Grace X. Ma

Cervical Cancer Prevention: New Tools and Old Barriers

Cervical cancer is the second most common female tumor worldwide, and its incidence is disproportionately high (>80%) in the developing world. In the United States, in which Papanicolaou (Pap) tests have reduced the annual incidence to approximately 11,000 cervical cancers, >60% of cases are reported to 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, 2 new approaches for cervical cancer prevention have emerged: 1) HPV vaccination to prevent infections in younger women (aged ≤18 years) and 2) carcinogenic HPV detection in older women (aged ≥30 years). Together, HPV vaccination and testing, if used in an age‐appropriate manner, have the potential to transform cervical cancer prevention, particularly among underserved populations. Nevertheless, 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. In the current study, the delivery of cervical cancer prevention strategies to these US populations that experience a high cervical cancer burden (African‐American women in South Carolina, Alabama, and Mississippi; Haitian immigrant women in Miami; Hispanic women in the US‐Mexico Border; Sioux/Native American women in the Northern Plains; white women in the Appalachia; and Vietnamese‐American women in Pennsylvania and New Jersey) is reviewed. The goal was to inform future research and outreach efforts to reduce the burden of cervical cancer in underserved populations. Cancer 2010.

Between two worlds: the use of traditional and Western health services by Chinese immigrants.

This study examined the use of traditional and Western health services by Chinese immigrants, as well as the cultural and socioeconomic factors affecting health-seeking behaviors and health service utilization patterns among the study population from the perspectives of consumers and Chinese health care providers. Two instruments were used for data collection. The first, a consumer instrument, was designed for interviews of service recipients; the second, a health provider instrument, was designed to elicit information from traditional and Western providers. A few topics in the former instrument were cross-examined from the perspectives of health care providers. The investigation employed a combination of qualitative and quantitative research methods for data collection. Qualitative ethnographic methods used included: (1) participant-observation, (2) face-to-face interview, and (3) case study. To complement the qualitative data, structured quantitative survey were conducted with all selected informants. A total of 105 informants participated in the study: 75 Chinese consumers and 30 Chinese health professionals. The latter group was composed of Western physicians and traditional practitioners. Results revealed several patterns of health-seeking and service utilization behaviors among the Chinese of Houston and Los Angeles. These included high rates of self-treatment and home remedies (balanced diets and other alternative medicines); medium rates of utilization of integrated Western and traditional health services, including travel to country of origin for care; and low rates of exclusive utilization of Western or traditional Chinese treatments.

Model minority at risk: expressed needs of mental health by Asian American young adults.

The objective of this study is to obtain and discuss in-depth information on mental health problems, including the status, barriers, and potential solutions in 1.5 and 2nd generation Asian American young adults. As a part of the Health Needs Assessment project, the researchers conducted two focus groups with 17 young adults (mainly 1.5 or 2nd generation) from eight Asian American communities (Asian Indian, Cambodian, Chinese, Indonesian, Korean, Taiwanese, Thai, and Vietnamese) in Montgomery County, Maryland. We developed a moderator’s guide with open-ended questions and used it to collect qualitative data. Using a software, we organized and identified emergent themes by major categories. Participants reported a several common sources of stress that affect the mental health of Asian American young adults including: pressure to meet parental expectations of high academic achievement and live up to the “model minority” stereotype; difficulty of balancing two different cultures and communicating with parents; family obligations based on the strong family values; and discrimination or isolation due to racial or cultural background. Young Asian Americans tend not to seek professional help for their mental health problems; instead they use personal support networks—close friends, significant others, and religious community. Participants suggested that Asian cultural norms that do not consider mental problems important, and associated stigma of seeking professional care might undermine their mental health help seeking behavior. Our findings support a need for delivering culturally appropriate programs to raise awareness of mental health and cultural training for health providers to deliver culturally appropriate care.

A Multifaceted Intervention to Increase Cervical Cancer Screening among Underserved Korean Women

Objective: Despite the proven survival benefits associated with cervical cancer screening, use of the Pap test continues to be suboptimal in some population subgroups, such as among Korean-American women who face considerable barriers to screening. Therefore, we evaluated a multifaceted intervention that combined psychoeducational counseling with patient navigation to address both psychosocial and access barriers to screening. Method: Women (n = 102) were recruited from Korean community centers and assigned to the intervention or control condition. The intervention group received cervical cancer education and patient navigation delivered by bilingual Korean health educators. The control group received general health education, including information about cervical cancer and screening. Assessments were obtained at baseline and postintervention. Screening behavior was assessed at 6 months postintervention. Results: At baseline, 17% of participants reported having had a Pap test in the previous year. At 6 months postintervention, 83% of women in the intervention group had obtained screening compared with 22% in the control group, χ2(1) = 41.22, P < 0.001. Multivariate logistic regression analyses indicated that participation in the intervention was associated with screening (P < 0.001). Fewer psychosocial barriers (e.g., discomfort at having a stranger perform Pap) and greater self-efficacy were also associated with screening (P < 0.05). Conclusion: A combined modality intervention that delivers education with patient navigation training and assistance resulted in increased screening rates. Multifaceted approaches may be effective in reducing the psychosocial, access, and language barriers that contribute to cancer health disparities in underserved populations. (Cancer Epidemiol Biomarkers Prev 2007;16(6):1–5)

Prevalence and Predictors of Tobacco Use Among Asian Americans in the Delaware Valley Region

OBJECTIVES This study examined tobacco use rates and potential predictors of use among Asian Americans residing in the Delaware Valley region. METHODS A cross-sectional survey design was used. The sample consisted of 1174 Chinese, Koreans, Vietnamese, and Cambodians. RESULTS Findings indicated that the mean age at initiation of tobacco use was 18.3 years. Among the respondents, 40.2% had a history of tobacco use, and 29.6% were current users. Men were more likely than women to smoke. There were significant differences between never smokers, current smokers, and ex-smokers in sex, ethnicity, educational attainment, and marital and employment status. CONCLUSIONS The findings suggest that tobacco use is still a serious public health problem among Asian Americans, especially men.

Community-based colorectal cancer intervention in underserved Korean Americans

BACKGROUND Despite evidence of a decline in both incidence and prevalence of colorectal cancer nationwide, it remains the second most commonly diagnosed cancer and the third highest cause of mortality among Asian Americans, including Korean Americans. This community-based and theoretically guided study evaluated a culturally appropriate intervention program that included a bilingual cancer educational program among Korean Americans including information on CRC risks, counseling to address psychosocial and access barriers, and patient navigation assistance. METHODS A two-group quasi-experimental design with baseline and post-intervention assessment and a 12-month follow-up on screening was used in the study. Korean Americans (N=167) were enrolled from six Korean churches. The intervention group received culturally appropriate intervention program addressing accessibility and psychosocial barriers, and navigation assistance for screening. The control group received general health education that included cancer-related health issues and screening. RESULTS There was a significant difference (p<0.05) between the post-intervention and control groups in awareness of CRC risk factors. There was also a significant improvement in the pre-post across HBM measures in the intervention group for perceived susceptibility (p<0.05) and benefits and barriers to screening (p<0.001). At baseline, 13% of participants in the intervention group and 10% in control group reported having had a CRC cancer screening test in the previous year. At the 12-month post-intervention follow-up, 77.4% of participants in the intervention group had obtained screening compared to 10.8% in the control group. CONCLUSION While health disparities result from numerous factors, a culturally appropriate and church-based intervention can be highly effective in increasing knowledge of and access to, and in reducing barriers to CRC screening among underserved Koreans.

Knowledge, Attitudes, and Behaviors of Hepatitis B Screening and Vaccination and Liver Cancer Risks Among Vietnamese Americans

Hepatitis B Virus (HBV) infection is a serious health problem among Asian Americans. Vietnamese Americans are disproportionately affected by liver cancer compared with other racial and ethnic groups. Vietnamese males have the highest incidence of liver cancer of any racial group; incidence of liver cancer among Vietnamese males is 11 times higher than among White males. Nearly 80% of liver cancer is attributed to HBV. This study measured knowledge, attitudes, and behaviors related to HBV screening and vaccination. The study was conducted among 256 Vietnamese Americans in the greater Philadelphia and New Jersey area, with a large number of underserved, recent immigrants with low socioeconomic status and limited English proficiency. Participants were recruited from Vietnamese community-based organizations. Overall, 46.3% of the sample had heard of HBV or knew about the availability of screening (32.6%) or vaccination (35.5%) while 7.5% were ever screened and 6.3% had been vaccinated. Community-based, culturally appropriate interventions for Vietnamese Americans and health care providers should increase screening and vaccination rates.

Operationalization of community-based participatory research principles: Assessment of the National Cancer Institute's Community Network Programs

OBJECTIVES We examined how National Cancer Institute-funded Community Network Programs (CNPs) operationalized principles of community-based participatory research (CBPR). METHODS We reviewed the literature and extant CBPR measurement tools. On the basis of that review, we developed a 27-item questionnaire for CNPs to self-assess their operationalization of 9 CBPR principles. Our team comprised representatives of 9 of the National Cancer Institutes 25 CNPs. RESULTS Of the 25 CNPs, 22 (88%) completed the questionnaire. Most scored well on CBPR principles of recognizing community as a unit of identity, building on community strengths, facilitating colearning, embracing iterative processes in developing community capacity, and achieving a balance between data generation and intervention. CNPs varied in the extent to which they employed CBPR principles of addressing determinants of health, sharing power among partners, engaging the community in research dissemination, and striving for sustainability. CONCLUSIONS Although the development of assessment tools in this field is in its infancy, our findings suggest that fidelity to CBPR processes can be assessed in a variety of settings.

Factors associated with mental health service use in Latino and Asian immigrant elders.

Objectives: The purpose of this study was to examine factors associated with the mental health service use of Latino and Asian immigrant elders. Adapting Andersens behavioral health model of health service utilization, predisposing, enabling, and mental health need factors were considered as potential predictors for use of mental health services. Method: Data were drawn from a nationally representative dataset, the National Latino and Asian American Survey (NLAAS). Hierarchical logistic regression analyses of mental health service use were conducted for Latino (N = 290) and Asian (N = 211) immigrant elders. Results: For both groups of immigrant elders, poor self-rated mental health was associated with significantly greater mental health service use, even after controlling for all other variables. For Latinos, use of mental health services was significantly associated with both predisposing factors (being younger and female) and mental health need factors (having any mood disorders and poor self-rated mental health). Among Asians, only mental health need factors (having any mood disorders and poor self-rated mental health) significantly affected mental health service use. In addition, poor self-rated mental health mediated the association between mood disorders and mental health service use only in Latino immigrant elders. Conclusion: Results highlight an important role of self-rated mental health as a potential barrier in the use of mental health services, and suggest intervention strategies to enhance service use.

Evidence-Based Intervention to Reduce Access Barriers to Cervical Cancer Screening Among Underserved Chinese American Women

OBJECTIVE The primary objective of the present study was to evaluate the effects of a community-based pilot intervention that combined cervical cancer education with patient navigation on cervical cancer screening behaviors among Chinese American women residing in New York City. METHODS Chinese women (n = 134) who had not had a Pap test within the previous 12 months were recruited from four Asian community-based organizations (CBOs). Women from two of the CBOs received the intervention (n = 80) consisting of education, interaction with a Chinese physician, and navigation assistance, including help in identifying and accessing free or low-cost screening services. The control group (n = 54) received education delivered by Chinese community health educators and written materials on general health and cancer screening, including cervical cancer, the Pap test, and information about sites that provided free screening. Study assessments were obtained in-person at baseline and postintervention. Screening behavior was self-reported at 12-month postintervention and verified by medical staff. RESULTS In the 12-month interval following the program, screening rates were significantly higher in the intervention group (70%) compared to the control group (11.1%). Hierarchical logistic regression analyses indicated that screening behavior was associated with older age (OR = 1.08, 95% CI = 1.01-1.15, p < .05). In addition, women with poorer English language fluency (OR = 0.30, 95% CI = 0.10-0.89, p < .05) and who did not have health insurance were less likely to obtain screening (OR = 0.15, 95% CI = 0.02-0.96, p < .05). Among health beliefs, greater perceived severity of disease was positively associated with screening behavior (OR = 4.26, 95% CI = 1.01-18.04, p < .05). CONCLUSIONS Community-based programs that provide combined education and patient navigation may be effective in overcoming the extensive linguistic and access barriers to screening faced by Chinese American women.