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1.  Acculturation and dietary change among Chinese immigrant women in the United States 
US Chinese immigrants undergo a transition to increased chronic disease risk commonly attributed to acculturative and dietary changes. Longitudinal data to confirm this are lacking.
We examined acculturation and diet over time in 312 Chinese immigrant women in Philadelphia, recruited October 2005 to April 2008 and followed with interviews and dietary recalls until April 2010. Associations were modeled using generalized estimating equations to account for repeated measures over time.
Increasing length of US residence was associated with a small (~1%/year) but significant increase in acculturation score (p<0.0001), which in turn was significantly associated with increased energy density of the diet, percent of energy from fat, and sugar intake, and lower dietary moderation score.
These findings provide longitudinal evidence that acculturation increases with length of US residence and is accompanied by dietary changes. However, the changes were small enough that their health impact is unclear. Factors besides acculturation that affect immigrant health and that affect the acculturation trajectory itself warrant investigation.
PMCID: PMC4370775  PMID: 25281323
Acculturation; Chinese; diet; immigrants; longitudinal
2.  Stressful life events are associated with insulin resistance among Chinese immigrant women in the United States 
Preventive medicine reports  2015;2:563-567.
Chinese immigrants experience increased chronic disease risk following migration to the US. Although the impact of lifestyle changes (e.g., diet) on disease risk has been extensively studied, associations of psychosocial stress and disease risk have attracted less attention. Thus, the objective of the present study was to examine associations between stress and insulin resistance in foreign-born Chinese American women.
From October, 2005 to April, 2008, 423 women recruited from southeastern Pennsylvania completed questionnaires reporting stressful life events. Blood samples were analyzed for fasting insulin and fasting glucose levels, which were used to estimate insulin resistance according to the homeostasis model assessment (HOMAIR).
In logistic regression analyses, a greater number of negative life events was associated with insulin resistance (OR=1.17, 95% CI=1.02–1.34), controlling for age, level of acculturation, marital status, body mass index, and waist circumference. Similarly, greater negative life event impact ratings were also associated with insulin resistance (OR=1.08, 95% CI=1.01–1.16) controlling for relevant covariates.
This is one of the first studies to examine associations between psychosocial stress and insulin resistance in Chinese immigrant women. These findings contribute to a growing body of literature on stress and diabetes risk in an immigrant population.
PMCID: PMC4555990  PMID: 26346575
Asian; immigrant; stress; negative life events; insulin resistance
3.  Increasing Asian American participation in clinical trials by addressing community concerns 
Clinical trials (London, England)  2014;11(3):328-335.
Asians Americans are underrepresented in clinical trials, but little is known about the factors that contribute to clinical trial participation in this population.
The purpose of this study was to identify knowledge, barriers, facilitators and cultural influences on participating in clinical trials among three Asian American ethnic groups. Concurrently, we sought to identify mechanisms and messages to facilitate dissemination of information and to identify strategies to promote clinical trial participation in this population.
Eight focus groups were conducted (n=103) with Chinese (4 groups), Korean (2 groups), and Vietnamese (2 groups) Americans. Each group was conducted with a moderator and a translator using a standardized guide.
Participants discuss the benefits of contributing to science, future generations and their families by being in clinical trials. Some participants think clinical trials would give hope to those with terminal illnesses. A doctor's recommendation, being sick and needing more options for treatment are motivators for Asian Americans. Having some guarantee of treatment effectiveness and lack of side effects facilitates participation. Cultural or religious beliefs are not believed to prevent clinical trial participation.
This qualitative, two-site study included 3 Asian American ethnic groups and is not meant to establish prevalence of beliefs.
Asian Americans need more information about clinical trials and their benefits to science and the larger community. Healthcare providers can play pivotal roles in enhancing recruitment of Asian Americans. Basing recruitment goals on percentage representation in most US geographic areas does not provide sufficient numbers to allow for analysis of minorities like Asian American groups. The discovery of important group-specific harms and benefits depends on greater participation of racial/ethnic subgroups.
PMCID: PMC4156927  PMID: 24603005
Clinical trials; Asian Americans; recruitment; cancer
4.  A pilot study of psychosocial functioning and vascular endothelial growth factor in head and neck cancer patients 
Head & neck  2013;36(8):1113-1119.
Psychosocial functioning is associated with vascular endothelial growth factor (VEGF) in various patient populations. This study examined whether psychosocial functioning in patients with head and neck squamous cell carcinoma (HNSCC) is associated with tumor VEGF expression, a protein that stimulates angiogenesis and is associated with poor prognosis.
Forty-two newly diagnosed patients completed assessments of psychosocial functioning (i.e. depressive symptoms, perceived stress, anxiety, social support) prior to surgery. Tumor samples were obtained for VEGF analysis and HPV-typing.
Poorer psychosocial functioning was associated with greater VEGF expression controlling for disease stage (OR=4.55, 95% CI = 1.72, 12.0, p < 0.01). When examined by HPV-status, the association between psychosocial functioning and VEGF remained significant among HPV-negative patients (OR=5.50, 95% CI = 1.68, 17.3, p < 0.01), but not among HPV-positive patients.
These findings inform our understanding of the biobehavioral pathways that may contribute to poor outcomes in non-HPV-associated HNSCCs.
PMCID: PMC4099415  PMID: 23804308
depressive symptoms; perceived stress; anxiety; social support; human papillomavirus
5.  Stressful life events are associated with insulin resistance among Chinese immigrant women in the United States 
Preventive Medicine Reports  2015;2:563-567.
Chinese immigrants experience increased chronic disease risk following migration to the US. Although the impact of lifestyle changes (e.g., diet) on disease risk has been extensively studied, associations of psychosocial stress and disease risk have attracted less attention. Thus, the objective of the present study was to examine associations between stress and insulin resistance in foreign-born Chinese American women.
From October, 2005 to April, 2008, 423 women recruited from southeastern Pennsylvania completed questionnaires reporting stressful life events. Blood samples were analyzed for fasting insulin and fasting glucose levels, which were used to estimate insulin resistance according to the homeostasis model assessment (HOMAIR).
In logistic regression analyses, a greater number of negative life events were associated with insulin resistance (OR = 1.17, 95% CI = 1.02–1.34), controlling for age, level of acculturation, marital status, body mass index, and waist circumference. Similarly, greater negative life event impact ratings were also associated with insulin resistance (OR = 1.08, 95% CI = 1.01–1.16) controlling for relevant covariates.
This is one of the first studies to examine the associations between psychosocial stress and insulin resistance in Chinese immigrant women. These findings contribute to a growing body of literature on stress and diabetes risk in an immigrant population.
•We examined life event stress and insulin resistance in Chinese immigrant women.•Positive life event stress was not associated with insulin resistance.•Greater exposure to negative life events was associated with insulin resistance.•More research is needed on the role of psychosocial factors in immigrant health.
PMCID: PMC4555990  PMID: 26346575
BMI, body mass index; GEQ-A, General Ethnicity Questionnaire—American; HOMAIR, homeostasis model assessment-estimated insulin resistance; OR, odds ratio; CI, confidence interval; Asian; Immigrant; Stress; Negative life events; Insulin resistance
6.  Acculturative stress and inflammation among Chinese immigrant women 
Psychosomatic medicine  2014;76(5):320-326.
Among Chinese immigrant populations, increasing duration of US residence is associated with elevated risk for various chronic diseases. Although lifestyle changes following migration have been extensively studied in immigrant populations, less understood is the psychosocial impact of acculturative stress upon biological markers of health. Thus, the purpose of the present study is to examine associations between acculturative stress and inflammatory markers in a Chinese immigrant population.
Study participants (n=407 foreign-born Chinese American women) completed questionnaires assessing levels of stress, including acculturative stress and positive and negative life events in the past year. Participant height and weight were measured using standard protocols and blood samples were drawn for assessment of circulating serum levels of C-reactive protein (CRP) and soluble tumor necrosis factor receptor 2 (sTNFR2).
Higher levels of acculturative stress were significantly associated with higher levels of CRP (B=0.07, 95% CI=0.01-0.13, p=0.031) and sTNFR2 (B=0.02, 95% CI=0.004-0.03, p=0.012), adjusting for age and body mass index (BMI). The latter association was no longer statistically significant when overall acculturation (i.e., identification with American culture) was included in the model. Life events were not associated with CRP or sTNFR2.
This study shows that acculturative stress is associated with inflammation markers in a Chinese immigrant population. These findings suggest that immigrant health trajectories may be adversely influenced by psychological distress associated with the demands of acculturation. Replication in other immigrant samples is needed to fully establish the biological correlates and clinical consequences of acculturation stress.
PMCID: PMC4164056  PMID: 24846001
migration; acculturation; stress; Asian; inflammation
7.  Caregiving Choice and Emotional Stress among Cancer Caregivers 
Caring for a relative or friend with cancer may be highly demanding and emotionally burdensome. Theory suggests that personal characteristics of a caregiver may contribute directly to a caregiver's emotional health. An underexplored variable is a caregiver's perception of choice in providing care to a relative or friend. Thus, this study sought to characterize perceived choice in providing care among family cancer caregivers and examine its association with emotional stress. This study is a secondary analysis of cross-sectional telephone interviews of 1,247 family caregivers, which included 104 cancer caregivers. The findings indicated that a high majority of cancer caregivers expressed elevated emotional stress. Most caregivers perceived themselves to have had a choice in providing care; however, a perceived lack of choice in providing care was significantly associated with greater emotional stress. Assessing clinical and policy-related strategies for alleviating concerns related to choice may be of value in the cancer context.
PMCID: PMC4148462  PMID: 24221954
Caregiving; stress; cancer; caregiver; choice
8.  An integrative review of U.S. studies: Caregiver psychological health and hospitalization characteristics of older adult care recipients 
This integrative review involved studies conducted in the United States that assessed hospitalizations of older adults receiving family care and the psychological health of the family caregivers. The primary objectives were to: 1) summarize findings between caregiver psychological health and older care recipient hospitalizations, and 2) describe how caregiver psychological health has been measured with regard to older care recipient hospitalizations.
Online databases were searched for papers published in English from 2000 through July, 2013. Search terms included combinations of the following keywords: care recipient; hospitalization(s); caregiver; caregiver burden; caregiver psychosocial health; family caregiver; and patient outcomes. Inclusion criteria included: 1) studies conducted in the U.S.; 2) articles assessing caregiver psychological health (e.g., burden, strain, depressive or anxious symptoms) and older care recipient hospitalizations in the U.S.; 3) samples including caregivers of care recipients with a mean age of 65 years or older.
Few studies in the U.S. have assessed hospitalization characteristics of older care recipients and the psychological health of their family caregivers. All analyses incorporated a measure of depression, while the measurement of other psychological health constructs (e.g., anxious symptoms, perceived burden) was limited or absent. Findings note the potential importance of focusing on readmissions rates in light of caregiver psychological health. Findings also note the benefit of caregiver emotional and instrumental support toward reducing hospitalizations among older adults receiving family care.
PMCID: PMC4138695  PMID: 24496113
Caregiving; aging; distress
9.  Factors Associated with Willingness to Participate in Biospecimen Research Among Chinese Americans 
Biopreservation and Biobanking  2014;12(2):131-138.
A paucity of information exists on the recruitment of Asian Americans for biospecimen research. Although studies show that Chinese Americans are at high risk for hepatitis B virus (HBV) infection, little is known about their willingness to participate in HBV-related biospecimen research and how knowledge, attitudes, and cultural factors impact their willingness to participate. The study was guided by Community-Based Participatory Research principles. Data were derived from an assessment study on HBV-related biospecimen research participation among Chinese Americans in the Philadelphia region. The assessment was conducted with 415 Chinese Americans recruited from eight Chinese community-based organizations. Cultural beliefs, knowledge, and attitudes toward biospecimen research were examined for associations with their willingness to participate in biospecimen banking research. Overall, 192 (46.3%) of 415 participants who completed the assessment indicated they were willing to participate if they were invited to donate blood to be frozen and stored for future HBV biospecimen studies. Cultural variables significant in bivariate analysis included collectivism, knowledge about biospecimen research, and Yin-Yang beliefs. Fatalism and individualism were not associated with participation willingness. In multivariate analysis, age, health care attitudes, and trust were significantly associated with willingness to participate in biospecimen banking research. Asian American communities have little knowledge of biospecimen banking and will benefit from educational campaigns that emphasize collective benefits and attitudes towards and trust in the health care system. Understanding cultural factors is important for improving Chinese Americans' knowledge, awareness, and intentions of participation in biospecimen research. Similar efforts need to be undertaken to develop culturally appropriate educational intervention programs to increase participation in biospecimen research among other Asian American groups.
PMCID: PMC3995351  PMID: 24749880
10.  Information and communication needs of Chinese American breast cancer patients: perspectives on survivorship care planning 
The existing knowledge on the survivorship experiences of Chinese American breast cancer survivors (CABCS) has arisen largely from aggregated data across multiethnic or multicancer studies that have focused on quality of life. Little is known about Chinese American perspectives and preferences for survivorship care.
To examine the experiences of CABCS to better understand their information and communication needs and their preferences for survivorship care plans (SCPs).
16 CABCS, aged 37-72 years, were recruited through community-based organizations in the Northeast United States to participate in one-on-one telephone interviews about their breast cancer survivorship experience. The semistructured interviews were conducted in Mandarin, Cantonese, or English. Two investigators transcribed and translated the audio recordings into English and analyzed the interview transcripts using established methods of qualitative content analysis.
Three main themes were identified through analysis of interview transcripts: the need for evidence-based and culturally and linguistically appropriate health information; the role of language or communication barriers and culture in accessing care and communicating with providers; and preferences for SCP elements and format.
The sample may not be representative of the entire population of CABCS.
The findings provide insight into the information and communication needs and SCP preferences of CABCS. Understanding the cultural nuances that underlie these needs and preferences is critical for improving CABCS's quality of life after treatment for cancer. SCPs that incorporate Chinese-language resources and address the unique cultural needs of this population should be developed and they should include information about diet and nutrition as well as traditional Chinese medicine.
PMCID: PMC4370226  PMID: 25811036
11.  Baseline health perceptions, dysphagia and survival in head and neck cancer 
Cancer  2013;120(6):840-847.
Baseline dysphagia, more common than abnormalities on formal swallowing testing, is believed to predict survival in untreated head and neck cancer patients. We hypothesized that patient-reported dysphagia impacts multiple domains of quality of life and predicts disease recurrence and disease-related death.
The Swal-QOL, a dysphagia-specific measure, and the EuroQOL were administered to 159 patients prior to treatment with curative intent, in this prospective cross-sectional cohort study. Logistic regression evaluated associations among clinical and subjective measures. Multivariable competing risk regression tested the impact of clinical, tumor and patient-reported measures on survival.
Baseline dysphagia, pain and diminished patient-reported health state (PRHS) were more closely associated with weight loss prior to treatment and advanced T-classification, than any other clinical feature. However, only 56% (23/40) of patients reporting dysphagia had >5% weight loss. Dysphagia was associated with pain and/or diminished PRHS, independent of weight loss. Female patients were more likely to report pain and dysphagia, while males reported dysphagia alone. Dysphagia predicted recurrence and disease related death, adjusting for T and N classification, performance status, smoking and weight loss, and accounting for competing risks of death (RFS: HR 3.8 (95%CI 1.7–8.4), p=.001; DOD HR 4.2 (95%CI 1.04–5), p=.004).
Baseline dysphagia affects multiple domains of quality of life and general health perceptions in untreated head and neck cancer patients. A dysphagia measure captures the effort of maintaining nutrition with cancer, identifying patients with or at risk for weight loss, and predisposed to disease recurrence and disease-related death.
PMCID: PMC3951722  PMID: 24352973
12.  Breast cancer experience and survivorship among Asian Americans: A systematic review 
Breast cancer is the most common cancer in Asian American women, and the number of Asian American breast cancer survivors is rapidly increasing. Although Asian Americans are one of the fastest growing and most heterogeneous ethnic groups in the United States, limited data exist in regard to their breast cancer experience and survivorship.
A systematic review of the breast cancer experience literature was conducted and included studies of Asian Americans or their subgroups as a major category of study participants. Of the 125 studies reviewed, 10 qualitative studies, 10 quantitative studies, 5 studies that used a mixed-method approach, and 1 intervention study met the criteria for inclusion.
Qualitatively, Asian Americans reported unmet physical and emotional needs and challenges during survivorship. Quantitative studies consistently found that socioeconomic status, cultural health beliefs, immigration stress, acculturation level, English proficiency, social support, and spirituality influence Asian American breast cancer patients’ health behaviors and health-related quality of life (HRQOL). Studies also revealed significant variation in breast cancer reaction and HRQOL within Asian American subgroups.
Although research on Asian American breast cancer experience and survivorship is sparse, we concluded that Asian Americans experience disrupted HRQOL following breast cancer diagnosis and treatment, interwoven with their cultural and socio-ecological system, and that programs focused on improving cancer survivorship outcomes among this ethnic minority group are limited. Most studies have concentrated on the West coast population, and there is significant underrepresentation of longitudinal and intervention studies. Implications for study design, measurement, and future research areas are also included.
Implications for Cancer Survivors
The results highlight a need to understand ethnic differences and to take into account social, cultural, and linguistic factors in breast cancer survivorship experiences among Asian American subgroups as a means to develop culturally relevant and linguistically appropriate interventions designed to improve HRQOL.
PMCID: PMC3945715  PMID: 24214498
survivorship; breast cancer; Asian Americans; literature review
13.  Culturally Appropriate Education Intervention on Biospecimen Research Participation Among Chinese Americans 
Chinese Americans are at increased risk for hepatitis B virus (HBV) infection. To reduce or eliminate disparities in HBV-related infection rates, participation in scientific investigations of HBV risk and treatment, including biospecimen sampling, is important. However, Asian Americans have low rates of participation in biospecimen research, and little is known about how educational interventions affect knowledge and participation in HBV-related biospecimen research.
Eight Chinese community-based organizations participated in a quasi-experimental, two-group design with education assessments at pre- and post-workshop and a three-month follow-up. Four sites were randomly assigned to receive the intervention (n = 175) and four sites to receive general health education (control; n = 240).
Participant knowledge about biospecimen research increased from pre- to post-education in the intervention but not in the control condition. Of intervention participants, 83.4% (146/175) donated one tube of blood for future HBV biospecimen research, and 50.9% (89/175) donated another tube of blood for HBV testing. In contrast, only 1.1% of participants in the control condition reported donating a blood sample at follow-up assessment.
The intervention program significantly increased knowledge of and participation in HBV biospecimen research among Chinese Americans. Community-based participatory research (CBPR) methods featured active support by community leaders, a culturally specific curriculum, and convenient, immediate access to blood sampling, which resulted in high donation rates.
HBV-related morbidity and mortality is an urgent problem faced by Chinese Americans. CBPR provides a model for engaging communities in early detection, vaccination, and treatment that can reduce this health threat.
PMCID: PMC3955025  PMID: 24609847
biospecimen research; biobanking; Chinese Americans; Hepatitis B; cultural factors
14.  Equol-producing status, isoflavone intake, and breast density in a sample of US Chinese women 
Differences in ability to metabolize daidzein to equol might help explain inconsistent findings regarding isoflavones and breast cancer. We examined equol producing status in relation to breast density, a marker of breast cancer risk, and evaluated whether an association of isoflavone intake with breast density differs by equol producing status in a sample of Chinese immigrant women.
Participants were 224 women, age 36–58 years, enrolled in a study on diet and breast density. All women completed dietary recall interviews, underwent a soy challenge to assess equol producing status, and received a mammogram assessed for breast density using a computer-assisted method.
In our sample, 30% were classified as equol producers. In adjusted linear regression models, equol producers had significantly lower mean dense tissue area (32.8 vs. 37.7 cm2, p=0.03) and lower mean percent breast density (32% vs. 35%, p=0.03) than non-producers. Significant, inverse associations of isoflavone intake with dense area and percent density were apparent, but only in equol producers (interaction p=0.05 for both).
These results support the possibility that equol producing status affects breast density, and that effects of isoflavones on breast density depend on ability to metabolize daidzein to equol.
While these findings warrant confirmation in a larger sample, they offer a possible explanation for the inconsistent findings regarding soy intake and breast density and possibly also breast cancer risk. The findings further suggest the importance of identifying factors that influence equol producing status, and exploring appropriate targeting of interventions.
PMCID: PMC3833816  PMID: 24019393
15.  Psychological reactivity to laboratory stress is associated with hormonal responses in postmenopausal women 
The present study examined associations between psychological reactivity and hormonal responses to a standardized laboratory stressor (the Trier Social Stress Test [TSST]) in postmenopausal women.
Forty postmenopausal women ages 50–74 completed anxiety and mood assessments prior to and following the TSST. Blood samples were drawn across multiple time points for assessment of cortisol, adrenocorticotropic hormone (ACTH), and DHEA.
As expected, significant increases in anxiety and negative affect and decreases in positive affect were observed from pre- to post-TSST; however, the magnitude of change in anxiety and mood varied considerably across individuals. Analyses indicated that greater increases in anxiety and negative affect from pre- to post-TSST were associated with higher levels of cortisol, ACTH, and DHEA, controlling for race, age, body mass index, and smoking status. Changes in positive affect were not associated with cortisol, ACTH, or DHEA.
These findings suggest that enhanced reactivity to stress is associated with higher hormone levels among postmenopausal women, which could have potential implications for health.
PMCID: PMC4046251  PMID: 24595153
Trier Social Stress Test; anxiety; negative affect; cortisol; DHEA; ACTH
16.  Depressive Symptoms and Serum Lipid Levels in Young Adult Women 
Journal of behavioral medicine  2012;36(2):143-152.
Accumulating data suggest that depression is associated with risk factors for cardiovascular disease, but few studies have investigated potential behavioral mediators of such associations, particularly among women. In this study of healthy young adult women (n = 225), we examined associations among depressive symptoms, health behaviors, and serum lipid levels. Depressive symptoms were assessed with the 20-item Center for Epidemiologic Studies – Depression (CES-D) scale, and a fasting blood sample was obtained for serum lipid levels, including total cholesterol, high-density lipoprotein (HDL-C) and low-density lipoprotein (LDL-C). Diet was measured using 24-hour recalls, and other health behaviors (physical activity, smoking) were assessed via self-report questionnaire. Results indicated a modest negative association between depressive symptoms and LDL-C levels. Higher levels of depressive symptoms were also associated with lower total and insoluble dietary fiber intake, both of which were associated with HDL-C and LDL-C. Mediational analyses indicated a significant indirect effect of depressive symptoms on LDL-C via total and insoluble dietary fiber in unadjusted analyses, but not in adjusted analyses. The present findings suggest that depressive symptoms are inversely associated with serum LDL-C levels in young adult women, but that these associations are not likely mediated by adverse lifestyle behaviors.
PMCID: PMC3376669  PMID: 22382824
Depression; cholesterol; health behaviors; diet
17.  Health Beliefs Associated with Cervical Cancer Screening Among Vietnamese Americans 
Journal of Women's Health  2013;22(3):276-288.
Vietnamese American women represent one of the ethnic subgroups at great risk for cervical cancer in the United States. The underutilization of cervical cancer screening and the vulnerability of Vietnamese American women to cervical cancer may be compounded by their health beliefs.
The objective of this study was to explore the associations between factors of the Health Belief Model (HBM) and cervical cancer screening among Vietnamese American women.
Vietnamese American women (n=1,450) were enrolled into the randomized controlled trial (RCT) study who were recruited from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey. Participants completed baseline assessments of demographic and acculturation variables, health care access factors, and constructs of the HBM, as well as health behaviors in either English or Vietnamese.
The rate of those who had ever undergone cervical cancer screening was 53% (769/1450) among the participants. After adjusting for sociodemographic variables, the significant associated factors from HBM included: believing themselves at risk and more likely than average women to get cervical cancer; believing that cervical cancer changes life; believing a Pap test is important for staying healthy, not understanding what is done during a Pap test, being scared to know having cervical cancer; taking a Pap test is embarrassing; not being available by doctors at convenient times; having too much time for a test; believing no need for a Pap test when feeling well; and being confident in getting a test.
Understanding how health beliefs may be associated with cervical cancer screening among underserved Vietnamese American women is essential for identifying the subgroup of women who are most at risk for cervical cancer and would benefit from intervention programs to increase screening rates.
PMCID: PMC3601630  PMID: 23428284
18.  Challenges and Needs of Chinese and Korean American Breast Cancer Survivors: In-Depth Interviews 
Breast cancer incidence and the number of breast cancer survivors have been rapidly increasing among Chinese and Korean women in the United States. However, few data are available regarding quality of life in Asian American breast cancer survivors. This qualitative study aims to describe Asian American women’s perceptions of quality of life and their breast cancer experiences. In-depth interviews with four Chinese and five Korean American breast cancer survivors and three oncologists were conducted in Chinese, Korean, or English. Interviews were recorded and transcripts were translated into English. Qualitative analyses were performed by two independent coders and then discussed and agreed upon by the research team. The respondents reported that the breast cancer experience had affected various domains of quality of life, but women reported having limited resources with which to cope effectively. Depression, anxiety, and stress were commonly reported, but women rarely discussed these issues with family and friends or sought professional help. As immigrants, women’s loneliness and a lack of social support and culturally relevant resources seemed to be major barriers to maintaining good quality of life. Women also expressed interest in learning more about alternative therapies and relaxation skills. These findings can be used to help inform the development of a culturally appropriate intervention for Asian American breast cancer survivors. Future programs may provide information in women’s native languages to teach skills to cope with stress and anxiety, increase women’s self-efficacy within the context of their cultural background, and enhance social support among women from the same ethnic group.
PMCID: PMC3766352  PMID: 24019995
breast cancer; quality of life; survivorship; Asian American; Chinese American; Korean American
19.  Pathways of Breast Cancer Screening Among Chinese American Women 
The purpose of this community-based study was to develop a structural equation model for factors contributing to breast cancer screening among Chinese American women.
A cross-sectional design included a sample of 440 Chinese American women aged 40 years and older. The initial step involved use of confirmatory factor analysis, which included the following variables: access/satisfaction with health care, enabling, predisposing, and cultural and health belief factors. Structural equation model analyses were conducted to evaluate factors related to breast cancer screening in Chinese American women.
Initial univariate analyses indicated that women without health insurance were significantly more likely to report being never-screened compared to women with health insurance. Structural equation modeling techniques were used to evaluate the utility of the Sociocultural Health Behavior model in understanding breast cancer screening among Chinese American women. Results indicated that enabling and predisposing factors were significantly and positively related to breast cancer screening. Cultural factors were significantly associated with enabling factors and satisfaction with healthcare. Overall, the proposed model explained 34% of the variance in breast cancer screening among Chinese American women.
The model highlights the significance of enabling and predisposing factors in understanding breast cancer screening behaviors among Chinese American women. In addition, cultural factors were associated with enabling factors, reinforcing the importance of providing translation assistance to Chinese women with poor English fluency and increasing awareness of the critical role of breast cancer screening. Partnering with community organizations may help to facilitate and enhance the screening rates.
PMCID: PMC3762685  PMID: 24013711
Mammograms; Breast cancer screening; Chinese women
20.  Pilot Study: Health Behaviors Associated with HPV Vaccine Uptake among Adolescents 
Despite approval of a vaccine found to be very effective in preventing human papillomavirus (HPV) infection and related cancers, many young people have not yet been vaccinated. Since health behaviors tend to co-occur, the purpose of the current study was to examine relationships among HPV vaccine uptake and other health behaviors among adolescents.
Fifty-nine high school students completed a paper-and-pencil pilot survey regarding HPV vaccine knowledge and attitudes as well as HPV vaccination and other health behaviors.
We found that HPV vaccination was significantly associated with health-promoting behaviors among girls (e.g., not smoking, p = .02), whereas vaccination willingness was associated with health risk behaviors among boys (e.g., higher sugar diet, p = .03).
Effective interventions to promote HPV vaccination among adolescents may benefit from a simultaneous focus on multiple health behaviors and/or health in general. Interventions tailored by gender may also be beneficial.
PMCID: PMC3695443  PMID: 23803777
HPV vaccine acceptance; health risk behaviors; health promotion behaviors; adolescents
21.  What Is Lacking in Patient-Physician Communication: Perspectives from Asian American Breast Cancer Patients and Oncologists 
Journal of behavioral health  2012;1(2):10.5455/jbh.20120403024919.
Interactions between breast cancer patients and their oncologists are important as effective patient-physician communication can facilitate the delivery of quality cancer care. However, little is known about patient-physician communication processes among Asian American breast cancer patients, who may have unique communication needs and challenges. Thus, we interviewed Asian American patients and several oncologists to explore patient-physician communication processes in breast cancer care.
We conducted in-depth interviews with nine Chinese- or Korean American breast cancer patients and three Asian American oncologists who routinely provided care for Asian American patients in the Washington DC metropolitan area in 2010. We conducted patient interviews in Chinese or Korean and then translated into English. We conducted physicians’ interviews in English. We performed qualitative analyses to identify themes.
For women with limited English proficiency, language was the greatest barrier to understanding information and making treatment-related decisions. Both patients and oncologists believed that interpretation provided by patients’ family members may not be accurate, and patients may neglect to ask questions because of their worry of burdening others. We observed cultural differences regarding expectations of the doctor’s role and views of cancer recovery. As expressed by the patients and observed by oncologists, Asian American women are less likely to be assertive and are mostly reliant on physicians to make treatment decisions. However, many patients expressed a desire to be actively involved in the decision-making process.
Findings provide preliminary insight into patient-physician communication and identify several aspects of patient-physician communication that need to be improved for Asian American breast cancer patients. Proper patient education with linguistically and culturally appropriate information and tools may help improve communication and decision-making processes for Asian American women with breast cancer.
PMCID: PMC3566873  PMID: 24496377
Asian American; breast cancer; patient-physician communication; language barrier; cultural difference; treatment decision making
22.  Informational Needs of Head and Neck Cancer Patients 
Health and technology  2012;2(1):57-62.
Treatment for head and neck squamous cell carcinoma (HNSCC) can lead to considerable functional impairment. As a result, HNSCC patients experience significant decrements in quality of life, high levels of emotional distress, deteriorations in interpersonal relations, and increased social isolation. Studies suggest that HNSCC patients may have extensive informational and psychosocial needs that are not being adequately addressed. However, few programs have been developed to address the needs of HNSCC patients. Therefore, we conducted a pilot study of HNSCC patients to: 1) characterize patients' informational needs; and 2) describe preferred formats and time points for receiving such information. The majority of participants desired additional information regarding treatment options, managing changes in swallowing and speaking, and staying healthy after treatment. Overall, patients with early-stage disease reported more informational needs compared to patients with advanced disease. Female patients were more likely to desire information about coping with emotional stress and anxiety than male patients. Younger patients (29–49 years) were more interested in receiving information about sexuality after cancer compared to their older (50+) counterparts. Although information was requested throughout the cancer trajectory, most patients preferred to receive such information at diagnosis or within 1–3 months post-treatment. The majority of patients reported having computer and Internet access, and they were most receptive to receiving information delivered via the Internet, from a DVD, or from pamphlets and booklets. The relatively high percentage of patients with computer and Internet access reflects a growing trend in the United States and supports the feasibility of disseminating health information to this patient population via Internet-based programs.
PMCID: PMC3327509  PMID: 22518350
Head and neck cancer; informational needs; Treatment side effects; Internet
23.  Socioeconomic position and lower dietary moderation among Chinese immigrant women in the United States 
Public Health Nutrition  2011;15(3):415-423.
To examine associations of education and occupation, as indicators of socioeconomic position (SEP), with dietary intake and diet quality in a sample of Chinese immigrant women.
Cross-sectional. Data collection included four days of dietary recalls and information on education and current occupation for participants and their spouses.
Philadelphia, PA, USA.
423 Chinese immigrant women recruited 10/05-4/08.
In multivariate models, both higher education level and occupation category were significantly associated with higher energy density and intake of energy and sugar. Education was additionally associated with intake of sugar-sweetened beverages (p=0.01) and lower dietary moderation (p=0.01). With joint categorization based on both education and occupation, we observed significant trends indicating higher energy density (p=0.004) and higher intake of energy (p=0.001) and sugar (p=0.04), but less dietary moderation (p=0.02) with higher SEP.
In this sample of US Chinese immigrants, higher SEP as indicated by education level and occupation category was associated with differences in dietary intake, and with less dietary moderation. While higher SEP is typically linked to healthier diet in higher income nations, in these immigrants the association of SEP with diet follows the pattern of their country of origin – a lower-income country undergoing the nutrition transition.
PMCID: PMC3340423  PMID: 21806866
24.  Psychological functioning of caregivers for head and neck cancer patients 
Oral Oncology  2011;48(1):18-25.
Patients with head and neck squamous cell carcinoma (HNSCC) often require assistance from family caregivers during the treatment and post-treatment period. This review article sought to summarize current findings regarding the psychological health of HNSCC caregivers, including factors that may be associated with poorer psychological health. Online databases (PUBMED, MEDLINE and PSYCINFO) were searched for papers published in English through September 2010 reporting on the psychological health of caregivers of HNSCC patients. Eleven papers were identified. Caregivers experience poorer psychological health, including higher levels of anxious symptoms, compared to patients and to the general population. Fear of patient cancer recurrence is evident among caregivers and is associated with poorer psychological health outcomes. The 6-month interval following diagnosis is a significant time of stress for caregivers. Greater perceived social support may yield positive benefits for the psychological health of caregivers. To date, there have been relatively few reports on the psychological health of caregivers of HNSCC patients. Well designed, prospective, longitudinal studies are needed to enhance our understanding of how caregiver psychological health may vary over the cancer trajectory and to identify strategies for improving caregiver outcomes.
PMCID: PMC3357183  PMID: 22154127
Caregiving; Psychological health; Emotional distress; Anxiety; Depression; Head and neck cancer
25.  Correlates of Cervical Cancer Screening among Vietnamese American Women 
Objective. Vietnamese American women are at the greatest risk for cervical cancer but have the lowest cervical cancer screening rates. This study was to determine whether demographic and acculturation, healthcare access, and knowledge and beliefs are associated with a prior history of cervical cancer screening among Vietnamese women. Methods. Vietnamese women (n = 1450) from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey participated in the study and completed baseline assessments. Logistic regression analyses were performed. Results. Overall levels of knowledge about cervical cancer screening and human papillomavirus (HPV) are low. Factors in knowledge, attitude, and beliefs domains were significantly associated with Pap test behavior. In multivariate analyses, physician recommendation for screening and having health insurance were positively associated with prior screening. Conclusion. Understanding the factors that are associated with cervical cancer screening will inform the development of culturally appropriate intervention strategies that would potentially lead to increasing cervical cancer screening rates among Vietnamese women.
PMCID: PMC3449126  PMID: 23008526

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