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1.  Evaluation of a Radionovela to Promote HPV Vaccine Awareness and Knowledge Among Hispanic Parents 
Journal of community health  2011;36(6):957-965.
Hispanic women have more than a 1.5-fold increased cervical cancer incidence and mortality compared to non-Hispanic white women in the United States. The Centers for Disease Control recommends the HPV vaccine for females at ages 11 and 12 years, though it is approved for females aged 9–26 to protect against the primary types of high-risk HPV (HPV-16 and HPV-18) that cause approximately 70% of cervical cancer cases. Few culturally-tailored Spanish HPV vaccine awareness programs have been developed. This study evaluates the efficacy of a Spanish radionovela as an educational tool. Rural Hispanic parents of daughters aged 9–17 (n = 88; 78 mothers and 10 fathers) were randomized to listen to the HPV vaccine radionovela or to another public service announcement. Participants completed a 30 min pretest posttest questionnaire. Parents who listened to the HPV radionovela (intervention group) scored higher on six knowledge and belief items. They were more likely to confirm that HPV is a common infection (70% vs. 48%, P = .002), to deny that women are able to detect HPV (53% vs. 31%, P = .003), to know vaccine age recommendations (87% vs. 68%, P = .003), and to confirm multiple doses (48% vs. 26%, P = .03) than control group parents. The HPV vaccine radionovela improved HPV and HPV vaccine knowledge and attitudes. Radionovela health education may be an efficacious strategy to increase HPV vaccine awareness among Hispanic parents.
doi:10.1007/s10900-011-9395-1
PMCID: PMC4065612  PMID: 21452030
Rural Hispanic parents; HPV vaccine education; Cervical cancer prevention; Efficacy evaluation
2.  The TOTS Community Intervention to Prevent Overweight in American Indian Toddlers: A Feasibility and Efficacy Study 
Journal of community health  2010;35(6):667-675.
Objective
Excess weight gain in American Indian/Alaskan native (AI/AN) children is a public health concern. This study tested 1) the feasibility of delivering community-wide interventions, alone or in combination with family-based interventions, to promote breastfeeding and reduce the consumption of sugar-sweetened beverages; and 2) whether these interventions decrease Body Mass Index (BMI)-Z scores in children 18–24 months of age.
Methods
Three AI/AN tribes were randomly assigned to two active interventions; a community-wide intervention alone (tribe A; n=63 families) or community-wide intervention containing a family component (tribes B and C; n=142 families). Tribal staff and the research team designed community-tailored interventions and trained community health workers to deliver the family intervention through home visits. Feasibility and acceptability of the intervention and BMI-Z scores at 18–24 months were compared between tribe A and tribes B&C combined using a separate sample pretest, posttest design.
Results
Eighty-six percent of enrolled families completed the study. Breastfeeding initiation and 6-month duration increased 14 and 15%, respectively, in all tribes compared to national rates for American Indians. Breastfeeding at 12 months was comparable to national data. Parents expressed confidence in their ability to curtail family consumption of sugar-sweetened beverages. Compared to a pretest sample of children of a similar age two years before the study begun, BMI-Z scores increased in all tribes. However, the increase was less in tribes B &C compared to tribe A (−0.75, p=0.016).
Conclusion
Family, plus community-wide interventions to increase breastfeeding and curtail sugar-sweetened beverages attenuate BMI rise in AI/AN toddlers more than community-wide interventions alone.
doi:10.1007/s10900-010-9270-5
PMCID: PMC4058573  PMID: 20508978
Obesity prevention; infants; toddlers; breastfeeding; sugar-sweetened beverages
3.  Improving Health Promotion to American Indians in the Midwest United States: Preferred Sources of Health Information and Its Use for the Medical Encounter 
Journal of community health  2012;37(6):1253-1263.
American Indians and Alaska Natives suffer significant health disparities for many infectious and chronic diseases as compared to the general population. Providing accurate and culturally tailored health information to underserved groups has been shown to influence health behaviors and health outcomes. Little prior research has explored American Indians health information use and preferences. National representative sample surveys such as the Health Information National Trends Survey provide some data on minority groups but are underpowered to provide useful information on American Indians. The present study analyzes data from a survey of over 900 American Indians from the Midwest United States and explores their sources of health information, their preferences for information presentation, and their use of health information prior to and during medical encounters. We conclude that campaigns targeting Natives should be narrowly focused and be community driven or employing community resources. American Indians use a diversity of media sources to obtain health information, with the Internet being underutilized compared to the general population. Partnership with Indian Health Service providers and pharmacists, as well as traditional healers, in the development and dissemination of new health information for Natives may provide the “expert” tone needed to promote health improvements in American Indians.
doi:10.1007/s10900-012-9564-x
PMCID: PMC4049568  PMID: 22477671
AIAN; American Indians; Midwest US; Health disparities; Health information; Medical encounter
4.  Perceptions, Barriers, and Suggestions for Creation of a Tobacco and Health Website among American Indian/Alaska Native College Students 
Journal of community health  2013;38(3):486-491.
Information concerning American Indian/Alaska Native (AI/AN) Internet use and health information needs is dearth. Our research team explored Internet use among AI/AN college students to determine Internet use in relation to health information seeking behaviors. We used a tobacco site example for participants to describe what they desired in a health site designed specifically for AI/AN. Using a community-based participatory research approach, we conducted 14 focus groups with AI/AN college students (N=108), to better understand their perceptions of and attitudes toward Internet use and health information needs. Daily Internet use was reported across strata yet health topics investigated differed among groups. Participants in all strata desired a health website that was easy to navigate and interactive. Respectful representation of Native culture was a concern, yet no consensus was reached for a multi-tribal audience. Participants felt a website should use caution with cultural depictions due to the possible misinterpretation. Overall, participants agreed that recreational and traditional tobacco use should be differentiated and the variation of traditional use among tribes acknowledged. Data concerning Internet use for health information among AI/AN college students are needed to establish baseline indicators to effectively address disparities.
doi:10.1007/s10900-012-9634-0
PMCID: PMC3594072  PMID: 23149568
American Indian/Alaska Native; College Students; Community-based Participatory Research; Healthcare Disparities; Qualitative Research
5.  Barriers to Cervical Cancer Screening among Middle-aged and Older Rural Appalachian Women 
Journal of community health  2013;38(3):500-512.
Although cervical cancer rates in the United States have declined sharply in recent decades, certain groups of women remain at elevated risk, including middle-aged and older women in central Appalachia. Cross-sectional baseline data from a community-based randomized controlled trial were examined to identify barriers to cervical cancer screening. Questionnaires assessing barriers were administered to 345 Appalachian women aged 40-64, years when Pap testing declines and cervical cancer rates increase. Consistent with the PRECEDE/PROCEED framework, participants identified barriers included predisposing, enabling, and reinforcing factors. Descriptive and bivariate analyses are reported, identifying (a) the most frequently endorsed barriers to screening, and (b) significant associations of barriers with sociodemographic characteristics in the sample. Recommendations are provided to decrease these barriers and, ultimately, improve rates of Pap tests among this traditionally underserved and disproportionately affected group.
doi:10.1007/s10900-012-9639-8
PMCID: PMC3600402  PMID: 23179390
Cervical cancer; screening; barriers; Appalachia; middle-aged
6.  EVALUATION OF A HEPATITIS B LAY HEALTH WORKER INTERVENTION FOR CAMBODIAN AMERICANS 
Journal of community health  2013;38(3):546-553.
Cambodian Americans have high rates of chronic hepatitis B virus (HBV) infection. However, only about one-half of Cambodian Americans have been serologically tested for HBV. We conducted a randomized controlled trial to evaluate the impact of a lay health worker (LHW) intervention on HBV testing and knowledge levels among Cambodian Americans. The study group included 250 individuals who participated in a community based survey in metropolitan Seattle and had not been tested for HBV. Experimental group participants received a LHW intervention addressing HBV and control group participants received a LHW intervention addressing physical activity. Trial participants completed a follow-up survey six months after randomization. Over four-fifths (82%) of randomized individuals participated in a LHW home visit and the follow-up survey response rate was 80%. Among participants with follow-up data, 22% of the experimental group and 3% of the control group reported HBV testing (p<0.001). The experimental and control group testing difference remained significant in an intent-to-treat analysis. The experimental group was significantly more likely than the control group to know that Cambodians have higher rates of HBV infection than whites, HBV cannot be spread by eating food prepared by an infected person, HBV cannot be spread by sharing chopsticks, and HBV cannot be spread by shaking hands. Our findings indicate LHW interventions are acceptable to Cambodian Americans and can positively impact both HBV testing and knowledge levels.
doi:10.1007/s10900-012-9649-6
PMCID: PMC3633619  PMID: 23299978
Cambodian Americans; Hepatitis B Infection; Lay Health Workers
7.  Differences in Hypertension by Sexual Orientation Among U.S. Young Adults 
Journal of community health  2013;38(3):588-596.
Using a nationally representative data set, this study provides the first estimates of differences in hypertension by sexual orientation using objective measures of systolic and diastolic blood pressure. Logistic regressions showed that there were no differences in hypertensive risk between mostly heterosexual/bisexual identified-respondents and heterosexual-identified respondents among both men and women. Gay men, however, are almost twice as likely (odds ratio = 1.92, p <.01) to be hypertensive compared to heterosexual men. The elevated risk is not explained by measures of minority stress, nor by cardiovascular disease risk factors such as smoking, alcohol use, drug use, BMI, or physical activity. No differences in hypertension risk by sexual orientation were detected among female respondents. The results suggest that gay men face an excess risk for hypertension compared to heterosexual men that is not explained by differences in measured health behaviors.
doi:10.1007/s10900-013-9655-3
PMCID: PMC3642207  PMID: 23397511
Hypertension; Sexual orientation; Lesbians; Gays; Health behavior
8.  Self-reported barriers to colorectal cancer screening in a racially diverse, low-income study population 
Journal of community health  2013;38(2):285-292.
Colorectal cancer (CRC) screening is underutilized, especially in low income, high minority populations. We examined the effect test-specific barriers have on colonoscopy and fecal immunochemical test (FIT) completion, what rationales are given for non-completion, and what “switch” patterns exist when participants are allowed to switch from one test to another. Low income adults who were not up-to-date with CRC screening guidelines were recruited from safety-net clinics and offered colonoscopy or FIT (n=418). Follow up telephone surveys assessed test-specific barriers. Test completion was determined from patient medical records. For subjects who desired colonoscopy at baseline, finding a time to come in and transportation applied more to non-completers than completers (p = 0.001 and p < 0.001, respectively). For participants who initially wanted FIT, keeping track of cards, never putting stool on cards, and not remembering to mail cards back applied more to non-completers than completers (p = 0.003, p = 0.006, and p < 0.001, respectively). The most common rationale given for not completing screening was a desire for the other screening modality: 7% of patients who initially preferred screening by FIT completed colonoscopy, while 8% of patients who initially preferred screening by colonoscopy completed FIT. We conclude that test-specific barriers apply more to subjects who did not complete CRC screening. As a common rationale for test non-completion is a desire to receive a different screening modality, our findings suggest screening rates could be increased by giving patients the opportunity to switch tests after an initial choice is made.
doi:10.1007/s10900-012-9612-6
PMCID: PMC3560309  PMID: 22976770
colorectal cancer screening; barriers; FIT; colonoscopy; test preference
9.  Knowledge of Obesity and Its Impact on Reproductive Health Outcomes Among Urban Women 
Journal of community health  2013;38(2):261-267.
This prospective survey study assessed the knowledge of reproductive outcomes that are affected by obesity among women in an urban community. A total of 207 women attending a community fair on the south side of Chicago participated in the study. A survey assessing knowledge of BMI and of the effects of obesity on general, cardiometabolic and reproductive health outcomes was administered. Subjects ranged in age from 18 to 70 years (mean ± SD, 48.6 ± 12.9 years) and ranged in BMI from 17.3 to 52.1 kg/m2 (mean ± SD, 31.2 ± 6.7 kg/m2). The following percentages of women were aware that obesity increases the risk of miscarriage (37.5%), irregular periods (35.8%), infertility (33.9%), cesarean section (30.8%), breast cancer (28.0%), birth defects (23.7%), stillbirth (14.1%), and endometrial cancer (18.1%). This study found that while women in an urban community are aware of the cardiometabolic risks associated with obesity, they demonstrate limited knowledge of the effects of obesity on reproductive outcomes. Public education is needed to increase knowledge and awareness of the reproductive consequences of obesity. Women of reproductive age may be uniquely responsive to obesity education and weight loss intervention.
doi:10.1007/s10900-012-9609-1
PMCID: PMC3563852  PMID: 22961295
community health; knowledge; obesity; reproduction; women
10.  Substance and hookah use and living arrangement among fraternity and sorority members at US colleges and universities 
Journal of community health  2013;38(2):238-245.
Hookah tobacco smoking is associated with substantial toxicant exposures and is increasing among college students in the US. Greek (fraternity/sorority) students, especially those living in Greek housing, have high rates of risky alcohol use. The extent to which this is true for other substances, including hookah tobacco smoking, is not well known. The objective of this study is to examine associations between Greek involvement and living arrangement (non-member, non-resident member, resident member) and rates of hookah tobacco smoking, in relation to other substances, among US college students. We used national data from 82,251 student responses from the 2008–2009 administrations of the National College Health Assessment. Generalized estimating equations were utilized to determine adjusted odds ratios for substance use outcomes based on involvement and living arrangements, while adjusting for covariates and clustering of students within institutions. Among resident members, ever use was highest for marijuana (52.4%), hookah (48.5%) and cigarettes (46.6%). In multivariable models, adjusted odds were lowest for non-Greeks and highest for Greek resident members. Compared to non-Greeks, Greek resident members had nearly double the odds for current use of hookah, cigars, and marijuana, as well as two and a half times the odds for current use of smokeless tobacco and three times the odds for alcohol bingeing. Similar to other substances, hookah tobacco smoking is highest among Greek resident members, compared with both Greeks living outside Greek housing and non-Greeks. It is valuable for substance use surveillance and intervention to focus on Greek resident members.
doi:10.1007/s10900-012-9605-5
PMCID: PMC3594445  PMID: 22903805
tobacco; substance abuse; college; hookah; Greek-letter
11.  Low-income parents’ perceptions of pediatrician advice on early childhood education 
Journal of community health  2013;38(1):195-204.
BACKGROUND
The American Academy of Pediatrics recommends that pediatricians promote early childhood education (ECE). However, pediatricians have met resistance from low-income parents when providing anticipatory guidance on some topics outside the realm of physical health. Parents’ views on discussing ECE with the pediatrician have not been studied.
OBJECTIVES
We sought to understand low-income parents’ experiences and attitudes with regard to discussing early childhood education (ECE) with the pediatrician and to identify opportunities for pediatrician input.
METHODS
We conducted 27 in-depth, semi-structured, qualitative interviews with parents of 3- and 4-year-old patients (100% Medicaid, 78% African American) at an urban primary care center. Interviews were audio-recorded, transcribed verbatim, and reviewed for themes by a multidisciplinary team.
RESULTS
Most low-income parents in our study reported they primarily sought ECE advice from family and friends but were open to talking about ECE with the pediatrician. They considered their children’s individual behavior and development to be important factors in ECE decisions and appreciated pediatricians’ advice about developmental readiness for ECE. Participants’ decisions about ECE were often driven by fears that their children would be abused or neglected. Many viewed 3 years as the age at which children had sufficient language skills to report mistreatment and could be safely enrolled in ECE.
CONCLUSIONS
Participants were generally accepting of discussions about ECE during well child visits. There may be opportunity for the pediatrician to frame ECE discussions in the context of development, behavior, and safety and to promote high-quality ECE at an earlier age.
doi:10.1007/s10900-012-9642-0
PMCID: PMC3910351  PMID: 23324946
early childhood education; anticipatory guidance; well child care
12.  Substance Use and Sexual Risk Mediated by Social Support among Black Men 
Journal of community health  2013;38(1):62-69.
Health and social disparities are widespread among men who have sex with men (MSM). Although literature indicates that Black MSM (BMSM) are no more likely than other MSM to report sexual risk behaviors, such as unprotected anal intercourse, studies have reported that buying and trading sex appear to be important risk factors for BMSM. Substance use generally is not significantly greater among BMSM than other MSM, studies have found that BMSM report more powder and crack cocaine use than other MSM. The lack of adequate coping skills and social support for BMSM has also been documented. This paper examines differences in substance use, sexual risk behaviors and social support among Black and non-black MSM, in a sample of 515 men participating in a randomized intervention trial. BMSM reported higher rates of substance dependence (72.2% vs. 59.5%, P=.015) and buying sex (49.1% vs. 17.4%, P<.000) than non-Black MSM. BMSM also reported lower levels of social support than other MSM on all measures included in the study; e.g., getting help and emotional support from others (38.0% vs. 52.8%, P<.006). Mediation analyses showed that BMSM’s higher rates of substance dependence and buying sex are partially mediated by lower levels of social support. Our data appear to show that lack of social support is an important influence on risk behaviors among BMSM. Qualitative data also supported these findings. Sexual risk and substance use prevention interventions should address BMSM’s capacity to build adequate and supportive relationships.
doi:10.1007/s10900-012-9582-8
PMCID: PMC3502649  PMID: 22752575
African American; MSM; substance use; sexual risk behavior; social support
13.  Injection drug users trained by overdose prevention programs: Responses to witnessed overdoses 
Journal of community health  2013;38(1):133-141.
In response to the growing public health problem of drug overdose, community-based organizations have initiated overdose prevention programs (OPP), which distribute naloxone, an opioid antagonist, and teach overdose response techniques. Injection drug users (IDUs) have been targeted for this intervention due to their high risk for drug overdose. Limited research attention has focused on factors that may inhibit or prevent IDUs who have been trained by OPPs to undertake recommended response techniques when responding to a drug overdose. IDUs (n=30) trained by two OPPs in Los Angeles were interviewed in 2010–11 about responses to their most recently witnessed drug overdose using an instrument containing both open and closed-ended questions. Among the 30 witnessed overdose events, the victim recovered in 29 cases while the outcome was unknown in one case. Participants responded to overdoses using a variety of techniques taught by OPP. Injecting the victim with naloxone was the most common recommended response while other recommended responses included stimulating the victim with knuckles, calling 911, and giving rescue breathing. Barriers preventing participants from employing recommended response techniques in certain circumstances included prior successes using folk remedies to revive a victim, concerns over attracting police to the scene, and issues surrounding access to or use of naloxone. Practical solutions, such as developing booster sessions to augment OPP, are encouraged to increase the likelihood that trained participants respond to a drug overdose with the full range of recommended techniques.
doi:10.1007/s10900-012-9591-7
PMCID: PMC3516627  PMID: 22847602
Community-Based Organizations; Overdose Prevention; Naloxone; Injection Drug User
14.  Predictors of Hypertension Among Filipino Immigrants in the Northeast US 
Journal of community health  2013;38(5):847-855.
Hypertension remains disproportionately high among Filipinos compared to other racial and ethnic minority populations, and little research on cardiovascular disease risk factors has been conducted among Filipino immigrants in the Northeastern part of the United States. To determine hypertension prevalence and risk factors among Filipino Americans in the New York City area, blood pressure and other clinical measurements were taken from a sample of Filipino Americans during 119 community health screenings conducted between 2006 and 2010. Additional socio-demographic and health-related characteristics were also collected via a cross-sectional survey. A total of 1,028 Filipino immigrants completed the survey and had clinical readings collected. Bivariate analyses and logistic regression were performed in order to predict and assess risk factors for hypertension among our sample. Fifty-three percent of individuals were hypertensive, and half of hypertensive individuals were uninsured. Logistic regression indicated that older age, male gender, living in the United States for over 5 years, a BMI greater than 23.0 kg/m2, an elevated glucose reading, a family history of hypertension, and fair or poor self-reported health status were predictors of hypertension. There is a great need to develop more effective community-based interventions in the Filipino community to address cardiovascular health disparities.
doi:10.1007/s10900-013-9689-6
PMCID: PMC3894061  PMID: 23553685
Hypertension; Blood pressure; Ethnicity; Filipino Americans; Health status
15.  Impact of socioeconomic status and sociodemographic factors on melanoma presentation among ethnic minorities 
Journal of community health  2011;36(3):10.1007/s10900-010-9328-4.
Minority melanoma patients have worse survival. In this study, we evaluated the impact of socioeconomic and demographic factors on minority melanoma patients presenting to two different New York City hospitals (one public and one private) managed by the same multidisciplinary team. Sociodemographic and clinicopathologic characteristics were retrieved for melanoma patients presenting to Bellevue Hospital Center (BHC), a public hospital, and the New York University Cancer Institute (NYUCI), a private cancer center. Socioeconomic data was obtained from the United States Census Bureau database. The Kruskal-Wallis and chi-square tests were used to evaluate the associations between race/ethnicity and continuous and categorical variables (e.g. income, stage at presentation), respectively. Minorities comprised 2% (27/1296) of melanoma patients at the NYUCI compared to 42% (50/119) at BHC. Those presenting to the NYUCI were more likely to have a higher median household income (p=0.05), a higher educational level (p=0.04), and an earlier stage at presentation (p=0.02) than those at BHC. NYUCI patients were predominantly covered by commercial insurance (70%), whereas Medicaid (62%) was common among BHC patients. Only 19% of Hispanic patients at BHC chose English as their preferred language. Our data demonstrate that language and health care system factors affect melanoma presentation in minorities.
doi:10.1007/s10900-010-9328-4
PMCID: PMC3881593  PMID: 21080042
melanoma; socioeconomic status; minority health; delayed diagnosis; treatment
16.  Health and Health Care of Mothers and Children in a Suburban Area of Luanda, Angola 
Journal of Community Health  2013;39:617-626.
Population health data available in Angola are often insufficient to guide the planning of health interventions. To address this gap, the goal of the present study was to investigate the health of mothers and infants in a suburban municipality in Luanda (Cacuaco), in order to provide a baseline for future comparisons. This was a prevalence study investigating infants younger than 2 years of age and their mothers. Mothers were interviewed, and children’s height and weight were measured. Of 749 mothers interviewed, 98.5 % (95 % CI 98.2–99.1 %) had at least one prenatal visit and 51.7 % (95 % CI 47.4–56.3 %) had a health card. Most mothers with a health card had their first prenatal visit before the 20th week of pregnancy, and had at least four prenatal visits; 81.1 % (95 % CI 78.3–84.1 %) of mothers also had their child’s health card. Prevalence of exclusive breastfeeding at 6 months was 19 % (95 % CI 16.2–23.1 %). Prevalence of low height-for-age and low BMI-for-age were 32 and 6 %, respectively. Mothers with higher education levels were more likely to have had their first prenatal visit earlier, to have had more prenatal visits, to have given birth at a health facility, and to have her own and her child’s health cards. Results showed a high prevalence of prenatal care and a low frequency of acute malnutrition. Maternal education level, among factors studied, was the predominant correlate of more positive health behaviors. These findings suggest important progress of mother and child health in Cacuaco, and may serve as a baseline for the planning of health interventions.
doi:10.1007/s10900-013-9808-4
PMCID: PMC4000416  PMID: 24370599
Primary health care; Maternal health; Child health; Community health planning; Angola
17.  Community Variation in Adolescent Access to Indoor Tanning Facilities 
Journal of community health  2013;38(2):10.1007/s10900-012-9603-7.
Melanoma rates among younger women in New Hampshire (NH) are rising. In urban studies, youth proximity to tanning facilities has been linked to indoor tanning, a proven cause of melanoma. Youth access has not been examined in rural settings. To determine on a statewide basis the influence of rurality and community income level on female students' ease of access to tanning facilities, all NH tanning facilities (N = 261) and high schools (N = 77) in 2011 were spatially and statistically analyzed to determine schools with more facilities within 2 miles of the school and greater capacity (fewer female students per facility), for indoor tanning. Schools above the state-wide average for both measures were classified as “Easy Access” to indoor tanning. Among NH high schools, 74 % have 1 or more tanning facility within two miles and 22 % have “Easy Access” to tanning facilities. Ease of access did not differ by rurality. Lower-income school status was an independent predictor of both greater capacity and “Easy Access”. While urban and rural teens have similar access to indoor tanning, female students in lower-income communities have easier access. Variations in access by community size and income must be considered in planning interventions to address youth indoor tanning.
doi:10.1007/s10900-012-9603-7
PMCID: PMC3857705  PMID: 23011517
Recreational tanning; Skin neoplasms; Adolescence; Rural communities
18.  High Prevalence of Chronic Non-Communicable Conditions Among Adult Refugees: Implications for Practice and Policy 
Journal of community health  2012;37(5):10.1007/s10900-012-9552-1.
The global rise in non-communicable disease (NCD) suggests that US-based refugees are increasingly affected by chronic conditions. However, health services have focused on the detection of infectious disease, with relatively limited data on chronic NCDs. Using data from a retrospective medical record review of a refugee health program in the urban Northeast (n = 180), we examined the prevalence of chronic NCDs and NCD risk factors among adult refugees who had recently arrived in the US, with attention to region of origin and family composition. Family composition was included because low-income adults without dependent children are at high risk of becoming uninsured. We found that half of the adult refugees in this sample had at least one chronic NCD (51.1%), and 9.5% had three or more NCDs. Behavioral health diagnoses were most common (15.0%), followed by hypertension (13.3%). Half of adults were overweight or obese (54.6%). Chronic NCDs were somewhat more common among adults from Iraq, but this difference was not significant (56.8 vs. 44.6%). Chronic NCDs were common among adults with and without dependent children (61.4 vs. 44.6%, respectively), and these two groups did not significantly differ in their likelihood of having a chronic NCD after adjustment for age and gender (AOR = 0.78, 95% CI = 0.39, 1.55). This study suggests that chronic NCDs are common among adult refugees in the US, including refugees at high risk for uninsurance. We propose that refugee health services accommodate screening and treatment for chronic NCDs and NCD risk factors, and that insurance outreach and enrollment programs target recently arrived refugees.
doi:10.1007/s10900-012-9552-1
PMCID: PMC3857959  PMID: 22382428
Emigrant and immigrant/chronic diseases; Refugees/chronic diseases; Refugees/epidemiology
19.  Well-Being and Perceived Quality of Life in Elderly People Displaced After the Earthquake in L’Aquila, Italy 
Journal of Community Health  2013;39:531-537.
On 6 April 2009, the city of L’Aquila was hit by a violent earthquake that destroyed almost all of its medieval centre, and the surviving inhabitants were evacuated and relocated in temporary quarters or undamaged homes. The aim of this study was to investigate the perceived quality of life of the elderly population 3 years after the earthquake in relation to the social and logistic issues of new housing. The study was carried out between October 2011 and March 2012, and involved 571 subjects aged over 65 years living in the municipality of L’Aquila. The interviews took place in the surgeries of general practitioners and the city’s Department of Prevention and Vaccination in the anti-influenza immunisation period. The instrument used was a 36-item questionnaire with closed, multiple choice answers divided into the following sections: demographics, everyday activities, health and perceived health, and the quality of life in the city. The results show that, 3 years after the earthquake, the elderly population living in the new towns and temporary housing of L’Aquila have a worse perception of their quality of life than the others. They feel a certain social isolation and wish to live elsewhere. Governments faced with the problems arising from a natural calamity should take into account all of the elements making up a good quality of life and, before making choices whose impact cannot be changed, consider both their immediate and long-term social consequences.
doi:10.1007/s10900-013-9793-7
PMCID: PMC4000418  PMID: 24302517
Earthquake; Elderly; Quality of life; Social relationships
20.  Evaluating the Training of Filipino American Community Health Advisors to Disseminate Colorectal Cancer Screening 
Journal of community health  2012;37(6):1218-1225.
Community health advisor-led interventions are associated with improved health promotion behaviors, such as cancer screening, but the process of training community health advisors is rarely described and evaluated. We trained 91 Filipino Americans from 19 organizations to conduct small-group sessions with members of their organizations to promote colorectal cancer screening. Community health advisors completed brief pre- and post-training surveys that included knowledge of colorectal cancer screening guidelines (4 items), perceived self-efficacy of performing specific tasks (15-item scale, Cronbach’s alpha >.90) and satisfaction with the training itself (5 items). Community health advisors had high levels of knowledge and self-efficacy at pre-training, but levels increased significantly immediately after the 6-hour training (percent of knowledge items answered correctly: 63% to 94%; self-efficacy: 8.2 to 8.9 on a 10 point scale, both p<.001). Correlates of self-efficacy at pre- and post-test were high educational attainment, health care background, high level of participation in the organization, being perceived by others as a leader, and frequent participation in research activities in the past. Consistent evaluation measuring similar constructs across studies may help to standardize the quality of the training, and may improve the implementation of community health advisor-led programs.
doi:10.1007/s10900-012-9557-9
PMCID: PMC3383892  PMID: 22430865
lay health educator; community health educator; evaluation of training; self-efficacy; knowledge; satisfaction
21.  Appalachian Residents’ Perspectives on New U.S. Cigarette Warning Labels 
Journal of community health  2012;37(6):1269-1278.
Introduction
The U.S. Food and Drug Administration revealed new pictorial warning labels in June 2011 for cigarette packages, yet little is known about how these labels are perceived by U.S. residents. We examined the reactions to and attitudes about the new labels among residents of Appalachian Ohio, a region with a high smoking prevalence.
Methods
We conducted focus groups with Appalachian Ohio residents between July and October 2011. Participants included healthcare providers (n=30), community leaders (n=26), parents (n=28), and young adult men ages 18–26 (n=18).
Results
Most participants supported the addition of the new labels to U.S. cigarette packages, though many were unaware of the labels prior to the focus groups. Participants did not think the labels would be effective in promoting smoking cessation among smokers in their communities, but they were more positive about the potential of the labels to reduce smoking initiation. Smokers reported positive feedback about the more graphic labels, particularly those showing a man with a tracheal stoma or a person with severe oral disease. The labels that include a cartoon image of an ill infant and a man who quit smoking received the most negative feedback.
Conclusions
Participants generally supported adding pictorial warning labels to U.S. cigarette packages, but only a few of labels received mostly positive feedback. Results offer early insight into how the new labels may be received if they are put into practice.
doi:10.1007/s10900-012-9566-8
PMCID: PMC3430827  PMID: 22527659
smoking; warning label; cigarette; Appalachia
22.  Ohio Appalachia public health department personnel: Human papillomavirus (HPV) vaccine availability, and acceptance and concerns among parents of male and female adolescents 
Journal of community health  2012;37(6):1157-1163.
Public health departments (n=48) serving the 32 counties of Ohio Appalachia were contacted to determine human papillomavirus (HPV) vaccine availability and to assess patient and parental attitudes, perceived barriers, and decisional differences about vaccination for male and female adolescents. Nurses or nursing supervisors in 46 of 48 health departments agreed to participate with 45 (97.8%) reporting that HPV vaccines were available for males and females. HPV vaccination barriers reported most frequently were lack of knowledge about the vaccines, concerns about potential side effects, the newness of the HPV vaccines, and parents believing their children were not sexually active or were too young to receive an HPV vaccine. Provider reports of the primary differences in the acceptability of an HPV vaccine among parents of males compared to the parents of females were lack of awareness that an HPV vaccine was available for males, not understanding why the vaccine should be given to males, and fear of vaccination increasing sexual promiscuity among female adolescents. Half of the health departments (n=24) reported that parents of females were more receptive toward HPV vaccination, 16 health departments reported no difference in acceptability based on gender of the child, and 5 health departments reported that parents of males were more receptive. This study suggests that there are different informational needs of males and females and parents of male and female children when making an informed decision about HPV vaccination. Findings highlight content to include in strategies to increase HPV vaccination rates among Appalachia Ohio residents.
doi:10.1007/s10900-012-9613-5
PMCID: PMC3490016  PMID: 22968822
HPV vaccines; cervical cancer; health care disparities; adolescent; Appalachian region
23.  Ethnic differences in smoking rate, nicotine dependence, and cessation-related variables among adult smokers in Hawaii 
Journal of community health  2012;37(6):1226-1233.
This study tests hypotheses concerning ethnic disparities in daily cigarette smoking rates, nicotine dependence, cessation motivation, and knowledge and past use of cessation methods (e.g., counseling) and products (e.g., nicotine patch) in a multiethnic sample of smokers in Hawaii. Previous research has revealed significant differences in smoking prevalence among Native Hawaiians, Filipinos, Japanese, and Caucasians in Hawaii. However, no study has examined differences in dependence and cessation-related knowledge and practices among smokers representing these ethnic groups. Participants were recruited through newspaper advertisement as part of a larger smoking cessation intervention study. Participants (N=919; M age=45.6, SD=12.7; 48% Women) eligible to participate provided self-report data through mail and telephone. Participants included 271 self-identified Native Hawaiians, 63 Filipinos, 316 Caucasians, 145 “East Asians” (e.g., Japanese, Chinese), and 124 “Other” (e.g., Hispanic, African-American). Pair-wise comparisons of means, controlling for age, gender, income, education, and marital status, indicated that Native Hawaiian smokers reported significantly higher daily smoking rates and higher levels of nicotine dependence compared to East Asians. Native Hawaiian smokers reported significantly lower motivation to quit smoking than Caucasians. Further, Filipino and Native Hawaiian smokers reported lesser knowledge of cessation methods and products, and less frequent use of these methods and products than Caucasians. The results suggest that Native Hawaiian and Filipino smokers could be underserved with regard to receiving cessation-related advice, and may lack adequate access to smoking cessation products and services. In addition, cessation interventions tailored for Native Hawaiian smokers could benefit from a motivational enhancement component.
doi:10.1007/s10900-012-9558-8
PMCID: PMC3425666  PMID: 22438074
24.  Low HPV Vaccine Coverage among Female Community College Students 
Journal of community health  2012;37(6):1136-1144.
Objectives
This study assessed HPV vaccination and its correlates among culturally diverse 18–26 year-old community college women in Los Angeles. Specific research questions were: (1) What proportion of respondents have initiated the HPV vaccine, and what proportion have completed the three-dose series? (2) What demographic (e.g., age, ethnicity), psychosocial (e.g., vaccine-related beliefs, perceived social norms), and health care-related variables (e.g., health insurance status, provider recommendation, health care trust and satisfaction) are associated with vaccine initiation for this sample?
Method
Participants were recruited from the campus of a community college in central Los Angeles. All female students between 18 and 26 were eligible to participate. An anonymous web-based survey assessed number of HPV vaccine doses received as well as demographic information, HPV- and HPV vaccine-related knowledge, attitudes, and behavior, perceived social norms, provider & health care system factors, sexual behavior, cervical health, and mother-daughter communication about sex. Analyses were conducted using 178 surveys. Multivariate logistic regression tested the relationships of statistically significant bivariate predictors to vaccine initiation.
Results
Those who initiated the vaccine were younger, more often had a health-related academic major, thought the vaccine to be safer, perceived HPV severity lower, and perceived higher social approval for HPV vaccination than those unvaccinated. All who had initiated the vaccine had a doctor’s recommendation.
Conclusion
To increase uptake among 18–26-year-old women, research should explore provider interventions to increase vaccine recommendation, and also identify individuals and groups who may have negative beliefs about vaccine safety and efficacy to provide support in vaccine decision-making.
doi:10.1007/s10900-012-9572-x
PMCID: PMC3747828  PMID: 22669623
HPV vaccine; cervical cancer prevention; college women; community college; ethnic minority women
25.  Perception of Colonoscopy Benefits: A Gap in Patient Knowledge? 
Journal of community health  2012;37(3):10.1007/s10900-011-9506-z.
Purpose
To determine associations between specific colonoscopy patient characteristics, exam characteristics and patients’ perception of colonoscopy reducing their risk of dying from colorectal cancer.
Methods
A cross-sectional analysis was conducted using data (2004–2008) from the New Hampshire Colonoscopy Registry, consisting of a self-report questionnaire, colonoscopy report form, and a follow-up questionnaire, which included the question, “Having a colonoscopy decreased my chances of dying from colon cancer”. Chi-square tests and logistic regression were used to assess differences in patient responses by patient and colonoscopy characteristics.
Results
A majority of patients (N=5672, 81%) agreed that having a colonoscopy decreased their chances of dying from colon cancer. Patients with a personal history of polyps were more likely to agree that colonoscopy reduced their chances of dying compared to patients without prior polypectomy [OR (95% CI) = 1.34 (1.06, 1.69)] and patients with a family history of colorectal cancer were 33% more likely to agree to the statement than those without a family history [OR (95% CI) = 1.33 (1.12, 1.58)].
Conclusions
Personal history of polyps and family history of colorectal cancer are significant predictors of patients’ positive perception of colonoscopy, suggesting that personal experience may influence the perceived benefit of colonoscopy. Intervention efforts should be made to effectively disseminate knowledge of the benefit of colonoscopy.
doi:10.1007/s10900-011-9506-z
PMCID: PMC3839232  PMID: 22109385
colonoscopy; colorectal cancer; screening; patient perception

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