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1.  Applying Systems Engineering to Implement an Evidence-based Intervention at a Community Health Center 
Journal of health care for the poor and underserved  2012;23(4):10.1353/hpu.2012.0190.
Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.
PMCID: PMC3856720  PMID: 23698657
Systems engineering; workflow; implementation; evidence-based interventions
2.  Barriers and Facilitators to Colorectal Cancer Screening in Vietnamese Americans: A Qualitative Analysis 
Vietnamese Americans are the fourth largest Asian ethnic group in the United States. Colorectal cancer (CRC) ranks as one of the most common cancers in Vietnamese Americans. However, CRC screening rates remain low among Vietnamese Americans, with 40% of women and 60% of men reporting never having a sigmoidoscopy, colonoscopy, or Fecal Occult Blood Test.
We partnered with a Federally Qualified Health Center (FQHC) in Seattle, Washington, to conduct focus groups as part of a process evaluation. Using interpreters, we recruited and conducted three focus groups comprised of 6 women screened for CRC, 6 women not screened for CRC, and 7 men screened for CRC, which made up a total of 19 FQHC patients of Vietnamese descent between 50 and 79 years old. Three team members analyzed transcripts using open coding and axial coding. Major themes were categorized into barriers and facilitators to CRC screening.
Barriers include lack of health problems, having comorbidities, challenges with medical terminology, and concerns with the colonoscopy. Participants singled out the risk of perforation as a fear they have towards colonoscopy procedures. Facilitators include knowledge about CRC and CRC screening, access to sources of information and social networks, and physician recommendation.
Our focus groups elicited information that adds to the literature and has not been previously captured through published surveys. Findings from this study can be used to develop more culturally appropriate CRC screening interventions and improve upon existing CRC screening programs for the Vietnamese American population.
PMCID: PMC4334440  PMID: 24756545
3.  Development of Intervention Materials for Individuals With Limited English Proficiency 
Medical care  2008;46(9 0 1):10.1097/MLR.0b013e31817f0cde.
According to recent US census data, 52 million people reported speaking a language other than English at home, and almost 45% of this population reported limited English proficiency (LEP). Colorectal cancer (CRC) ranks among the top 3 most common cancers for several Asian ethnic groups, yet screening remains underutilized by Asian Americans.
This article describes the development of culturally and linguistically appropriate intervention materials for individuals with LEP. We discuss lessons learned from this research and implications for the translation of research into practice.
The Health Behavior Framework served as the conceptual model for this study, and qualitative findings guided the development of our intervention materials (a video and pamphlet). To recommend Western preventive behaviors, the research team bridged the gap between Western and Chinese values and beliefs by devoting particular attention to: (1) the target population's sociocul-tural values and health beliefs; and (2) unique linguistic features of the Chinese language.
Key lessons learned from this study include the importance of: (1) a conceptual framework to guide intervention development; (2) incorporating sociocultural values and health beliefs into the intervention; (3) addressing and capitalizing on complex linguistics issues; (4) using qualitative methodology in cross-cultural research; and (5) contributions from a multicultural and multilingual research team. Other lessons relate to the translation of research findings into practice. We surmise that lessons learned from this study may be pertinent to the promotion of CRC screening among other patient groups with LEP and applicable to additional cancer screening tests.
PMCID: PMC3860055  PMID: 18725834
limited English proficiency; colorectal cancer screening; culturally and linguistically appropriate materials
4.  Clinical Trials: Understanding and Perceptions of Female Chinese-American Cancer Patients 
Cancer  2005;104(12 Suppl):2999-3005.
Under-representation of minority and female participants prompted the U.S. legislature to mandate the inclusion of women and minorities in federally funded research. Recruitment of minorities to participate in clinical trials continues to be challenging. Although Asian Americans constitute one of the major minority groups in the U.S., published literature contains sparse data concerning the participation of Asian Americans in cancer clinical trials. The authors completed qualitative, semistructured interviews with 34 participants: Chinese-American female cancer patients ages 20–85 years or their family members. Interviews were conducted in Cantonese, Mandarin, or English and were audiotaped. Chinese interviews were translated into English, and all interviews were transcribed subsequently into English. A team of five coders individually reviewed then met to discuss the English transcripts. The authors used the constant comparative technique throughout the entire coding process as part of the analysis. Among participants, 62% lacked any knowledge of clinical trials, and many expressed negative attitudes toward clinical trials. Barriers to participation included inadequate resources, language issues, and a lack of financial and social support. Facilitating factors included recommendations by a trusted oncologist or another trusted individual and information in the appropriate language. It is noteworthy that family members played an important role in the cancer experience of these participants. To promote participation, there is a need to increase knowledge of clinical trials among Chinese cancer patients. It also is necessary to examine the applicability of current patient-physician communication and interaction models. In addition, decision-making based on Asian philosophies within the context of Euro-American bio-ethics requires further study.
PMCID: PMC1810650  PMID: 16247796
traditional Chinese medicine; patient participation; Asian Americans; clinical trials
5.  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
7.  Tobacco Use by Chinese-American Men: An Exploratory Study of the Factors Associated with Cigarette Use and Smoking Cessation 
There is little information on cigarette use and smoking cessation in Asian Pacific Islanders. This study explored factors associated with tobacco use in the largest Asian American ethnic group – Chinese American men.
Chinese American men age 17 or older, recruited by convenience sampling, were interviewed by a male trilingual and bicultural interviewer. Open-ended, semi-structured interviews were coded using PRECEDE framework under two categories: cigarette use and smoking cessation.
Smoking, favorably perceived and valued, plays an important role in Chinese society. Lack of appropriate information and some beliefs pose challenges to effective tobacco control. Participants expressed willingness to adhere to no smoking rules and regulation. Attitudes and perceptions in the U.S. towards cigarette smoking, which differ from those in China, reinforce attitudes more favorable to smoking cessation.
Themes elicited challenge mainstream smoking cessation approaches for Chinese American men. Further exploration of these results are needed to develop effective tobacco control in this and possibly other Asian American populations.
PMCID: PMC1618775  PMID: 11567512
8.  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
9.  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
10.  Continuity of Care and Colorectal Cancer Screening by Vietnamese American Patients 
Colorectal cancer (CRC) screening rates among Asian Americans are 30–50% lower than among Whites. Using practice management and electronic medical records data from a community health center, we examined the association of CRC screening with continuity of care and comorbidity. These variables have not previously been studied in Asian American and limited-English proficient populations.
After obtaining IRB approval, we extracted data in 2009 on age-eligible Vietnamese patients who had one or more clinic visits in the prior 24 months. Our analysis examined associations between CRC screening (per current US Preventive Services Task Force guidelines) and clinic site, demographics, insurance status, continuity of care, comorbidities, and provider characteristics.
We identified a total of 1,016 eligible patients (604 at Clinic 1 and 412 at Clinic 2). Adherence to CRC screening was lower for patients who were male; lacked insurance; had only one medical visit in the past 12 months; and had no assigned primary care provider. Our multivariable models showed higher screening rates among patients who were female; had public health insurance; and had more than one medical visit in the past 12 months, regardless of “high” or “low” continuity of care.
We found no association between higher continuity of care and CRC screening. Additional primary care systems research is needed to guide cancer screening interventions for limited-English proficient patients.
PMCID: PMC3856709  PMID: 21133636
Colorectal cancer; screening; Vietnamese Americans
11.  A Cross-border Comparison of Hepatitis B Testing Among Chinese Residing in Canada and the United States 
The Western Pacific region has the highest level of endemic hepatitis B virus (HBV) infection in the world, with the Chinese representing nearly one-third of infected persons globally. HBV carriers are potentially infectious to others and have an increased risk of chronic active hepatitis, cirrhosis, and hepatocellular carcinoma. Studies from the U.S. and Canada demonstrate that immigrants, particularly from Asia, are disproportionately affected by liver cancer.
Given the different health care systems in Seattle and Vancouver, two geographically proximate cities, we examined HBV testing levels and factors associated with testing among Chinese residents of these cities.
We surveyed Chinese living in areas of Seattle and Vancouver with relatively high proportions of Chinese residents. In-person interviews were conducted in Cantonese, Mandarin, or English. Our bivariate analyses consisted of the chi-square test, with Fisher’s Exact test as necessary. We then performed unconditional logistic regression, first examining only the city effect as the sole explanatory variable of the model, then assessing the adjusted city effect in a final main-effects model that was constructed through backward selection to select statistically significant variables at alpha = 0.05.
Survey cooperation rates for Seattle and Vancouver were 58% and 59%, respectively. In Seattle, 48% reported HBV testing, whereas in Vancouver, 55% reported testing. HBV testing in Seattle was lower than in Vancouver, with a crude odds ratio of 0.73 (95% CI = 0.56, 0.94). However after adjusting for demographic, health care access, knowledge, and social support variables, we found no significant differences in HBV testing between the two cities. In our logistic regression model, the odds of HBV testing were greatest when the doctor recommended the test, followed by when the employer asked for the test.
Findings from this study support the need for additional research to examine the effectiveness of clinic-based and workplace interventions to promote HBV testing among immigrants to North America.
PMCID: PMC3856895  PMID: 19640196
Asian and Pacific Islanders; chronic hepatitis B; liver cancer; prevention clinic
12.  Preparedness for Cardiac Emergencies among Cambodians with Limited English Proficiency 
Journal of Community Health  2012;37(1):176-180.
In the United Sates, populations with limited English proficiency (LEP) report barriers to seeking emergency care and experience significant health disparities, including being less likely to survive cardiac arrest than whites. Rapid utilization of 9-1-1 to access emergency services and early bystander CPR (cardiopulmonary resuscitation) is crucial for successful resuscitation of out-of-hospital cardiac arrest patients. Little is understood about Asian LEP communities’ preparedness for emergencies. In this exploratory survey, we sought to assess intentions to call 9-1-1 in an emergency and knowledge of CPR in the Cambodian LEP community. We conducted an in-person interview with 667 Cambodian adults to assess their intentions to call 9-1-1 and their awareness of and training in bystander CPR. While the majority of participants stated that they would call 9-1-1 in an emergency, almost one-third of the sample would call a friend or family member. Awareness of CPR was very high but training in CPR was lower, especially for women. A higher level of English proficiency and greater proportion of time in the US was a strong predictor of CPR training and intention to call 9-1-1 in an emergency. This suggests that greater efforts need to be made to reach the most linguistically-isolated communities (those with little or no English) with emergency information in Khmer.
PMCID: PMC3202051  PMID: 21748487
CPR; immigrants; limited English proficiency; language; emergency preparedness
13.  Systems Antecedents for Dissemination and Implementation: A Review and Analysis of Measures 
There is a growing emphasis on the role of organizations as settings for dissemination and implementation. Only recently has the field begun to consider features of organizations that impact on dissemination and implementation of evidence-based interventions. This manuscript identifies and evaluates available measures for 5 key organizational-level constructs: (1) leadership; (2) vision; (3) managerial relations; (4) climate; and (5) absorptive capacity. Overall the picture was the same across the five constructs—no measure was used in more than one study, many studies did not report the psychometric properties of the measures, some assessments were based on a single response per unit, and the level of the instrument and analysis did not always match. We must seriously consider the development and evaluation of a robust set of measures that will serve as the basis of building the field, allow for comparisons across organizational types and intervention topics, and allow a robust area of dissemination and implementation research to develop.
PMCID: PMC3272116  PMID: 21724933
14.  Current Realities of Delivering Mammography Services in the Community: Do Challenges with Staffing and Scheduling Exist? 
Radiology  2005;235(2):391-395.
To evaluate the current (2001–2002) capacity of community-based mammography facilities to deliver screening and diagnostic services in the United States.
Institutional review board approvals and patient consent were obtained. A mailed survey was sent to 53 eligible mammography facilities in three states (Washington, New Hampshire, and Colorado). Survey questions assessed equipment and staffing availability, as well as appointment waiting times for screening and diagnostic mammography services. Criterion-related content and construct validity were obtained first by means of a national advisory committee of academic, scientific, and clinical colleagues in mammography that reviewed literature on existing surveys and second by pilot testing a series of draft surveys among community mammography facilities not inclusive of the study facilities. The final survey results were independently double entered into a relational database with programmed data checks. The data were sent encrypted by means of file transfer protocol to a central analytical center at Group Health Cooperative. A two-sided P value with α = .05 was considered to show statistical significance in all analyses.
Forty-five of 53 eligible mammography facilities (85%) returned the survey. Shortages of radiologists relative to the mammographic volume were found in 44% of mammography facilities overall, with shortages of radiologists higher in not-for-profit versus for-profit facilities (60% vs 28% reported). Shortages of Mammography Quality Standards Act–qualified technologists were reported by 20% of facilities, with 46% reporting some level of difficulty in maintaining qualified technologists. Waiting times for diagnostic mammography ranged from less than 1 week to 4 weeks, with 85% performed within 1 week. Waiting times for screening mammography ranged from less than 1 week to 8 weeks, with 59% performed between 1 week and 4 weeks. Waiting times for both diagnostic and screening services were two to three times higher in high-volume compared with low-volume facilities.
Survey results show shortages of radiologists and certified mammography technologists.
PMCID: PMC3143037  PMID: 15798153
15.  Diffusion of Cardiopulmonary Resuscitation Training to Chinese Immigrants with Limited English Proficiency 
Cardiopulmonary resuscitation (CPR) is an effective intervention for prehospital cardiac arrest. Despite all available training opportunities for CPR, disparities exist in participation in CPR training, CPR knowledge, and receipt of bystander CPR for certain ethnic groups. We conducted five focus groups with Chinese immigrants who self-reported limited English proficiency (LEP). A bilingual facilitator conducted all the sessions. All discussions were taped, recorded, translated, and transcribed. Transcripts were analyzed by content analysis guided by the theory of diffusion. The majority of participants did not know of CPR and did not know where to get trained. Complexity of CPR procedure, advantages of calling 9-1-1, lack of confidence, and possible liability discourage LEP individuals to learn CPR. LEP individuals welcome simplified Hands-Only CPR and are willing to perform CPR with instruction from 9-1-1 operators. Expanding the current training to include Hands-Only CPR and dispatcher-assisted CPR may motivate Chinese LEP individuals to get trained for CPR.
PMCID: PMC3200204  PMID: 22046544
16.  Evaluation of a Hepatitis B Lay Health Worker Intervention for Chinese Americans and Canadians 
Journal of community health  2009;34(3):165-172.
Hepatitis B testing is recommended for immigrants from countries where hepatitis B infection is endemic. However, only about one-half of Chinese in North America have received hepatitis B testing. We conducted a randomized controlled trial to evaluate the effectiveness of a hepatitis B lay health worker intervention for Chinese Americans/Canadians. Four hundred and sixty individuals who had never been tested for hepatitis B were identified from community-based surveys of Chinese conducted in Seattle, Washington, and Vancouver, British Columbia. These individuals were randomly assigned to receive a hepatitis B lay health worker intervention or a direct mailing of physical activity educational materials. Follow-up surveys were completed six months after randomization. Self-reported hepatitis B testing was verified through medical records review. A total of 319 individuals responded to the follow-up survey (69% response rate). Medical records data verified hepatitis B testing since randomization for nine (6%) of the 142 experimental group participants and three (2%) of the 177 control group participants (p=0.04). At follow-up, a higher proportion of individuals in the experimental arm than individuals in the control arm knew that hepatitis B can be spread by razors (p<0.001) and during sexual intercourse (p=0.07). Our findings suggest that lay health worker interventions can impact hepatitis B-related knowledge. However, our hepatitis B lay health worker intervention had a very limited impact on hepatitis B testing completion. Future research should evaluate other intervention approaches to improving hepatitis B testing rates among Chinese in North America.
PMCID: PMC2735565  PMID: 19127416
Chinese Americans/Canadians; Hepatitis B; Lay health worker
17.  Hepatitis B Testing and Vaccination in Immigrants Attending English as a Second Language Classes in British Columbia, Canada 
Hepatitis B virus (HBV) is a growing health issue in Canada, especially given that population growth is now largely the result of immigration. Immigrants from countries with high HBV prevalence and low levels of HBV vaccination have an excess risk of liver disease and there is a need for increased diligence in HBV blood testing and possibly vaccination among these populations.
This study describes the sociodemographic characteristics associated with a history of HBV testing and HBV vaccination in immigrants from several countries with high HBV prevalence who are attending English classes.
759 adult immigrants attending English as a Second Language classes completed a self-administered questionnaire asking about sociodemographic characteristics and history of HBV testing and HBV vaccination. Descriptive statistics and adjusted ORs were calculated to explore these associations.
71% reported prior HBV testing, 8% reported vaccination without testing, and 21% reported neither testing nor vaccination. Age, education and country of birth all showed significant effects for both testing and vaccination.
Health care practitioners need to be cognizant of HBV testing, and possibly vaccination, in some of their patients, including immigrants from countries with endemic HBV infection. Infected persons need to be identified by blood testing in order receive necessary care to prevent or delay the onset of liver disease as well as to adopt appropriate behaviours to reduce the risk of transmission to others. Close contacts of infected persons also require HBV testing and subsequent vaccination (if not infected) or medical management (if infected).
PMCID: PMC2862471  PMID: 20192572
Hepatitis B; diagnosis; primary prevention; immigrants
Chinese immigrants to North America experience cancer-related health disparities and underutilize preventive care. Little is known about Chinese immigrants' sources of health information.
A population-based survey of Chinese immigrants was conducted in Vancouver, British Columbia and Seattle, Washington.
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.
Health educators should consider available media outlets as well as the characteristics of a target community when planning intervention programs for Chinese immigrants.
PMCID: PMC2836713  PMID: 19838895
19.  Perceptions of Cardiovascular Health in Underserved Communities 
Preventing Chronic Disease  2010;7(2):A30.
Cardiovascular disease is the leading cause of deaths and illnesses in US adults, and the prevalence is disproportionately high in underserved populations. In this study, we assessed respondents' understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with the longer-term goal of developing appropriate interventions.
Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site's researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results and identified common themes and differences.
Themes clustered in 3 areas (barriers to cardiovascular health, constraints related to multiple roles, and suggestions for effective communications and programs). Barriers spanned individual, social and cultural, and environmental levels; women in particular cited multiple roles (eg, competing demands, lack of self-care). Programmatic suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups (eg, AARP), health care providers (but with noticeable differences of opinion), family and friends, and printed materials.
Interventions to decrease barriers to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions.
PMCID: PMC2831784  PMID: 20158958
20.  Development Of An ESL Curriculum To Educate Chinese Immigrants About Hepatitis B 
Journal of community health  2008;33(4):217-224.
Chinese immigrants to North America have substantially higher rates of chronic hepatitis B infection than the general population. One area for strategic development in the field of health education is the design and evaluation of English-as-a-Second language (ESL) curricula. The theoretical perspective of the Health Behavior Framework, results from a community-based survey of Chinese Canadian immigrants with limited English proficiency, and findings from focus groups of ESL instructors as well as Chinese ESL students were used to develop a hepatitis B ESL educational module. This research was conducted in Vancouver, British Columbia. Survey data showed that less than three-fifths of the respondents had been tested for hepatitis B, and documented some important hepatitis B knowledge deficits. Further, only about one-quarter had ever received a physician recommendation for hepatitis B serologic testing. The ESL curriculum aims to both promote hepatitis B testing and improve knowledge, and includes seven different ESL exercises: Warm-up, vocabulary cards, information-gap, video, jigsaw, guided discussion, and problem/advice cards. Our quantitative and qualitative methods for curriculum development could be replicated for other health education topics and in other limited English speaking populations.
PMCID: PMC2691859  PMID: 18373185
Chinese immigrants; English as a second language (ESL); Health education; Hepatitis B
21.  AANCART Best Practices: Cancer Awareness Activities for Seattle’s Cambodian Community 
Cancer  2005;104(12 Suppl):2916-2919.
Census data indicate that Cambodian Americans are economically disadvantaged and linguistically isolated. In addition, cancer registry data show that Southeast Asians experience several cancer-related health disparities (e.g., markedly elevated risks of cervical and liver cancer). The Seattle regional Asian American Network for Cancer, Awareness, Research, and Training (AANCART) site has implemented a community-based cancer awareness program for Cambodian immigrants in collaboration with a Cambodian community coalition. Our cancer awareness program has the following goals: to assist individuals and organizations in advocating for a healthy community, to provide information within a cultural context, and to deliver information in ways that are useful and meaningful to the community. The program was guided by a community assessment that included the use of published data as well as information from qualitative interviews, focus groups, and quantitative surveys. Examples of community awareness activities include group presentations at community-based organizations (e.g., during English as a second language classes), health fair participation (including at nontraditional venues such as a farmers’ market serving Cambodians), and educational displays in neighborhood locations (e.g., at Cambodian video stores). In addition, the Seattle AANCART site has both inventoried and developed culturally appropriate Khmer language cancer education materials and disseminated materials through the ETHNOMED website. Our approach recognizes that limited English language proficiency may preclude many Cambodians from understanding publicly disseminated information, and Cambodian immigrants are often isolated and tend to stay close to their own neighborhoods.
PMCID: PMC1811046  PMID: 16276540
AANCART; cancer; Asian; Cambodian; qualitative research
22.  Cancer preventive screening: A cross-border comparison of United States and Canadian Chinese women 
Preventive medicine  2005;41(1):36-46.
To compare screening mammography and Pap testing among Chinese women in Seattle, Washington to Vancouver, and British Columbia.
Using community-based sampling methods, trilingual female interviewers surveyed Chinese women in Seattle and Vancouver. Multiple preventive health behaviors and health care access variables were assessed. Mammography analysis included 409 women aged 50–74 years. Pap testing analysis included 973 women aged 20–69 years. Main outcome measures were ever use and use in the last 2 years of screening mammography and Pap testing.
Chinese women in Vancouver were younger, more educated and fluent in English. Unadjusted rates of mammography and Pap testing were similar between the two cities. Provider type was consistently associated with screening in both cities; female providers had the highest rates and Chinese male providers the lowest. Adjusted logistic regression analysis demonstrated similar mammography use in the two cities. However, for Pap testing, women in Seattle had higher odds of screening compared to Vancouver.
Despite universal health care coverage and baseline characteristics typically associated with greater utilization of preventive screening services, Chinese women in Vancouver did not have higher rates of screening mammography and Pap testing compared to Chinese women in Seattle.
PMCID: PMC1704080  PMID: 15916991
Chinese; PAP testing; Mammography; Preventive screening; Universal health coverage
23.  Cervical Cancer Screening Among Chinese Immigrants in Seattle, Washington 
Journal of immigrant health  2001;3(1):15-21.
Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants.
We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years.
The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration.
Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated.
PMCID: PMC1618776  PMID: 16228798
Chinese immigrants; cervical cancer; Pap testing
24.  Cancer Control Research among Cambodian Americans in Washington 
We summarized previous and ongoing cancer control research among Cambodian immigrants in Washington.
A literature review of articles and published abstracts was conducted.
Cambodian Americans have a limited understanding of Western biomedical concepts, and low levels of cancer screening participation.
Culturally appropriate cancer control interventions for Cambodian Americans should be developed, implemented, and evaluated.
PMCID: PMC1618774  PMID: 11567509
25.  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

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