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1.  Environmental Influences on Tobacco Use Among Asian American and Pacific Islander Youth 
Health promotion practice  2013;14(5 0):40S-47S.
There is growing interest in understanding individual and environmental influences on youth risk behaviors, including tobacco use. The purpose of this article is to describe the processes and findings from a study that sought to increase the capacity of Asian American and Pacific Islander (AAPI) community-based organizations to understand and address the environmental influences on tobacco use among AAPI youth. Using a multimethod approach to data collection that included GIS (geographic information system) mapping, Photovoice, and individual youth surveys, a team of community and university researchers conducted a 3-year study to assess and address the environmental influences of tobacco use among youth. Community-based participatory research principles guided the study and facilitated unique capacity building and analyses throughout the study period. Results in Long Beach from all three methods highlighted the associations between youth smoking and environmental factors: GIS mapping identified at least 77 separate locations of pro-tobacco influences, photographs captured many of these locations and provided youth leaders with opportunities to identify how other influences contributed to smoking risk, and surveys of youth indicated that perceived community safety and proximity to pro-tobacco influences were associated with smoking in the past 30 days. Subsequent community-based organization activities undertaken by study partners are also discussed, and lessons learned summarized.
PMCID: PMC4360954  PMID: 23632078
advocacy; Asian; minority health; community-based participatory research; health research; Pacific Islander; tobacco prevention and control
2.  Using Photovoice to Assess and Promote Environmental Approaches to Tobacco Control in AAPI Communities 
Health promotion practice  2011;12(5):654-665.
Asian American and Pacific Islander (AAPI) communities face enormous health disparities, with tobacco use contributing to high rates of cancer and heart disease. There is growing interest nationwide on the influence of environmental factors on tobacco use. AAPI communities have been found to have higher exposures to tobacco company marketing compared to the general population. The authors describe the use of Photovoice (a qualitative needs assessment technique) to empower AAPI youth to identify and understand environmental characteristics associated with tobacco use in four AAPI communities in California and Washington. Of the six major environmental themes identified from the photos, three themes were found across all four communities. Debrief sessions with youth and community leaders underscore the relevance of Photovoice for identifying community needs and motivating community organization for change. Despite some logistical challenges, Photovoice exemplifies the power and potential of this community-based methodology to capture how the environment influences youth on tobacco use.
PMCID: PMC3691960  PMID: 21955822
tobacco use; qualitative; needs assessment; environment; Asian American; Pacific Islander; youth; Photovoice
3.  Promoting Breast Cancer Screening Among Chamorro Women in Southern California 
Asian American and Pacific Islander women represent a significant at-risk population for breast cancer, with their mortality rates rising while rates fall for all other racial groups.
This 3-year study employed a quasi-experimental design to test the influence of an intervention on screening rates among women age 50 years and older in Southern California compared to Northern California.
Despite significant exposure of women to the educational elements in Southern California, the intervention did not increase women’s knowledge, attitudes, or screening behaviors.
We discuss several study design and implementation limitations that could have influenced the study’s results.
PMCID: PMC3689549  PMID: 18444041
4.  Needs and Experiences of Samoan Breast Cancer Survivors in Southern California 
Hawaii Medical Journal  2011;70(11 Suppl 2):35-39.
Breast cancer rates are increasing among Samoan and other Pacific Islander women, yet studies of their social support needs are nearly non-existent. The purpose of this paper is to report on the cultural dimensions of social support among Samoan breast cancer survivors in Southern California.
Data for this paper came from a larger one-and-a-half year study of the social support needs of Samoan breast cancer survivors and their family and friends. In-depth, retrospective, qualitative interviews were conducted with a purposeful sample of 20 Samoan survivors who were recruited from an existing social support program as well as the general community.
We documented important informational needs and behaviors, social support needs and experiences, and spirituality issues for the Samoan breast cancer survivors.
Our findings underscore the need for culturally-specific social support services for Samoans, as well as the necessity of community-based participatory research to define and explore social support and other survivorship needs in this understudied population. Recommendations from the community report-back, stressed the importance of expanding community Samoan cancer social support groups through collaborations with Samoan leaders and churches.
PMCID: PMC3254226  PMID: 22235157
5.  Community capacity for cancer control collaboration: Weaving an islander network for cancer awareness, research and training for Pacific Islanders in Southern California 
Cancer detection and prevention  2008;32(Suppl 1):S37-S40.
Addressing cancer health disparities constitutes a national priority in this country, with funding for Pacific Islander efforts initiated seven years ago by the National Cancer Institute. In 2005, the Weaving an Islander Network for Cancer Awareness, Research and Training (WINCART) was launched in Southern California by a collaboration of community and university organizations to build upon past efforts to decrease cancer health disparities for Chamorros, Native Hawaiians, Marshallese, Samoans and Tongans.
To assess community organizational capacity to participate in collaborative cancer control for Pacific Islanders, a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis was undertaken. Two staff members per community organization (CBO) performed the SWOT analyses, with grids analyzed for commonalities and differences between all organizations.
Staff informants provided many examples of what they perceived as organizational strengths and weaknesses with regards to promoting cancer control for their respective Pacific Islander populations. CBO strengths included strong leadership and extensive community experience. Challenges included limited resources, lack of staff skills in some areas, and difficulty recruiting volunteers. In addition, many external opportunities and threats to cancer control promotion were identified.
Results from the SWOT analyses have been used to identify topics for community organizational trainings and supports within WINCART, with the goals of increasing their participation in the development and implementation of collaborative, community-university driven efforts to decrease cancer disparities for Pacific Islanders in Southern California.
PMCID: PMC2719104  PMID: 18359580
cancer control; organizational capacity; Pacific Islanders; community capacity
6.  Using Entertainment-Education to Promote Cervical Cancer Screening in Thai Women 
Southeast Asian women in California have high cervical cancer incidence and mortality rates, but low levels of Pap screening. No published reports have addressed screening among Thai women. Entertainment-education (EE) is a useful strategy for low-literacy, culturally diverse populations. This quasi-experimental study determined whether a soap-opera-themed, Thai-language EE video was superior to a print handout for increasing knowledge, attitudes, and behavioral intention toward Pap testing. No uniform differences were found between the intervention group (video) and the control group (brochure). Both educational modalities appeared to result in selected increases in knowledge and attitudes.
PMCID: PMC4372047  PMID: 22581487
Entertainment-Education; Cervical Cancer Screening; Thai Women; Pap screening
7.  Role of Spirituality in Coping with Breast Cancer: A Qualitative Study of Samoan Breast Cancer Survivors and their Supporters 
The use of spirituality for guidance and coping affects the quality of life in many cancer survivors and their supporters. Previous research has focused on coping strategies among cancer and terminally ill survivors, primarily among White and African American women. However, the length and extent to which these strategies have been researched in a cultural and communal context, such as Pacific Islanders, is not documented. The purpose of this qualitative study was to explore spiritual coping among a cross-sectional sample of 20 Samoan women diagnosed with breast cancer and 40 of their supporters (family and/or friends) in Southern California. In-depth interviews were conducted retrospectively with survivors and their supporters by trained bilingual/bicultural interviewers. The interviews were recorded, transcribed (and translated where applicable), and analyzed using the grounded theory approach to identify major themes for each group. Results illustrated that spirituality provided considerable emotional and logistical assistance to both survivors and their supporters, with particularly churches playing a potentially important role in the development of social support programs for both groups. This study supports the use of faith-based communities as forums to increase health education and understanding the further use of spiritual coping for cancer survivors, family, and friends.
PMCID: PMC3774055  PMID: 24049511
Samoans; breast cancer; spirituality; survivors; family members; friends
8.  Contextualization of HIV and HPV risk and prevention among Pacific Islander young adults in Southern California 
Social science & medicine (1982)  2012;75(4):699-708.
HIV and sexually transmitted human papillomavirus (HPV) are associated with each other and with the development of comorbid cancer. Current epidemiology indicates that among Pacific Islanders in the United States, young adults are at highest risk of HIV and HPV. In our inductive community based participatory research study, we used focus groups and key informant interviews (March – August 2010) with young adults, parents, community leaders, and providers (n = 95) to identify and contextualize factors that shape HIV and HPV risk and prevention among young adults in Chamorro and Tongan communities in Southern California. We identified nine themes that incorporated the following principal factors: misinformation and otherization; dominant concerns regarding premarital pregnancy; restricted intergenerational communication; family shame and privacy; gendered manifestations of religio-cultural norms; barriers impeding access to sexual health resources; parents’ role in prevention; community vs. individual responsibility; and family and ethnic pride. Our thematic findings fit well with Rhodes’ “risk and enabling environment” heuristic (2009), which we used to contextualize risk and prevention at micro and macro levels of physical, social, economic, and policy environments. We propose the addition of a separate cultural environment to the heuristic and conclude that a focus on applying individual and community agency at the micro-level would be an approachable starting point for intervention for our local Pacific Islander communities and groups in similar ecological contexts globally. Enhanced community-led education programs and engagement of religious and other community leaders to facilitate intergenerational communication could counteract taboos that obstruct prevention.
PMCID: PMC3383406  PMID: 22647562
USA; HIV; Human papillomavirus (HPV); Pacific Islanders; Tongan; Chamorro; Young adults; Community Based Participatory Research; gender
9.  Sources of Information that Promote Breast and Cervical Cancer Knowledge and Screening Among Native Hawaiians in Southern California 
Breast and cervical cancers are the second and fourth leading causes of cancer death among Asian and Pacific Islander women. Despite screening exams that can detect these cancers early and increase survival, racial and ethnic populations continue to be disproportionately affected. This study examined the sources of information and their impacts on cancer screening compliance among native Hawaiians in Orange County, California. A community-based participatory research approach was used to conceive, design, implement, and analyze data. A relatively small proportion of the study's native Hawaiian women were compliant with recommended breast and cervical cancer screenings, and their screening rates were below the national Healthy People 2010 standards. Knowledge of screening procedures, seeking advice from a doctor, and obtaining information from internet medical sites were associated with higher rates of compliance with cancer-screening procedures.
PMCID: PMC3709576  PMID: 20237883
Native Hawaiian; Breast cancer screening; Cervical cancer screening; Sources of information; Community-based participatory research
10.  Balancing Community and University Aims in Community-Based Participatory Research: A Pacific Islander Youth Study 
Community-based participatory research (CBPR) holds the promise of improving the planning, conduct, and long-term translation of research findings into community settings.
This 2-year, exploratory study applied CBPR structures and processes to the identification of individual, cultural and community factors associated with obesity among Pacific Islander (PI) youth in Southern California.
We describe the CBPR principles and strategies used by a community–university partnership to develop, implement, and report on the findings from assessments of obesity, physical activity, and nutritional intake among PI youth.
Although CBPR planning processes led to successes in community-based youth recruitment and retention, we learned key lessons regarding implementation of tailored assessment protocols, often involving problems arising from the university side of the CBPR collaborative.
CBPR has its strengths and limits; more studies are needed that report on processes to increase our understanding of how to balance research rigor with community sustainability.
PMCID: PMC3691961  PMID: 21441665
Community-based participatory research; primary prevention community health research
11.  A Community - Based Participatory Research Study of HIV and HPV Vulnerabilities and Prevention in Two Pacific Islander Communities: Ethical Challenges and Solutions 
We describe ethical issues that emerged during a one-year CBPR study of HIV and human papillomavirus (HPV) vulnerabilities and prevention in two Pacific Islander (PI) communities, and the collaborative solutions to these challenges reached by academic and community partners. In our project case study analysis, we found that ethical tensions were linked mainly to issues of mutual trust and credibility in PI communities; cultural taboos associated with the nexus of religiosity and traditional PI culture; fears of privacy breaches in small, interconnected PI communities; and competing priorities of scientific rigor versus direct community services. Mutual capacity building and linking CBPR practice to PI social protocols are required for effective solutions and progress toward social justice outcomes.
PMCID: PMC3691962  PMID: 23485672
HIV; human papillomavirus (HPV); Pacific Islanders; Chamorro; Tongan; research ethics; community-based participatory research; social justice
12.  Challenges in Identifying Native Hawaiians and Pacific Islanders in Population-Based Cancer Registries in the U.S 
Lack of disaggregated data for Native Hawaiians and Pacific Islanders (NHPIs) in the U.S. has resulted in severe gaps in understanding health disparities and unique health needs of NHPIs. Telephone interviews were conducted with 272 cancer patients identified by a population-based cancer registry. The self-reported NHPIs status was compared with that identified by the registry. Sensitivity, Specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) were calculated. Alternative NHPIs identification methods were explored. The registry had acceptable sensitivity (89%), specificity (96%) and NPV (99%), but low PPV (62%) in identifying NHPIs. Using additional information on surname and birthplace from the registry improved the identification of NHPIs, but either increased the false positive or decreased the counts of true NHPIs cases. Improved data collection methods and practices in identifying NHPIs in population-based cancer registries are needed and caution in interpreting cancer data for NHPIs is warranted.
PMCID: PMC3191111  PMID: 20803254
Native Hawaiians and Pacific Islanders; Cancer registry; Birthplace; Surnames
13.  Operationalization of community-based participatory research principles across the National Cancer Institute’s Community Network Programs 
American Journal of Public Health  2011;102(6):1195-1203.
To examine how the National Cancer Institute-funded Community Network Program (CNP) operationalized principles of community-based participatory research (CBPR).
Based on our review of the literature and extant CBPR measurement tools, scientists from nine of 25 CNPs developed a 27-item questionnaire to self-assess CNP operationalization of nine CBPR principles.
Of 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles to recognize community as a unit of identity, build on community strengths, facilitate co-learning, embrace iterative processes in developing community capacity, and achieve a balance between data generation and intervention. CNPs varied in extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging community in research dissemination, and striving for sustainability.
Although tool development in this field is in its infancy, findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.
PMCID: PMC3292685  PMID: 22095340
Cancer disparities; community health; empowerment; health status disparities; indigenous populations; minority health; partnerships; training
14.  Dietary Intakes, Obesity and Health Behaviors in Native Hawaiians Residing in Southern California 
Accessing dietary intakes, body mass index (BMI) and health behaviors in Native Hawaiians residing in Southern California.
Cross-sectional, community based participatory research.
Native Hawaiian (N = 55); Mean age 59 (± 15).
Main Outcome Measures
Diet, body mass index (BMI), and diet/exercise health behaviors. Collected diet via 24-hr dietary recalls, health behaviors through questionnaires and BMI via measurement/self-report.
Frequencies/means and multiple linear regression were used to assess diet, BMI, and health behaviors.
Nearly 90% of the participants were either overweight or obese. Less than 20% met the vegetable, fruit, fiber, and whole grain recommendations. Most were a little or somewhat sure (relative to almost always sure) about their ability “to stick with an exercise program when attending a cultural gathering”, and “when visiting Hawai‘i”.
Conclusions and Implications
These results suggest that developing a culturally-based education program to reduce obesity and improve diet is critical for Native Hawaiians residing in Southern California.
PMCID: PMC3360080  PMID: 22737649
15.  Diet, Psychosocial Factors Related to Diet and Exercise, and Cardiometabolic Conditions in Southern Californian Native Hawaiians 
Hawaii Medical Journal  2010;69(5 suppl 2):16-20.
Native Hawaiians are at higher risk for cardiometabolic disease, including diabetes and cardiovascular disease compared with other ethnic groups. Diet, body mass index (BMI) and psychosocial, as well as cultural issues may influence risk for cardiometabolic disease. Our team conducted a community-based participatory research study and examined diet, height/weight, psychosocial factors, and community health concerns in Native Hawaiians living in Southern California.
Design and Methods
Cross-section of 55 participants, ≥ 18 years old. Dietary data were collected via three 24-hr dietary recalls, anthropometrics were measured, and psychosocial factors and cardiometabolic conditions were self-reported. Talk story related to diet and health was completed in a sub-sample. Means and frequencies were calculated on dietary intakes, cardiometabolic disease and BMI. Independent t-test and chi square analyses, as appropriate, were performed to assess differences in dietary intakes, obesity and psychosocial factors between those with and without a pre-existing cardiometabolic condition.
Of those with pre-existing health conditions (n = 28), 72% reported being diagnosed with a cardiometabolic condition. For those with pre-existing cardiometabolic conditions, the daily vegetable consumption was 2.57 servings (± 1.66) and the mean fruit consumption was 1.43 servings (± 0.1.99). The mean fiber intake was 16.24 grams (± 6.92), the mean percentage energy from fat was 34.82% (± 6.40) and the mean % energy from carbohydrate was 47.15 (± 6.77). The psychosocial data showed significantly (p ≤ 0.05) lower social support, social interaction, self-monitoring and cognitive-behavioral strategies related to exercise for those with cardiometabolic disease compared with those without disease. All the talk story discussion groups expressed concern over diabetes and weight management, both as an individual and community issue.
The dietary data indicate that Native Hawaiians residing in Southern California should aim to increase their vegetable, fiber, and reduce % energy from fat and saturated fat. Additionally, the psychosocial data suggests that implementing physical activity programs based on socio-cultural values such as ohana, community gatherings, as well as individual self-monitoring and cognitive-behavioral strategies may improve cardiometabolic outcomes. In efforts to reduce cardiometabolic disease disparity, these data suggest that Native Hawaiians in Southern California are aware and concerned about cardiometabolic disease in the community, and that implementation of an effective energetic (diet plus physical activity) intervention that is socially, and culturally specific for Native Hawaiians in Southern California is critical.
PMCID: PMC3158438  PMID: 20544604
16.  Culturally-specific Physical Activity Measures for Native Hawaiian and Pacific Islanders 
Hawaii Medical Journal  2010;69(5 suppl 2):21-24.
Physical activity is an important contributor to the health disparities experienced by Native Hawaiian and Pacific Islander (NHPI) populations. A culturally-specific measurement instrument that minimizes interpretation bias is necessary to obtain accurate assessments of this lifestyle behavior. The purpose of this study was to 1) create two versions of the Pacific Islander Physical Activity Questionnaire (PIPAQ-short and PIPAQ-long) for United States NHPI, and 2) pilot test the PIPAQ instruments and two objective physical activity monitors to evaluate cultural-appropriateness and acceptability.
Forty NHPI adults (20M, 20F) aged 21–65 years attended focus group discussions addressing cultural perspectives related to physical activity. Feedback from participants, community leaders and physical activity experts guided cultural modifications to existing questionnaires to create PIPAQ-short and PIPAQ-long with accompanying showcards. Pilot testing of both PIPAQs and two objective physical activity monitors, the Actiheart and ActiTrainer, was carried out in another sample of 32 NHPI adults (17M, 15F) aged 18–63 years. Participants were instructed to wear one monitor for ≥10 hours/day for 7 consecutive days. At the follow-up visit, participants completed PIPAQ-short and PIPAQ-long, and a written and verbal exit interview to provide feedback on both subjective and objective instruments.
The majority of participants felt PIPAQ-long provided a more accurate reflection of activity levels, compared to PIPAQ-short. The Actiheart was the preferred monitor due to higher comfort and lower participant burden. Self-reported duration of physical activities was most difficult to recall, compared to activity type, frequency and intensity.
Both PIPAQ instruments and the Actiheart monitor have demonstrated cultural acceptability and appropriateness for NHPI adults. Future studies will investigate the validity and reliability of both PIPAQ instruments in larger samples of NHPI adults.
PMCID: PMC3158441  PMID: 20544605
17.  The Role of Medical Interpretation on Breast and Cervical Cancer Screening Among Asian American and Pacific Islander Women 
Journal of Cancer Education  2010;25(2):253-262.
We examined whether the impact of medical interpretation services was associated with the receipt of a mammogram, clinical breast exam, and Pap smear. We conducted a large cross-sectional study involving four Asian American and Pacific Islander (AAPI) communities with high proportions of individuals with limited English proficiency (LEP). Participants were recruited from community clinics, churches and temples, supermarkets, and other community gathering sites in Northern and Southern California. Among those that responded, 98% completed the survey rendering a total of 1,708 AAPI women. In a series of multivariate logistic regression models, it was found that women who typically used a medical interpreter had a greater odds of having received a mammogram (odds ratio [OR] = 1.85; 95% confidence interval [CI] = 1.21, 2.83), clinical breast exam (OR = 3.03; 95% CI = 1.82, 5.03), and a Pap smear (OR = 2.34; 95% CI = 1.38, 3.97) than those who did not usually use an interpreter. The study provides support for increasing language access in healthcare settings. In particular, medical interpreters may help increase the utilization of breast and cervical cancer screening among LEP AAPI women.
PMCID: PMC2878591  PMID: 20352398
Medical interpretation; Breast cancer; Cervical cancer; Screening; Asian American; Pacific Islander women

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