validated methods of calculating CRC screening rates in EHR data.
PMCID: PMC3157148  PMID: 21857818
colorectal cancer screening; self-report bias; validity; California Health Interview Survey; prevalence
19.  Peer Navigation Improves Diagnostic Follow-up after Breast Cancer Screening among Korean American Women: Results of a Randomized Trial 
Cancer causes & control : CCC  2010;21(11):1931-1940.
To test an intervention to increase adherence to diagnostic follow-up tests among Asian American women.
Korean American women who were referred for a diagnostic follow-up test (mainly diagnostic mammograms) and who had missed their follow-up appointment were eligible to participate in the study. Women from two clinics (N=176) were randomly allocated to a usual care control arm or a peer navigator intervention arm. A 20-minute telephone survey was administered to women in both study arms 6 months after they were identified to assess demographic and socio-economic characteristics and the primary outcome, self-reported completion of the recommended follow-up exam.
Among women who completed the survey at 6 month follow-up, self-reported completion of follow-up procedures was 97% in the intervention arm and 67% in the control arm (p<.001). Based on an intent-to-treat analysis of all women who were randomized and an assumption of no completion of follow-up exam for women with missing outcome data, self-reported completion of follow-up was 61% in the intervention arm and 46% in the usual care control arm (p<.069).
Our results suggest that a peer navigator intervention to assist Korean American women to obtain follow-up diagnostic tests after an abnormal breast cancer screening test is efficacious.
PMCID: PMC2959157  PMID: 20676928
mammography; Asian Americans; medically uninsured; health care disparities
20.  A Midpoint Process Evaluation of the Los Angeles Basin Racial and Ethnic Approaches to Community Health Across the US (REACH US) Disparities Center, 2007-2009 
Preventing Chronic Disease  2011;8(5):A115.
Racial/ethnic minority groups have higher risks for disease resulting from obesity.
Community Context
The University of California, Los Angeles, and the Los Angeles County Department of Public Health partnered with community organizations to disseminate culturally targeted physical activity and nutrition-based interventions in worksites.
We conducted community dialogues with people from 59 government and nonprofit health and social service agencies to develop wellness strategies for implementation in worksites. Strategies included structured group exercise breaks and serving healthy refreshments at organizational functions. During the first 2 years, we subcontracted with 6 community-based organizations (primary partners) who disseminated these wellness strategies to 29 organizations within their own professional networks (secondary worksites) through peer modeling and social support. We analyzed data from the first 2 years of the project to evaluate our dissemination approach.
Primary partners had difficulty recruiting organizations in their professional network as secondary partners to adopt wellness strategies. Within their own organizations, primary partners reported significant increases in implementation in 2 of the 6 core organizational strategies for promoting physical activity and healthy eating. Twelve secondary worksites that completed organizational assessments on 2 occasions reported significant increases in implementation in 4 of the 6 core organizational strategies.
Dissemination of organizational wellness strategies by trained community organizations through their existing networks (train-the-trainer) was only marginally successful. Therefore, we discontinued this dissemination approach and focused on recruiting leaders of organizational networks.
PMCID: PMC3181188  PMID: 21843418
21.  Constructing a Theoretically-Based Set of Measures for Liver Cancer Control Research Studies 
Preventive medicine  2009;50(1-2):68.
Measurement tools such as surveys assessing knowledge, attitudes and behaviors need to be theoretically consistent with interventions. The purpose of this paper 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.
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.
We constructed three questionnaires in Vietnamese, Hmong and Korean language 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.
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.
PMCID: PMC2813918  PMID: 19883680
hepatitis B virus; theory-based assessment instruments; cancer prevention; community-based research
22.  Peer navigation improves diagnostic follow-up after breast cancer screening among Korean American women: results of a randomized trial 
Cancer Causes & Control  2010;21(11):1931-1940.
To test an intervention to increase adherence to diagnostic follow-up tests among Asian American women.
Korean American women who were referred for a diagnostic follow-up test (mainly diagnostic mammograms) and who had missed their follow-up appointment were eligible to participate in the study. Women from two clinics (n = 176) were randomly allocated to a usual care control arm or a peer navigator intervention arm. A 20-min telephone survey was administered to women in both study arms six months after they were identified to assess demographic and socio-economic characteristics and the primary outcome, self-reported completion of the recommended follow-up exam.
Among women who completed the survey at six-month follow-up, self-reported completion of follow-up procedures was 97% in the intervention arm and 67% in the control arm (p < 0.001). Based on an intent-to-treat analysis of all women who were randomized and an assumption of no completion of follow-up exam for women with missing outcome data, self-reported completion of follow-up was 61% in the intervention arm and 46% in the usual care control arm (p < 0.069).
Our results suggest that a peer navigator intervention to assist Korean American women to obtain follow-up diagnostic tests after an abnormal breast cancer screening test is efficacious.
PMCID: PMC2959157  PMID: 20676928
Mammography; Asian Americans; Medically uninsured; Health care disparities
23.  Explaining disparities in colorectal cancer screening among five Asian ethnic groups: A population-based study in California 
BMC Cancer  2010;10:214.
Data from the California Health Interview Survey (CHIS) indicate that levels and temporal trends in colorectal cancer (CRC) screening prevalence vary among Asian American groups; however, the reasons for these differences have not been fully investigated.
Using CHIS 2001, 2003 and 2005 data, we conducted hierarchical regression analyses progressively controlling for demographic characteristics, English proficiency and access to care in an attempt to identify factors explaining differences in screening prevalence and trends among Chinese, Filipino, Vietnamese, Korean and Japanese Americans (N = 4,188).
After controlling for differences in gender and age, all Asian subgroups had significantly lower odds of having ever received screening in 2001 than the reference group of Japanese Americans. In addition, Korean Americans were the only subgroup that had a statistically significant decline in screening prevalence from 2001 to 2005 compared to the trend among Japanese Americans. After controlling for differences in education, marital status, employment status and federal poverty level, Korean Americans were the only group that had significantly lower screening prevalence than Japanese Americans in 2001, and their trend to 2005 remained significantly depressed. After controlling for differences in English proficiency and access to care, screening prevalences in 2001 were no longer significantly different among the Asian subgroups, but the trend among Korean Americans from 2001 to 2005 remained significantly depressed. Korean and Vietnamese Americans were less likely than other groups to report a recent doctor recommendation for screening and more likely to cite a lack of health problems as a reason for not obtaining screening.
Differences in CRC screening trends among Asian ethnic groups are not entirely explained by differences in demographic characteristics, English proficiency and access to care. A better understanding of mutable factors such as rates of doctor recommendation and health beliefs will be crucial for designing culturally appropriate interventions to promote CRC screening.
PMCID: PMC2888788  PMID: 20482868
24.  Factors Associated with Hepatitis B Testing Among Vietnamese Americans 
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.
Describe factors associated with hepatitis B testing among Vietnamese Americans.
A population-based telephone survey conducted in 2007–2008.
Vietnamese Americans age 18–64 and living in the Northern California and Washington, DC areas (N = 1,704).
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.
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.
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.
PMCID: PMC2881980  PMID: 20306150
hepatitis B; Vietnamese Americans; testing
25.  Relationship between perceived body weight and body mass index based on self- reported height and weight among university students: a cross-sectional study in seven European countries 
BMC Public Health  2010;10:40.
Despite low rates of obesity, many university students perceive themselves as overweight, especially women. This is of concern, because inappropriate weight perceptions can lead to unhealthy behaviours including eating disorders.
We used the database from the Cross National Student Health Survey (CNSHS), consisting of 5,900 records of university students from Bulgaria, Denmark, Germany, Lithuania, Poland, Spain and Turkey to analyse differences in perceived weight status based on the question: "Do you consider yourself much too thin, a little too thin, just right, a little too fat or much too fat?". The association between perceived weight and body mass index (BMI) calculated from self-reported weight and height was assessed with generalized non-parametric regression in R library gam.
Although the majority of students reported a normal BMI (72-84% of males, 65-83% of females), only 32% to 68% of students considered their weight "just right". Around 20% of females with BMI of 20 kg/m2 considered themselves "a little too fat" or "too fat", and the percentages increased to 60% for a BMI of 22.5 kg/m2. Male students rarely felt "a little too fat" or "too fat" below BMI of 22.5 kg/m2, but most felt too thin with a BMI of 20 kg/m2.
Weight ideals are rather uniform across the European countries, with female students being more likely to perceive themselves as "too fat" at a normal BMI, while male students being more likely to perceive themselves as "too thin". Programs to prevent unhealthy behaviours to achieve ill-advised weight ideals may benefit students.
PMCID: PMC2824734  PMID: 20105333

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