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1.  Developing Theoretically Based and Culturally Appropriate Interventions to Promote Hepatitis B Testing in 4 Asian American Populations, 2006–2011 
Introduction
Hepatitis B infection is 5 to 12 times more common among Asian Americans than in the general US population and is the leading cause of liver disease and liver cancer among Asians. The purpose of this article is to describe the step-by-step approach that we followed in community-based participatory research projects in 4 Asian American groups, conducted from 2006 through 2011 in California and Washington state to develop theoretically based and culturally appropriate interventions to promote hepatitis B testing. We provide examples to illustrate how intervention messages addressing identical theoretical constructs of the Health Behavior Framework were modified to be culturally appropriate for each community.
Methods
Intervention approaches included mass media in the Vietnamese community, small-group educational sessions at churches in the Korean community, and home visits by lay health workers in the Hmong and Cambodian communities.
Results
Use of the Health Behavior Framework allowed a systematic approach to intervention development across populations, resulting in 4 different culturally appropriate interventions that addressed the same set of theoretical constructs.
Conclusions
The development of theory-based health promotion interventions for different populations will advance our understanding of which constructs are critical to modify specific health behaviors.
doi:10.5888/pcd11.130245
PMCID: PMC4008952  PMID: 24784908
2.  EVALUATION OF A HEPATITIS B LAY HEALTH WORKER INTERVENTION FOR CAMBODIAN AMERICANS 
Journal of community health  2013;38(3):546-553.
Cambodian Americans have high rates of chronic hepatitis B virus (HBV) infection. However, only about one-half of Cambodian Americans have been serologically tested for HBV. We conducted a randomized controlled trial to evaluate the impact of a lay health worker (LHW) intervention on HBV testing and knowledge levels among Cambodian Americans. The study group included 250 individuals who participated in a community based survey in metropolitan Seattle and had not been tested for HBV. Experimental group participants received a LHW intervention addressing HBV and control group participants received a LHW intervention addressing physical activity. Trial participants completed a follow-up survey six months after randomization. Over four-fifths (82%) of randomized individuals participated in a LHW home visit and the follow-up survey response rate was 80%. Among participants with follow-up data, 22% of the experimental group and 3% of the control group reported HBV testing (p<0.001). The experimental and control group testing difference remained significant in an intent-to-treat analysis. The experimental group was significantly more likely than the control group to know that Cambodians have higher rates of HBV infection than whites, HBV cannot be spread by eating food prepared by an infected person, HBV cannot be spread by sharing chopsticks, and HBV cannot be spread by shaking hands. Our findings indicate LHW interventions are acceptable to Cambodian Americans and can positively impact both HBV testing and knowledge levels.
doi:10.1007/s10900-012-9649-6
PMCID: PMC3633619  PMID: 23299978
Cambodian Americans; Hepatitis B Infection; Lay Health Workers
3.  Community Health Worker Hepatitis B Education for Cambodian American Men and Women 
Background
Cambodian Americans have high rates of chronic hepatitis B virus (HBV) infection and liver cancer. There is very limited information about the utility of community health worker (CHW) approaches to cancer education for Asian American men. We have previously reported our positive findings from a trial of CHW education about HBV for Cambodian Americans who had never been tested for HBV. This report describes similarities and differences between the outcomes of our CHW HBV educational intervention among Cambodian American men and women.
Methods
The study group for this analysis included 87 individuals (39 men and 48 women) who were randomized to the experimental (HBV education) arm of our trial, participated in the CHW educational intervention, and provided follow-up data six months post-intervention. We examined HBV testing rates at follow-up, changes in HBV-related knowledge between baseline and follow-up, and barriers to HBV testing (that were reported to CHWs) by gender.
Results
At follow-up, 15% of men and 31% of women reported they had received a HBV test (p=0.09). HBV-related knowledge levels increased significantly among both men and women. With respect to HBV testing barriers, women were more likely than men to cite knowledge deficits, and men were more likely than women to cite logistic issues.
Discussion
Our study findings indicate that CHW interventions can positively impact knowledge among Cambodian American men, as well as women. They also suggest CHW interventions may be less effective in promoting the use of preventive procedures by Cambodian American men than women. Future CHW research initiatives should consider contextual factors that may differ by gender and, therefore, potentially influence the relative effectiveness of CHW interventions for men versus women.
PMCID: PMC3801266  PMID: 24083730
Cambodian Americans; Hepatitis B Infection; Liver Cancer; Community Health Workers
4.  Physical Activity among Cambodian Americans: An Exploratory Study 
Journal of community health  2012;37(5):1040-1048.
Introduction
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1007/s10900-011-9528-6
PMCID: PMC3437005  PMID: 22183889
Cambodian Americans; Physical activity
5.  SOURCES OF HEALTH INFORMATION AMONG CHINESE IMMIGRANTS TO THE PACIFIC NORTHWEST 
Background
Chinese immigrants to North America experience cancer-related health disparities and underutilize preventive care. Little is known about Chinese immigrants' sources of health information.
Methods
A population-based survey of Chinese immigrants was conducted in Vancouver, British Columbia and Seattle, Washington.
Results
The study group included 899 individuals. Less than three-quarters of the respondents reported receiving health information from healthcare providers and only a minority used the Internet as a source of health information. We found significant differences between the sources of health information in Seattle and Vancouver.
Conclusions
Health educators should consider available media outlets as well as the characteristics of a target community when planning intervention programs for Chinese immigrants.
doi:10.1080/08858190902854533
PMCID: PMC2836713  PMID: 19838895
6.  PAP TESTING AMONG VIETNAMESE WOMEN: HEALTH CARE SYSTEM AND PHYSICIAN FACTORS 
Journal of community health  2004;29(6):437-450.
Cervical cancer occurs more frequently among Vietnamese Americans than women of any other race/ethnicity. In addition, previous studies in California have documented low Papanicolaou (Pap) testing rates in Vietnamese communities. This study focused on health care system factors and physician characteristics associated with recent cervical cancer screening among Vietnamese women. A population-based survey was conducted in Seattle during 2002. In-person interviews were conducted by bilingual, bicultural female survey workers. The survey response rate was 82% and 518 women were included in the analysis. Seventy-four percent of the respondents reported having been screened for cervical cancer on at least one occasion, and 64% reported a Pap smear within the previous 2 years. Women with a regular doctor were more likely to have been recently screened than those without a regular doctor (OR = 2.33, 95% CI = 1.45–3.74). Among those with a regular doctor, having a male physician, receiving care at a private doctor’s office (rather than a community, hospital, or multi-specialty clinic), and concern about the cost of health care were independently associated with lower screening rates. Physician ethnicity was not associated with recent Pap smear receipt. The findings support targeted interventions for Vietnamese women without a regular physician and private doctors’ offices that serve Vietnamese Americans. The availability of low cost screening services should be publicized in Vietnamese communities.
PMCID: PMC1811063  PMID: 15587344
cervical cancer; immigrants; Pap testing; Vietnamese
7.  KNOWLEDGE OF CERVICAL CANCER RISK FACTORS AMONG CHINESE IMMIGRANTS IN SEATTLE 
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
8.  Pap Testing Stages of Adoption among Cambodian Immigrants 
Purpose
We examined levels of Pap testing and factors associated with screening participation among Cambodian refugees.
Methods
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.
Findings
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.
Conclusions
Our findings confirm low Pap testing rates among Cambodian immigrants, and suggest that targeted interventions should be multifaceted.
PMCID: PMC1592338  PMID: 11567513
9.  A Randomized Controlled Trial of Interventions to Promote Cervical Cancer Screening Among Chinese Women in North America 
Background
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.
Methods
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.
Results
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.
Conclusion
Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.
PMCID: PMC1592333  PMID: 11983755
10.  HEPATITIS B KNOWLEDGE AND PRACTICES AMONG CAMBODIAN AMERICAN WOMEN IN SEATTLE, WASHINGTON 
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
11.  HPV Vaccination Uptake among Cambodian Mothers 
Journal of Cancer Education  2012;27(1):145-148.
Women of Southeast Asian descent have higher cervical cancer incidence rates than any other group. Widespread use of HPV vaccination could prevent up to 70% of cervical cancers. There is little published information addressing HPV vaccination uptake among Asian Americans. We conducted a survey of Cambodian women with daughters who were age-eligible for HPV vaccination. Survey items addressed HPV vaccination barriers, facilitators, and uptake. Only 26% of the survey participants reported any of their age-eligible daughters had received vaccination, and only 40% reported a previous physician recommendation for vaccination. Higher levels of vaccine uptake were strongly associated with having received a doctor's recommendation for vaccination (P<0.001) and having asked a doctor for vaccination (p=0.002). HPV vaccine uptake was relatively low in our Cambodian study group. Educational initiatives should encourage health care providers who serve Cambodian families to recommend HPV vaccination and empower Cambodian mothers to ask their daughters' doctors for vaccination.
doi:10.1007/s13187-011-0269-0
PMCID: PMC3224678  PMID: 21861237
12.  FACTORS ASSOCIATED WITH HEPATITIS B TESTING AMONG CAMBODIAN AMERICAN MEN AND WOMEN 
Background
Cambodian Americans have an elevated risk of liver cancer. This health disparity is attributable to high rates of hepatitis B virus (HBV) infection. Our study examined factors associated with HBV testing among Cambodian men and women.
Methods
A population-based survey was conducted in the Seattle area. The Health Behavior Framework guided our survey instrument development. We attempted to interview a man and a woman in each household.
Results
The sample included 300 men and 367 women. About one-half of the male (45%) and female (54%) respondents had been tested for HBV. Two factors were independently associated with testing among men and women: a doctor had recommended testing and had asked a doctor for testing. Knowing that someone who looks and feels healthy can spread HBV was independently associated with testing among men.
Discussion
Low levels of HBV testing remain a public health problem among Cambodians. Interventions should improve patient-provider communication by encouraging providers who serve Cambodians to recommend HBV testing, as well as by empowering Cambodians to ask for testing.
doi:10.1007/s10903-011-9536-8
PMCID: PMC3282163  PMID: 22002705
Cambodian Americans; Hepatitis B Testing; Immigrant Health; Liver Cancer
13.  Understanding sub-optimal HPV vaccine uptake among ethnic minority girls 
Background
The introduction of HPV vaccines represents a breakthrough in the primary prevention of cervical cancer. However, little is known about vaccination uptake and correlates among U.S. low-income, ethnic minority and immigrant populations who may benefit most from the vaccine.
Methods
Telephone interviews (N=490) were conducted in six languages between January and November 2009 among mothers of vaccine-eligible girls (ages 9–18) using the Los Angeles County Department of Public Health, Office of Women’s Health service referral hotline. HPV and vaccine awareness, knowledge, beliefs, barriers, and daughter’s vaccine receipt were assessed.
Results
The sample consisted of low-income, uninsured, ethnic minority and immigrant women. Only 29% of daughters initiated the vaccine and 11% received all three doses. No ethnic differences were observed in initiation or completion rates. Ethnic differences were observed in HPV awareness, perceived risk, and other immunization related beliefs. The strongest predictor of initiation was vaccine awareness (OR=12.00). Daughter’s age and reporting a younger acceptable age for vaccination were positively associated with initiation. Mothers of unvaccinated girls reported lacking information about the vaccine to make a decision (66%) and not knowing where they could obtain the vaccine (74%).
Conclusion
Vaccination rates in this sample were lower than state and national estimates, and were associated with low levels of vaccine awareness. Interventions, including culturally targeted messaging, may be helpful for enhancing HPV vaccine knowledge, modifying vaccine-related beliefs and increasing uptake.
Impact
Our findings provide valuable guidance for developing interventions to address sub-optimal HPV vaccination in high risk groups.
doi:10.1158/1055-9965.EPI-11-0267
PMCID: PMC3132826  PMID: 21602307
HPV vaccine; cervical cancer prevention; minorities; health disparities; low-income
14.  “To be healthy and to live long, we have to exercise” – Psychosocial factors related to physical activity among Cambodian Americans 
Journal of community health  2011;36(3):381-388.
Regular physical activity produces various health benefits; however, relatively few adults in the United States (US) get enough physical activity. Little is known about physical activity behaviors, and barriers and facilitators to physical activity among Cambodian-Americans. Cambodian Americans were recruited from community venues to participate in one-on-one interviews and focus groups. A total of 20 adults (10 women and 10 men) participated in one-on-one interviews and 37 adults (23 women and 14 men) participated in one of four focus groups. Fifteen of the 20 interviews and all the focus groups were conducted in Khmer. Participants were generally born in Cambodia and over two-thirds had a high school education or less. About one-half of the participants met or exceeded the 2008 US Department of Health and Human Services physical activity guidelines. Commonly reported types of physical activity were walking, running, and working out at the gym. Barriers to physical activity included lack of time, inconvenient work hours, and family responsibilities. Perceived benefits of physical activity included improved health, improved appearance, and reductions in stress. Sweating caused by physical activity was thought to produce a variety of health benefits. Data from this qualitative study could be used to inform the development of culturally-relevant physical activity survey measures and culturally-relevant physical activity interventions for Cambodian Americans.
doi:10.1007/s10900-010-9319-5
PMCID: PMC3061236  PMID: 20924780
Physical activity; Asian Americans; Cambodian Americans; qualitative research
15.  Lessons Learned from the Application of a Vietnamese Surname List for Survey Research 
Surname lists are increasingly being used to identify Asian study participants. Two Vietnamese surname lists have previously been published: the Vietnamese Community Health Promotion Program (VCHPP) list and the Lauderdale list. This report provides findings from a descriptive analysis of the performance of these lists in identifying Vietnamese. To identify participants for a survey of Vietnamese women, a surname list (that included names that appear on the VCHPP list and/or Lauderdale list) was applied to the Seattle telephone book. We analyzed surname data for all addresses in the survey sample, as well as survey respondents. The VCHPP list identified 4,283 potentially Vietnamese households, and 79% of the households with established ethnicity were Vietnamese; and the Lauderdale list identified 4,068 potentially Viet-namese households, and 80% of the households with established ethnicity were Vietnamese. However, the proportions of contacted households that were Vietnamese varied significantly among commonly occurring surnames. The characteristics of women with surnames on the VCHPP and Lauderdale lists were equivalent. The two lists performed equally well in identifying Vietnamese households. Researchers might consider using different combinations of Vietnamese surnames, depending on whether accuracy or high population coverage is the more important consideration.
doi:10.1007/s10903-009-9296-x
PMCID: PMC2891931  PMID: 19798578
Vietnamese; Surname lists
16.  Hepatitis B Knowledge and Practices among Cambodian Americans 
Background
Liver cancer occurs more frequently among Americans of Southeast Asian descent than any other group. This health disparity can be attributed to high rates of hepatitis B virus (HBV) infection. We examined HBV awareness, knowledge about HBV transmission, HBV testing levels, and HBV vaccination levels among Cambodian Americans.
Methods
A population-based survey was conducted in metropolitan Seattle during 2010. The study sample included 667 individuals. We created a composite knowledge score (0–9) by summing the number of correct answers to survey items addressing HBV transmission. Data were analyzed using Generalized Estimating Equations.
Results
Seventy-eight percent of the study group had heard of HBV (before it was described to them). The proportions who knew that HBV cannot be spread by eating food prepared by an infected person, can be spread during childbirth, and can be spread during sexual intercourse were only 33%, 69%, and 72%, respectively. The mean knowledge score was 5.5 (standard deviation 1.7). Fifty percent of the survey respondents had been tested and 52% had been vaccinated. HBV awareness, higher knowledge scores, and vaccination were all associated (p<0.05) with younger age, higher educational level, younger age at immigration, and greater English proficiency.
Discussion
Our study findings confirm the need for Khmer language HBV programs for less acculturated and educated members of the Cambodian community. Such programs should aim to increase HBV testing rates, HBV vaccination rates among individuals who remain susceptible to infection, and levels of knowledge about routes of hepatitis B transmission.
PMCID: PMC3282166  PMID: 21790233
Cambodian Americans; hepatitis B; immigrant health; liver cancer
17.  Hepatitis B and Liver Cancer Beliefs among Korean Immigrants in Western Washington 
Cancer  2005;104(12 Suppl):2955-2958.
Hepatocellular cancer occurs more frequently among Koreans, Vietnamese, and Chinese than other racial/ethnic groups in the U.S. This excess risk can be attributed to high rates of chronic hepatitis B viral (HBV) infection and low rates of HBV vaccination among Asian immigrants. However, there is little available information regarding the hepatitis B knowledge, beliefs, and practices among Koreans, the fifth-largest Asian population in the U.S. This brief report summarizes results from 30 qualitative interviews and two focus groups investigating hepatitis and liver cancer prevention, behavior, and beliefs among first-generation Korean immigrant adults ages 18–64 years residing in the Seattle–Tacoma metropolitan area of Washington State. The report concludes with suggestions for future investigations to address the high rates of chronic HBV infection and hepatocellular cancer in this vulnerable population.
doi:10.1002/cncr.21518
PMCID: PMC1810969  PMID: 16276533
AANCART; cancer; Korean Americans; hepatitis B; vaccination; hepatocellular CA; qualitative research; serologic tests
18.  EVALUATION OF A CERVICAL CANCER LAY HEALTH WORKER INTERVENTION FOR VIETNAMESE AMERICAN WOMEN 
American journal of public health  2010;100(10):1924-1929.
Objectives
We conducted a trial to evaluate the effectiveness of a cervical cancer control intervention for Vietnamese women.
Methods
The study group included 234 women who had not received a Pap test in the last three years. Experimental group participants received a lay health worker home visit. Our trial end-point was Pap smear receipt within six months of randomization. Pap testing completion was ascertained through women's self-reports and medical record reviews. We examined intervention effects among women who had ever received a Pap smear (prior to randomization) and women who had never received a Pap smear.
Results
Three-quarters of the experimental group women completed a home visit. Ever screened experimental group women were significantly more likely to report Pap testing (p<0.02) and have records verified Pap testing (p<0.04) than ever screened control group women. There were no significant differences between the trial arms for women who had never been screened.
Conclusions
Our findings indicate that lay health worker interventions for Vietnamese women are feasible to implement and can positively impact levels of Pap testing use among ever screened women (but not never screened women).
doi:10.2105/AJPH.2009.190348
PMCID: PMC2936992  PMID: 20724673
Asian Americans; Cancer; Screening
19.  Cost Effectiveness of a Program to Promote Screening for Cervical Cancer in the Vietnamese-American Population 
Objectives
To conduct a randomized controlled trial to evaluate the cost effectiveness of a lay health worker-administered cervical cancer screening intervention for Vietnamese-American women.
Methods
The study group included 234 Vietnamese women in the Seattle, Washington area who had not received a Pap test in the last three years. Experimental group participants received a lay health worker home visit. The travel distance and time spent at each visit were recorded. Our trial end-point was Pap smear receipt within six months of randomization. Pap testing completion was ascertained through medical record reviews.
Results
For all Vietnamese women, regardless of their prior history of screening, the cost per intervention was $104.0 (95% CI: $89.6–$118.4). The change in quality-adjusted life days per intervention was 1.26 (95% CI: −5.43–7.96), resulting in an incremental cost-effectiveness ratio (ICER) of $30,015 per quality-adjusted life year. The probability that the ICER exceeds $100,000 is 9.1%.
Conclusions
The degree of cost effectiveness of such interventions is sensitive to the assumed duration of behavioral change and the participants’ prior history of screening.
PMCID: PMC3024547  PMID: 21039042
Cervical cancer; screening; cost effectiveness; lay health worker
20.  Feasibility and Acceptability of an English-as-a-Second Language Curriculum on Hepatitis B for Older Chinese American Immigrants 
Asian immigrants to the U.S. have an increased prevalence of hepatitis B virus (HBV) infection compared to native born individuals; an estimated 10 percent of Chinese immigrants are infected with HBV. Using qualitative data from focus groups, we developed an English-as-a-Second Language (ESL) curriculum that aimed to improve knowledge about key hepatitis B facts. The curriculum was pilot-tested among 56 students aged 50 and older from intermediate-level ESL classes at a community-based organization that serves Chinese immigrants. Post-curriculum data showed increases in knowledge that hepatitis B can cause liver cancer (73% at pre-test vs. 91% at post-test; p value = 0.01) and that individuals can be infected with hepatitis B for life (34% vs. 81%; p value <0.0001). These findings suggest that an ESL curriculum can successfully improve knowledge about the severity of hepatitis B and its routes of transmission among older Chinese American adults.
PMCID: PMC3007092  PMID: 21188280
HEPATITIS B; ESL CURRICULA; HEALTH LITERACY; CHINESE AMERICANS; HEPATITIS A
21.  PAP SMEAR RECEIPT AMONG VIETNAMESE IMMIGRANTS: THE IMPORTANCE OF HEALTH CARE FACTORS 
Ethnicity & health  2009;14(6):575-589.
Objective
Recent US data indicate that women of Vietnamese descent have higher cervical cancer incidence rates than women of any other race/ethnicity, and lower levels of Pap testing than white, black, and Latina women. Our objective was to provide information about Pap testing barriers and facilitators that could be used to develop cervical cancer control intervention programs for Vietnamese American women.
Design
We conducted a cross-sectional, community-based survey of Vietnamese immigrants. Our study was conducted in metropolitan Seattle, Washington. A total of 1,532 Vietnamese American women participated in the study. Demographic, health care, and knowledge/belief items associated with previous cervical cancer screening participation (ever screened and screened according to interval screening guidelines) were examined.
Results
Eighty-one percent of the respondents had been screened for cervical cancer in the previous three years. Recent Pap testing was strongly associated (p<0.001) with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. Women whose regular doctor was a Vietnamese man were no more likely to have received a recent Pap smear than those with no regular doctor.
Conclusion
Our findings indicate that cervical cancer screening disparities between Vietnamese and other racial/ethnic groups are decreasing. Efforts to further increase Pap smear receipt in Vietnamese American communities should enable women without a source of health care to find a regular provider. Additionally, intervention programs should improve patient-provider communication by encouraging health care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing, as well as by empowering Vietnamese women to specifically ask their physicians for Pap testing.
doi:10.1080/13557850903111589
PMCID: PMC2788032  PMID: 19626504
Cervical cancer; Immigrants; Pap testing; Vietnamese
22.  HPV Vaccine Knowledge and Beliefs Among Cambodian American Parents and Community Leaders 
Background
The cervical cancer incidence rate among Cambodian American women is 15.0 per 100,000, compared to 7.7 per 100,000 among non-Latina white women. HPV infection has been identified as a universal risk factor for cervical cancer. The HPV vaccine was recently approved in the United States for females aged 9–26 years. There is little information about HPV vaccination knowledge and beliefs in Southeast Asian communities.
Methods
We conducted 13 key informant interviews with Cambodian community leaders, as well as four focus groups with Cambodian parents (37 participants). Two of the focus groups included fathers and two of the focus groups included mothers. Interview and focus group questions addressed HPV vaccine barriers and facilitators.
Results
Participants had limited knowledge about HPV infection and the HPV vaccine. Barriers to HPV vaccination included a lack of information about the vaccine, as well as concerns about vaccine safety, effectiveness, and financial costs. The most important facilitators were a health care provider recommendation for vaccination and believing in the importance of disease prevention.
Discussion
Future cervical cancer control educational programs for Cambodians should promote use of the HPV vaccine for age-eligible individuals. Health care providers who serve Cambodian communities should be encouraged to recommend HPV vaccination.
PMCID: PMC2858686  PMID: 19640169
Cervical cancer; Cambodian Americans; HPV vaccine
23.  Chumnguh Thleum: Understanding Liver Illness and Hepatitis B Among Cambodian Immigrants 
Journal of Community Health  2010;36(1):27-34.
Cambodian immigrants are over 25 times more likely to have evidence of chronic hepatitis B infection than the general US population. Carriers of HBV are over 100 times more likely to develop liver cancer than non-carriers. Liver cancer incidence is the second leading cancer for Cambodian men and the sixth for Cambodian women. Despite this, this underserved population has received very little attention from health disparities researchers. Culturally and linguistically appropriate interventions are necessary to increase hepatitis B knowledge, serologic testing, and vaccination among Cambodian Americans. Eight group interviews were held with Cambodian American men (48) and women (49). Focus group discussion revealed unanticipated information about sociocultural influences on participants’ understanding about hepatitis B transmission, disease course, and prevention and treatment informed by humoral theories underlying Khmer medicine, by biomedicine, and by migration experiences. Our findings reveal the value of qualitative exploration to providing cultural context to biomedical information—a formula for effective health promotion and practice.
doi:10.1007/s10900-010-9277-y
PMCID: PMC3020312  PMID: 20496000
Cambodian immigrants; Hepatitis B; Qualitative research
24.  Evaluation of a Hepatitis B Educational ESL Curriculum for Chinese Immigrants 
Objectives
According to recent census data, 1,216,600 Canadians are of Chinese descent, and over 80% of Chinese Canadians are foreign born. Approximately 10% of Chinese immigrants are chronic carriers of hepatitis B, compared with less than 0.5% of the general population. English as a second language (ESL) classes provide ready access for individuals with limited English proficiency who are not reached by English language health education materials and media campaigns. We conducted a group-randomized trial to evaluate the effectiveness of a hepatitis B ESL educational curriculum for Chinese immigrants.
Methods
Five community-based organizations that provide ESL education in the greater Vancouver area participated in the study. Forty-one ESL classes (which included 325 Chinese students) were randomly assigned to experimental or control status. A follow-up survey, conducted six months after randomization, assessed knowledge about hepatitis B. Generalized estimating equations were used to analyze the data.
Results
Follow-up surveys were completed by 298 (92%) of the students. At follow-up, experimental group students were significantly (p<0.05) more likely than control group students to know that immigrants have higher hepatitis B infection rates than people who were born in Canada; hepatitis B can be spread during childbirth, during sexual intercourse and by sharing razors; hepatitis B is not spread by sharing eating utensils; and hepatitis B infection can cause cirrhosis and liver cancer.
Conclusion
Our findings indicate that ESL curricula can have a positive impact on health knowledge among Chinese immigrants with limited English. Future research should evaluate the effectiveness of ESL curricula for other immigrant groups, as well as other health topics.
PMCID: PMC2836807  PMID: 20209742
Chinese; health education; hepatitis B
25.  Opinions from ESL Instructors and Students about Curricula on Hepatitis B for Use in Immigrant Communities 
Background
Chinese immigrants in Canada have a disproportionately high risk for hepatitis B compared with non-Hispanic whites. Hepatitis B is the leading cause of hepatocellular carcinoma among Asian immigrants to North America. English as a Second Language (ESL) classes are an effective way of reaching newly immigrated individuals and are a potential channel for delivering health messages.
Methods
Using data from six focus groups among ESL instructors and students, we characterized perceptions about activities that are successfully used in ESL classrooms and strategies for delivering hepatitis B information.
Results
Instructors and students generally reported that activities which focused on speaking and listening skills and that addressed content relevant to students' daily lives were successful in the classroom. Instructors generally avoided material that was irrelevant or too difficult to understand. Focus group participants offered strategies for delivering hepatitis B information in ESL classrooms; these strategies included addressing symptoms and prevention, and not singling out a specific population subgroup in order to avoid stigmatization.
Conclusions
These findings might assist efforts to develop ESL curricula that target immigrant populations.
doi:10.1080/08858190802039151
PMCID: PMC2845299  PMID: 18709587
Hepatitis B; ESL; Chinese Canadians; curricula; focus groups

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