Dorcas Grigg-Saito

Building on the Strengths of a Cambodian Refugee Community Through Community-Based Outreach

Literature and practice are limited on strategies to reach elder Southeast Asian refugees by using their strengths and resilience. This article presents the Centers for Disease Control and Prevention—funded Cambodian Community Health 2010 Program in Lowell, Massachusetts, as a case example and provides refugee history, project background, community survey results about strengths and risks, literature on strengths-based approaches, outreach activities, and evaluation. The focus is elimination of health disparities in cardiovascular disease and diabetes. “Community conversations” and a daylong forum with community leaders were used to develop plans for outreach. A Cambodian Elders Council provided information and guidance used to refine the program. Key findings highlight involving elders in organizing events, avoiding reliance on literacy, integrating health promotion with socialization, using ties with Buddhist temples, developing transportation alternatives, and utilizing local Khmer-language media. Implications include applicability to other refugee communities with low literacy, high levels of trauma, limited English, and strong religious involvement.

Hepatitis B Testing and Vaccination Among Vietnamese- and Cambodian-Americans

We determined hepatitis B virus (HBV) testing and vaccination levels and factors associated with testing and vaccination among Vietnamese- and Cambodian-Americans. We also examined factors associated with healthcare professional (HCP)-patient discussions about HBV. We analyzed 2006 Racial and Ethnic Approaches to Community Health (REACH) 2010 Risk Factor Survey data from four US communities. We used logistic regression to identify variables associated with HBV vaccination, testing, and HCP-patient discussions about HBV. Of the 2,049 Vietnamese- and Cambodian-American respondents, 60% reported being tested for HBV, 35% reported being vaccinated against hepatitis B, and 36% indicated that they had discussed HBV with a HCP. Cambodian-Americans were less likely than Vietnamese-Americans to have been tested for HBV, while respondents with at least a high school diploma were more likely to have been tested for HBV. Respondents born in the US, younger individuals, and respondents with at least some college education were more likely to have been vaccinated against hepatitis B. HBV testing and vaccination remain suboptimal among members of these populations. Culturally sensitive efforts that target Vietnamese- and Cambodian-Americans for HBV testing and vaccination are needed to identify chronic carriers of HBV, prevent new infections, and provide appropriate medical management. HCPs that serve these populations should be encouraged to discuss HBV with their patients.

Self-Reported Health among Cambodians in Lowell, Massachusetts

National health data reported for Asians in the aggregate present a picture of good health, but significant health disparities exist between Southeast Asian refugees, and Cambodians in particular, and the overall population of the U.S. To effectively address health disparities, ethnically specific data is needed. Data from a community survey of 381 Cambodian adults 25 years of age and older are presented. Overall, 44% of respondents reported fair or poor health. Using multivariate logistic regression, we examined the relationships between self-rated health and demographics, timing of immigration, language use and literacy, and access to health care. In our final model those most likely to report fair or poor health were female, older, unable to work due to disability, to have spent a smaller proportion of their life in the U.S., and to have wanted to see a doctor in the past year, but not been able to.

Decreases in Smoking Prevalence in Asian Communities Served by the Racial and Ethnic Approaches to Community Health (REACH) Project

OBJECTIVES We examined trends in smoking prevalence from 2002 through 2006 in 4 Asian communities served by the Racial and Ethnic Approaches to Community Health (REACH) intervention. METHODS Annual survey data from 2002 through 2006 were gathered in 4 REACH Asian communities. Trends in the age-standardized prevalence of current smoking for men in 2 Vietnamese communities, 1 Cambodian community, and 1 Asian American/Pacific Islander (API) community were examined and compared with nationwide US and state-specific data from the Behavioral Risk Factor Surveillance System. RESULTS Prevalence of current smoking decreased dramatically among men in REACH communities. The reduction rate was significantly greater than that observed in the general US or API male population, and it was greater than reduction rates observed in the states in which REACH communities were located. There was little change in the quit ratio of men at the state and national levels, but there was a significant increase in quit ratios in the REACH communities, indicating increases in the proportions of smokers who had quit smoking. CONCLUSIONS Smoking prevalence decreased in Asian communities served by the REACH project, and these decreases were larger than nationwide decreases in smoking prevalence observed for the same period. However, disparities in smoking prevalence remain a concern among Cambodian men and non-English-speaking Vietnamese men; these subgroups continue to smoke at a higher rate than do men nationwide.

Long-term development of a "whole community" best practice model to address health disparities in the Cambodian refugee and immigrant community of Lowell, Massachusetts.

Cambodians in Lowell, Massachusetts, experience significant health disparities. Understanding the trauma they have experienced in Cambodia and as refugees has been the starting point for Lowell Community Health Centers whole community approach to developing community-based interventions. This approach places physical-psychosocial-spiritual needs at the center of focus and is attentive to individual and institutional barriers to care. Interventions are multilevel. The effect of the overall program comes from the results of each smaller program, the collaborations and coordination with the Cambodian community and community-based organizations, and the range and levels of services available through the health center.

Long-Term Refugee Health: Health Behaviors and Outcomes of Cambodian Refugee and Immigrant Women

Refugees in the United States have high rates of chronic disease. Both long-term effects of the refugee experience and adjustment to the U.S. health environment may contribute. While there is significant research on health outcomes of newly resettled refugees and long-term mental health experiences of established refugees, there is currently little information about how the combined effects of the refugee experience and the U.S. health environment are related to health practices of refugees in the years and decades after resettlement. We examined cross-sectional survey data for Cambodian refugee and immigrant women 35 to 60 years old (n = 160) from an established refugee community in Lowell, Massachusetts, to examine the potential contributors to health behaviors and outcomes among refugees and immigrants postresettlement. In our representative sample, we found that smoking and betel nut use were very low (4% each). Fewer than 50% of respondents walked for at least 10 minutes on 2 or more days/week. Using World Health Organization standards for overweight/obese for Asians, 73% of respondents were overweight/obese and 56% were obese, indicating increased risk of chronic disease. Depression was also high in this sample (41%). In multivariate models, higher acculturation and age were associated with walking more often; lower education and higher acculturation were related to higher weight; and being divorced/separated or widowed and being older were related to higher risk of depression. The interrelated complex of characteristics, health behaviors, and health outcomes of refugees merits a multifaceted approach to health education and health promotion for long-term refugee health.

Eight Americas: differences in Asian communities are important.

The article “Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States” [1] reports on what the authors describe as racial differences in mortality. The authors analyze what they label the “eight Americas” (i.e., Asian; Northland low-income rural white; Middle America; low-income whites in Appalachia and the Mississippi Valley; Western Native American; Black Middle America; Southern low-income rural black; high-risk urban black). In contrast to other races, “Asian” is treated as a single homogenous category. Income and geographical differences are not considered. The authors point out that they have likely collapsed across differences with the “Asian” category, but they go on to report their results as if such differences are inconsequential. They are not. With regard to health disparities, such differences are particularly important. Consider recent findings that speak to health differences within the nominal category of “Asian.” As a part of the Center for Disease Control and Preventions Racial and Ethnic Approaches to Community Health (REACH) 2010 program [2], a survey was conducted in 2001–2002 with a sample of Vietnamese in several counties in California and Cambodians in Lowell, Massachusetts (the second largest Cambodian community in the US). Comparing the results to the national 2002 Behavior Risk Factor Surveillance System survey that aggregates all Asian responses, the Koch-Weser et al. data indicate that the educational level and income of Cambodians and Vietnamese were substantially lower than all Asians, and that Cambodians and Vietnamese were three times more likely than other Asians to not have visited a doctor in the past year due to financial reasons. In addition, in comparison to all Asians or the general population, higher proportions of Cambodian and Vietnamese men reported smoking (50.4% and 30.4% respectively compared to 14.7% of aggregated Asians), and Cambodian and Vietnamese of both genders reported eating fewer vegetables (16.4% and 11.1%). And in the case of important chronic health problems such as diabetes, only 47.7% of Cambodians surveyed reported having their cholesterol checked and 41.9% reported having a hemoglobin A1c test conducted if they had diabetes. A 2002 representative survey of Cambodian adults over age 25 in Lowell, Massachusetts [3] found that Cambodians were more likely to report poor health than other Massachusetts residents (9% compared to 2%). Cambodian women and elders were much more likely to have experienced days of poor physical health (6.5 days on average for women and 8 days those over 50). A quarter of the Cambodian elders were symptomatic for depression, with the rate rising to 43% among women 50 and over. Although only 6% reported being uninsured, 23% wanted to see a doctor in the last year but could not, and 44% did not because of transportation problems. In short, existing findings indicate how diverse the health data can be within the overall category of “Asian.” The authors are to be applauded for their recognition of how misleading it can be to treat the categories of “blackness” or “whiteness” in undifferentiated ways. Unfortunately they have failed to extend that same understanding to the analysis they select for the category of Asians. As researchers and policy makers use the “Eight Americas” study to guide their efforts, the result could well be misleading interpretations that do a disservice to those very groups within the “Asian” category who face daily struggles with significant health problems and poor access to health care.

Using qualitative methods to develop a contextually tailored instrument: Lessons learned

Objective: To develop a population-specific instrument to inform hepatitis B virus (HBV) and human papilloma virus (HPV) prevention education and intervention based on data and evidence obtained from the targeted population of Khmer mothers reflecting their socio-cultural and health behaviors. Methods: The principles of community-based participatory research (CBPR) guided the development of a standardized survey interview. Four stages of development and testing of the survey instrument took place in order to inform the quantitative health survey used to collect data in stage five of the project. This article reports only on Stages 1-4. Results: This process created a new quantitative measure of HBV and HPV prevention behavior based on the revised Network Episode Model and informed by the targeted population. The CBPR method facilitated the application and translation of abstract theoretical ideas of HBV and HPV prevention behavior into culturally-relevant words and expressions of Cambodian Americans (CAs). Conclusions: The design of an instrument development process that accounts for distinctive socio-cultural backgrounds of CA refugee/immigrant women provides a model for use in developing future health surveys that are intended to aid minority-serving health care professionals and researchers as well as targeted minority populations.

CALL ME: meeting Asian youth where they are.

AFTER MORE THAN TWENTY years of working with inner-city youth, the Lowell, MA, Community Health Center Teen Coalition introduced its first Teen Help Card in 2002 (Images 1 and ​and2).2). Experience had shown that the best way to promote health care and social services to this segment of youth was by word-of-mouth, and this is what led to the Teen Help Cards’ success in outreach efforts. IMAGE 1 Lowell Community Health Center Teen Coalition 2008 Teen Help Card inside spread. IMAGE 2 Lowell Community Health Center Teen Coalition 2008 Teen Help Card outside spread. Through the organization of the Teen Coalitions Cambodian Youth Development Partnership, youth leaders created a social marketing campaign, “CALL ME,” solely to advertise the Teen Help Card. The campaign consisted of the creation of a t-shirt that matched the design of the card to provoke questions and discussion on what the slogan “CALL ME” was about. The card has a long list of phone numbers for local youth service agencies. Service categories include domestic violence, teen pregnancy prevention, HIV/AIDS counseling and testing, jobs, education and training, health care, gay and lesbian support programs, and drug counseling. Just as important as the mode of dissemination was the design of the card. The Teen Help Cards design had to speak to youth culture—otherwise it would end up in the trash along with so many other resource materials for youth. The card, with its silver-inked type on black cardstock, is young, urban, and fresh. To maintain the appeal of the Teen Help Card, it is updated every other year. Each year teams of youth leaders from the Lowell Community Health Center Teen Coalition, as well as other local youth service agencies, promote the pocket-sized cards on the street in places where youth congregate, distributing more than 10 000 cards annually in the greater Lowell area (Image 3). IMAGE 3 Lowell Community Health Center Teen Coalition Southeast Asian peer leaders participating in peer-to-peer outreach. The impact of the card has been phenomenal. No other piece of media provides such an extensive directory of local youth services. In a community where services are difficult to access, and personal barriers keep youth from seeking out these critical services, the Teen Help Card is connecting youth to assistance. The Lowell Community Health Center Teen Coalitions philosophy of meeting youth where they are—in this case on the street, in schools, and in transition—has put the Teen Help Card in the hands of tens of thousands of local youth.