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1.  A successful guide in understanding Latino immigrant patients: An aid for health care professionals 
Family & community health  2012;35(1):76-84.
It has been shown that cultural and linguistic barriers may have a great impact on the quality of health care received by immigrants. The recent growth of Latino immigrants in new areas of the country (particularly in the South) has presented great challenges to the health care system and health care professionals in these states. Through a NCI funded community-based educational program (Sowing the Seeds of Health), we created an informative DVD to aid health care providers in better understanding Latino immigrant health beliefs and health care seeking behaviors. The educational DVD presented information on how to provide culturally competent care as it relates to Latino immigrants, their expectations when seeking care, and common cultural beliefs and practices. Health care professionals and Latino immigrants participated in the development and content of the DVD.
The intervention was delivered though various mediums; on-site, on-line, two national webcasts and mailed copies of the DVD. Pre- post self-administered questionnaires assessing knowledge and attitudes regarding culture competency and relevant topics addressed in the DVD.
Four-hundred and sixty-three (N=463) health care professionals participated from across the United States. Intervention produced significant overall knowledge increase (p-value <0.001) in cultural competency, Latino cultural beliefs and barriers to healthcare access for Latino immigrants.
The findings indicate that a short DVD offered via multiple mediums may be a promising avenue for educating health care professionals about the needs and expectations of Latino immigrants in the U.S.
PMCID: PMC4174359  PMID: 22143490
2.  Acceptability and usability of self-collected sampling for HPV testing among African American women living in the Mississippi Delta 
HPV DNA testing has been shown to be an effective approach to cervical cancer screening, and self-collection sampling for HPV testing could be a potential alternative to Pap test, provided that women who tested positive by any method get timely follow-up and care. This feasibility study examined acceptability and usability of self-collected sampling for HPV testing among African American (AA) women in the Mississippi Delta in order to inform the development of interventions to promote cervical cancer screening in this population.
The study consisted of two phases. Phase I consisted of eight focus groups (N=87) with AA women to explore knowledge, attitudes, and beliefs about cervical cancer and HPV infection as well as acceptability of self-collected sampling for HPV testing. In Phase II, we examined the usability of this technology through one discussion group (N=9). The Health Belief Model guided data collection and analysis.
Although participants perceived themselves as susceptible to cervical cancer and acknowledged its severity, there was a lack of knowledge of the link between HPV and cervical cancer, and they expressed a number of misconceptions. The most frequent barriers to screening included embarrassment, discomfort, and fear of the results. Women in both phases were receptive to self-collection sampling for HPV testing. All participants in the usability phase expressed that self-collection was easy and they did not experience any difficulties.
Self-collection for HPV testing is an acceptable and feasible method among AA women in the Mississippi Delta to complement current cytology cervical cancer screening programs.
PMCID: PMC3596478  PMID: 23410619
gynecological cancer; sexually transmitted infections; health disparities
3.  Design and evaluation of a theory-based, culturally relevant outreach model for breast and cervical cancer screening for Latina immigrants 
Ethnicity & disease  2012;22(3):274-280.
Breast and cervical cancer are common among Latinas, but screening rates among foreign-born Latinas are relatively low. In this article we describe the design and implementation of a theory-based (PEN-3) outreach program to promote breast and cervical cancer screening to Latina immigrants, and evaluate the program’s effectiveness.
We used data from self-administered questionnaires completed at six annual outreach events to examine the sociodemographic characteristics of attendees and evaluate whether the program reached the priority population – foreign-born Latina immigrants with limited access to health care and screening services. To evaluate the program’s effectiveness in connecting women to screening, we examined the proportion and characteristics of women who scheduled and attended Pap smear and mammography appointments.
Among the 782 Latinas who attended the outreach program, 60% and 83% had not had a Pap smear or mammogram, respectively, in at least a year. Overall, 80% scheduled a Pap smear and 78% scheduled a mammogram. Women without insurance, who did not know where to get screening and had not been screened in the last year were more likely to schedule appointments (p < 0.05). Among women who scheduled appointments, 65% attended their Pap smear and 79% attended the mammogram. We did not identify significant differences in sociodemographic characteristics associated with appointment attendance.
Using a theoretical approach to outreach design and implementation, it is possible to reach a substantial number of Latina immigrants and connect them to cancer screening services.
PMCID: PMC3762980  PMID: 22870569
Cancer screening; community-based participatory research; program evaluation; Latina immigrants
4.  Development of a Theory-Based (PEN-3 and Health Belief Model), Culturally Relevant Intervention on Cervical Cancer Prevention Among Latina Immigrants Using Intervention Mapping 
Health promotion practice  2011;13(1):29-40.
The development of efficacious theory-based, culturally relevant interventions to promote cervical cancer prevention among underserved populations is crucial to the elimination of cancer disparities. The purpose of this article is to describe the development of a theory-based, culturally relevant intervention focusing on primary (sexual risk reduction) and secondary (Pap smear) prevention of cervical cancer among Latina immigrants using intervention mapping (IM). The PEN-3 and Health Belief Model provided theoretical guidance for the intervention development and implementation. IM provides a logical five-step framework in intervention development: delineating proximal program objectives, selecting theory-based intervention methods and strategies, developing a program plan, planning for adoption in implementation, and creating evaluation plans and instruments. We first conducted an extensive literature review and qualitatively examined the socio-cultural factors associated with primary and secondary prevention of cervical cancer. We then proceeded to quantitatively validate the qualitative findings, which led to development matrices linking the theoretical constructs with intervention objectives and strategies as well as evaluation. IM was a helpful tool in the development of a theory-based, culturally relevant intervention addressing primary and secondary prevention among Latina immigrants.
PMCID: PMC3982834  PMID: 21422254
intervention development; intervention mapping; cervical cancer prevention; Latina immigrants
5.  Social Support among African Americans with Heart Failure: Is There a Role for Community Health Advisors? 
The study had two objectives: (1) to gather Community Health Advisors’ (CHA) observations on the role of social support in lives of African Americans; and (2) based on CHAs’ observations and existing literature, to develop a lay support intervention framework depicting how social support may address the needs of African American heart failure patients.
Qualitative data were collected in semi-structured interviews among 15 community health advisors working in African American communities in Birmingham, AL.
Prominent themes included the challenge of meeting clients’ overlapping health care and general life needs, the variation in social support received from family and friends, and the opportunities for CHAs to provide multiple types of social support to clients. CHAs also believed that their support activities could be implemented among heart failure populations.
CHAs’ experiences with social support can inform a potential framework of a lay support intervention among African Americans with heart failure.
PMCID: PMC3509228  PMID: 22920609
heart failure; social support; African Americans; community health advisors
6.  Cervical Cancer Prevention: New Tools and Old Barriers 
Cancer  2010;116(11):2531-2542.
Cervical cancer is the second most common female tumor worldwide and its incidence is disproportionately high (>80%) in the developing world. In the U.S., where Pap tests have reduced the annual incidence to approximately 11,000 cervical cancers, more than 60% of cases occur in medically-underserved populations as part of a complex of diseases linked to poverty, race/ethnicity, and/or health disparities. Because carcinogenic human papillomavirus (HPV) infections cause virtually all cervical cancer, two new approaches for cervical cancer prevention have emerged: 1) HPV vaccination to prevent infections in younger women (≤18 years old) and 2) carcinogenic HPV detection in older women (≥30 years old). Together, HPV vaccination and testing, if used in an age-appropriate manner, have the potential to transform cervical cancer prevention particularly among underserved populations. Yet significant barriers of access, acceptability, and adoption to any cervical cancer prevention strategy remain. Without understanding and addressing these obstacles, these promising new tools for cervical cancer prevention may be futile. We share our experiences in the delivery of cervical cancer prevention strategies to U.S. populations experiencing high cervical cancer burden: African-American women in South Carolina, Alabama, Mississippi; Haitian immigrant women in Miami; Hispanic women in the U.S.-Mexico Border; Sioux/Native American women in the Northern Plains; white women in the Appalachia; and Vietnamese-American women in Pennsylvania and New Jersey. Our goal is to inform future research and outreach efforts to reduce the burden of cervical cancer in underserved populations.
PMCID: PMC2876205  PMID: 20310056
7.  Planning and implementation of a participatory evaluation strategy: A viable approach in the evaluation of community-based participatory programs addressing cancer disparities 
Evaluation and program planning  2009;32(3):221-228.
Community-based participatory research (CBPR) has been posited as a promising methodology to address health concerns at the community level, including cancer disparities. However, the major criticism to this approach is the lack of scientific grounded evaluation methods to assess development and implementation of this type of research. This paper describes the process of development and implementation of a participatory evaluation framework within a CBPR program to reduce breast, cervical, and colorectal cancer disparities between African Americans and whites in Alabama and Mississippi as well as lessons learned. The participatory process involved community partners and academicians in a fluid process to identify common ground activities and outcomes. The logic model, a lay friendly approach, was used as the template and clearly outlined the steps to be taken in the evaluation process without sacrificing the rigorousness of the evaluation process. We have learned three major lessons in this process: (1) the importance of constant and open dialogue among partners; (2) flexibility to make changes in the evaluation plan and implementation; and (3) importance of evaluators playing the role of facilitators between the community and academicians. Despite the challenges, we offer a viable approach to evaluation of CBPR programs focusing on cancer disparities.
PMCID: PMC2833106  PMID: 19232727
Participatory evaluation; cancer disparities; community-based participatory research; logic model
8.  Pictorial health warnings on cigarette packs and the impact on women 
Revista de Saúde Pública  2013;47(6):1123-1129.
To analyze the association between the pictorial graphic health warnings on cigarette packs and their impact on intention to quit smoking among women.
Population-based cross-sectional study among 265 women daily smokers in the State of Paraná in 2010. The sample size was calculated using cluster sampling. Participants were asked whether they had seen any pictorial graphic health warnings in the past 30 days, whether these warnings made them think about quitting, and intensity of these thoughts. The data was analyzed using logistic regression and the independent variables included age, educational attainment, whether they had children, whether they had attempted to quit smoking in the past 12 months, age of smoking initiation, number of cigarettes smoked per day, their town of residence, and how soon after waking do they smoke their first cigarette.
Participants (91.7%) reported seeing the pictorial graphic health warnings in the past 30 days. Women with elementary education or below and women with some/complete high school education were more likely to think about quitting smoking after seeing the pictorial graphic health warningsthan women with higher education (OR = 4.85; p = 0.0028 and OR = 2.91; p = 0.05), respectively). Women who attempted to quit smoking in the past 12 months were more likely to think about quitting than women who had not (OR = 2.49; p = 0.001). Quit attempts within the last 12 months were associated with intensity of these thoughts (OR = 2.2; p = 0.03).
Results show an association between pictorial graphic health warnings and intent to quit smoking among women with warnings having a greater impact among women with less education and who had attempted to quit smoking within the past year. Tobacco control strategies should be implemented across all groups of women regardless of their educational attainment.
PMCID: PMC4206097  PMID: 24626550
Women; Tobacco-Derived Products Publicity; Health Knowledge, Attitudes, Practice; Smoking Cessation, psychology; Cross-Sectional Studies
9.  Human papillomavirus genotypes detected in clinician-collected and self-collected specimens from women living in the Mississippi Delta 
There are no data available on human papillomavirus (HPV) infections in women living in the Mississippi Delta, where cervical cancer incidence and mortality among African American women is among the highest in the United States. The aim of this analysis was to report the age-specific prevalence of HPV in this population.
We recruited 443 women, 26–65 years of age, from the general population of women living in the Mississippi Delta to participate; 252 women had been screened for cervical cancer within the last 3 years while 191 had not. Women underwent a pelvic exam and had clinician-collected Pap sample taken for the routine cervical cancer screening by cytology. Women were asked to collect a self-collected specimen at home and return it to the clinic. Both specimens were tested for HPV genotypes.
Four hundred and six women (91.6%) had HPV genotyping results for the clinician-collected and self-collected specimens. The prevalence of carcinogenic HPV was 18.0% (95% CI: 14.4%-22.1%) for clinician-collected specimens and 26.8% (95% CI: 22.6%-31.4%) for self-collected specimens. The concordance for the detection of carcinogenic HPV between clinician-collected and self-collected specimens was only fair (kappa = 0.54). While the prevalence of carcinogenic HPV in either sample decreased sharply with increasing age (ptrend< 0.01), the prevalence of non-carcinogenic HPV did not, especially the prevalence of HPV genotypes in the alpha 3/4/15 phylogenetic group.
The prevalence of carcinogenic HPV in our sample of women living in the Mississippi Delta was greater than the prevalence reported in several other U.S. studies. The high carriage of HPV infection, along with lack of participation in cervical cancer screening by some women, may contribute to the high cervical cancer burden in the region.
PMCID: PMC3570306  PMID: 23289357
Human papillomavirus (HPV); Self-collection; Pap; Cervical intraepithelial neoplasia; Cervix
10.  Patterns of Blunt Use Among Rural Young Adult African-American Men 
Blunts are hollowed-out cigars or leaf tobacco filled with marijuana. Use of blunts has increased since the 1990s and, in 2005, 3.5% of all American youth were estimated to have used blunts in the past month. Blunt smokers may have greater odds of cannabis and tobacco dependency and are at risk of smoking-related diseases. Previous studies have suggested that blunt use is more common among blacks, older teens, and men. However, data pertaining to blunt use in non-adolescent African-American populations are scarce.
(1) To assess patterns of blunt use among young adult African-American men aged 19–30 years residing in five rural Black Belt counties in Alabama; (2) To compare these data with those from tobacco cigarette smokers within the same study population.
Verbal, face-to-face interviewer-administered survey of 415 participants collected and analyzed between December 2008 and February 2011.
159 respondents (38.3%) smoked cigarettes and 45 smoked blunts (10.8%). Of blunt smokers, 33 also smoked cigarettes (73.3%). Use of blunts was prevalent among unemployed, single men, and occupational blunt use was uncommon. Factors important in the initiation, maintenance and cessation of product use were similar for blunt and cigarette smokers, especially product use and acceptance by friends. Legal concerns were an important factor facilitating blunt cessation.
Blunt use is relatively common among male African Americans aged 19–30 years and is frequently associated with concomitant cigarette use. Tobacco control efforts in this male African-American population should also address blunt usage.
PMCID: PMC3244685  PMID: 22176848
11.  Strategies for Achieving Healthy Energy Balance Among African Americans in the Mississippi Delta 
Preventing Chronic Disease  2007;4(4):A97.
Low-income African Americans who live in rural areas of the Deep South are particularly vulnerable to diseases associated with unhealthy energy imbalance. The Centers for Disease Control and Prevention (CDC) has suggested various physical activity strategies to achieve healthy energy balance. Our objective was to conduct formal, open-ended discussions with low-income African Americans in the Mississippi Delta to determine 1) their dietary habits and physical activity levels, 2) their attitudes toward CDC's suggested physical activity strategies, and 3) their suggestions on how to achieve CDC's strategies within their own environment.
A qualitative method (focus groups) was used to conduct the study during 2005. Prestudy meetings were held with African American lay health workers to formulate a focus group topic guide, establish inclusion criteria for focus group participants, select meeting sites and times, and determine group segmentation guidelines. Focus groups were divided into two phases.
All discussions and focus group meetings were held in community centers within African American neighborhoods in the Mississippi Delta and were led by trained African American moderators. Phase I focus groups identified the following themes: overeating, low self-esteem, low income, lack of physical exercise, unhealthy methods of food preparation, a poor working definition of healthy energy balance, and superficial knowledge of strategies for achieving healthy energy balance. Phase 2 focus groups identified a preference for social support-based strategies for increasing physical activity levels.
Energy balance strategies targeting low-income, rural African Americans in the Deep South may be more effective if they emphasize social interaction at the community and family levels and incorporate the concept of community volunteerism.
PMCID: PMC2112870  PMID: 17875272

Results 1-11 (11)