Kevin Cassel

Using Drama to Prevent Teen Smoking: Development, Implementation, and Evaluation of Crossroads in Hawai`i

The use of drama as a preventive education measure has demonstrated success in various health promotion venues and offers promise in promoting positive youth attitudes and behavior change related to tobacco use. Especially important is a need to implement culturally relevant methods to reach youth. This article describes the development and implementation of a tobacco prevention drama for Asian and Pacific Islander youth. The resulting play, Crossroads, features a soap opera-style drama interspersed with humorous vignettes and multimedia effects and incorporates cultural cues, mannerisms, dress, and values consistent with Asian and Pacific Islander youth culture. Evaluation data indicate that the drama has an effect on audience knowledge, attitudes, and intended behavior, including a change in future intent to smoke cigarettes and the ability of audience members to develop connections with the characters in the play and apply concepts that are presented in the play to their own lives.

Health Information Seeking, Source Trust, and Culture: A Comparative Analysis of Health Information Trends and Needs Between Guam and the United States.

The Guam population offers a unique glimpse into Americans of Pacific Island ancestry and their communication and information-seeking behaviors, experiences, and needs relevant to cancer. National surveys do not typically include the U.S. territories, so there are limited data on the health and cancer information–seeking behaviors of these populations, in which health disparities persist. To fill this information gap, we conducted a survey on health communication in Guam using a modified version of the Health Information National Trends Survey instrument supplemented with items measuring specific cultural factors and communication practices. The results of the survey (N = 511) revealed some differences in health and cancer information–seeking patterns in Guam and the mainland United States. Sociodemographic variables, including sex, age, education, income, and employment, were significantly associated with health and cancer information seeking and Internet use. Levels of trust in various information sources were differentiated in the Guam and mainland U.S. samples. Logistic regression models revealed differences in factors predicting health and cancer information seeking and Internet use. The results suggest that these health information–seeking patterns and factors should be taken into account when developing communication strategies for more effective prevention and control programs.

HIV-Associated Anal Dysplasia: Experience from a Multiethnic-HIV Clinic in Hawaii

Purpose. To assess the proportion as well as predictors of anal dysplasia in HIV-infected Asian/Pacific Islanders. Methods. This was a retrospective chart review evaluating the proportion of anal dysplasia among a multiethnic population from an ambulatory university-based HIV clinic in Hawaii. Demographic, clinical, and virologic parameters were examined with respect to abnormal anal Pap smear. Variables included: Pap smear results (outcome variable), cytology results, age, self-reported ethnicity, CD4/ nadir CD4 counts, HIV viral load, antiretroviral therapy use, Hepatitis B and C co-infections, history of sexually transmitted diseases, personal history of cancer, tobacco use, alcohol use, intravenous drug abuse, family history of cancer, and history of genital/anal warts. Results. There were no significant differences in rates of abnormal Pap smear among the ethnic groups. Abnormal Pap smears were associated with history of genital warts (7% normal vs. 18% abnormal, p=.01) and alcohol consumption (16% vs. 27%, p=.05). Hepatitis B infection and current anti-retroviral therapy (ART) were associated with normal Pap cytology (9.7% vs. 0%, p=.03) and (96.8% vs. 86.5%, p=.05) respectively. Conclusions. No differences in the proportion of abnormal Pap smears were seen among ethnic groups followed within an ambulatory HIV clinic.

The Cancer Information Service: Using CBPR in Building Community Capacity

The National Cancer Institutes (NCIs) Cancer Information Service (CIS) Partnership Program followed many of the key principles of community-based participatory research in providing technical assistance to partner organizations. Using five case studies, this article describes how the CIS Partnership Program served to identify community needs and leaders, bringing resources together to build capacity and increase knowledge, and facilitate further dissemination of findings. CIS Partnership Program staff transcended the traditional health education role by building the capacity of community partners to bring cancer information in culturally appropriate ways to their own communities. The lessons learned by the CIS Partnership Program are useful for both academics and service organizations that would benefit from working with medically underserved communities.

Samoan Body and Soul Adapting an Evidence-Based Obesity and Cancer Prevention Program

Obesity-associated chronic diseases persist in Samoan populations in the United States. Samoans and African Americans share cultural similarities such as church affiliation, perceptions of weight and body size, and obesity-related health risks. Adapting an effective energy balance intervention originally designed for African Americans—Body and Soul—might be useful in reducing obesity among U.S. Samoans. To determine potential attractiveness and adaptations, we used aspects of grounded theory to analyze key-informant and focus group interviews with 31 purposively selected Samoans in Hawaii. We incorporated participatory features into the research with Samoan community members conducting parts of the study. From interview narratives, we identified relevant themes from Samoan culture, such as fa’aSamoa or the Samoan way, and specific energy balance activities to include in an obesity and cancer prevention intervention for U.S.-dwelling Samoans. Our findings describe methods to address health disparities by incorporating culturally appropriate health concepts into existing evidence-based interventions.

Sugar and Aldehyde Content in Flavored Electronic Cigarette Liquids

Introduction Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66). Methods Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fishers exact test, and Pearsons correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations. Results Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose. Conclusions Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity. Implications The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDAs interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.

Abstract A24: Pilot study to improve colon cancer screening for Native Hawaiian men

Purpose: Our pilot study, “No Ke Ola Pono o Na Kane”, used an existing peer-led, health-activated support group model employing the traditional Hawaiian practice of the “hale mua” (men9s house) to address health disparities in colon cancer screening among Native Hawaiian men (kane). The hale mua historically provided an opportunity for dialogue among kane about the methods used to sustain families, training needed for the initiation of young men into manhood, and for teaching the traditions of culture and family. Using a community-based approach, we repurposed and integrated this cultural practice into the study to promote health and well-being among Hawaiian men, including the use of Fecal Immunochemical Tests (FIT) in kane over age 50 who have not been screened for colon cancer. Background: In Hawai‘i, Hawaiian men have one of the highest death rates from colon cancer and are diagnosed at later stages compared to other racial/ethnic and gender groups. Early and regular screening for precancerous lesions can prevent 90% of colon cancers. However, Hawaiian men have limited access and are not as likely as other groups to be screened. Data from the Hawai‘i Behavioral Risk Factors Surveillance System (BRFSS), show that more than 58% of Native Hawaiian men over age 50 have never been screened for colon cancer. Research has demonstrated that community-based social networks may help Hawaiian men adopt healthy behaviors including colon cancer screenings. However, few studies have focused on utilizing existing social networks to promote colon cancer screening among Native Hawaiian men. Methods: Our pilot study was conducted statewide in Hawaii in 2015 over a 16 month period. Study staff adapted an existing peer-led model and recruited community volunteers to help deliver the intervention. Using a community participatory approach, No Ke Ola Pono o Na Kane9s education and discussion sessions were directed by a set of 3 Native Hawaiian facilitators including: 1) an Alaka‘i (leader); 2) a Kokua (scribe/support person); and 3) a Kauka (physician). The sessions were delivered through use of a standardized set of education and training materials. The session topics included: 1) a No Ke Ola Pono o Na Kane overview 2) Colorectal/Na‘au Health, 3) Lung Health, and 4) Oropharyngeal/Po‘o and Pu‘u Health. Each community site offered at least 3 of the 4 sessions. Each session9s health education component was delivered using a large printed flip chart. The flip chart content followed a standardized structure which included: 1) facilitator instructions; 2) a Mo‘olelo, a Hawaiian proverb that frames the health topic; 3) key facts; 4) a health-related discussion question; and 5) a wrap-up and evaluation. This standardized structure minimized the need for rigorous training for men to conduct the sessions confidently. Results: During the first year, a total of 170 kane attended one or more of the 20 statewide sessions. Attendance at each session averaged between 15-20 men, with 59% of men age 50 or over. Data from a survey of the 63 men attending the colon health session showed that 90% improved their knowledge about colon health, and approximately 50% (N=31) had not had a doctor discuss colon health or screening with them. Twenty five of the 63 kane who attended the colon sessions were eligible to take the FIT, five had been previously screened and 12 completed the tests with negative results. The overall session evaluations demonstrated that more 90% of men liked the hale mua approach and benefited from talking with other men about their health. Conclusions: This pilot study provided the initial proof-of-principal for our strategy to utilize the hale mua and social support to recruit Hawaiian men to participate in a colon screening education program and to adopt use of the FIT. The pilot data can be used to develop a larger randomized trial that examines how participation and content of sessions is associated with screening uptake. Citation Format: Kevin Cassel, Claire Hughes, Paula Higuchi, Pebbles Fagan, Palama Lee, S. Kalani Brady. Pilot study to improve colon cancer screening for Native Hawaiian men. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A24.

Addressing Risk and Reluctance at the Nexus of HIV and Anal Cancer Screening

Anal cancer disproportionately burdens persons living with human immunodeficiency virus (PLHIV) regardless of natal sex, sexual orientation, gender expression, and ethnic identity. Culturally competent communications are recommended to address health disparities, with sociocultural relevance ensured through constituent dialogic processes. Results are presented from six provider focus groups conducted to inform the promotion/education component of a Hawai‘i-based project on anal cancer screening tools. Krueger’s focus group methodology guided discussion queries. Verbatim transcripts of digitally recorded discussions were analyzed using grounded theory and PEN-3 procedures. Adherence to an audit trail ensured analytic rigor. Grounded theory analysis detected the overall theme of risk and reluctance to anal cancer screening, characterized by anal cancer not being “on the radar” of PLHIV, conflicting attributions of the anus and anal sex, fear of sex-shaming/-blaming, and other interrelated conceptual categories. PEN-3 analysis revealed strategies for destigmatizing anal cancer, through “real talk” (proactive, candid, nonjudgmental discussion) nested in a framework of sexual health and overall well-being, with additional tailoring for relevance to Native Hawaiians/Pacific Islanders, transgender persons, and other marginalized groups. Application of strategies for health practice are specific to the Hawai‘i context, yet may offer considerations for developing strengths-based, culturally relevant screening promotion/education with diverse PLHIV in other locales.

Abstract B56: Adapting SunSafe: A skin cancer prevention intervention for use with multiethnic high school students

Skin cancers are one of the most preventable types of cancer. However, since 2004, skin cancer incidence rates have increased 3% each year in the U.S. In 2015, more than 3 million Americans will develop skin cancer and 76,000 will need treatment for the most deadly form, melanoma. More than

Menthol cigarette smoking and obesity in young adult daily smokers in Hawaii

2.4 billion is spent annually on therapies, which does not consider the morbidity from disfiguring treatments. Increased exposure to ultraviolet radiation (UVR) from the sun or artificial sources is a primary risk factor and half the lifetime skin damage from UVR overexposure occurs before age 20. Recently, skin cancer prevention interventions delivered in U.S. primary and middle schools have demonstrated effectiveness. However, there is deficiency in interventions for high school students, whose health behaviors are transitioning from the purview of parents or caretakers. Changes in social norms, risk-taking and the desire for sexual appeal affect this group9s UVR exposure patterns and their perceived skin cancer risk. Few studies have addressed sun protection in multiethnic high school students, who underestimate their skin cancer risk. To address this gap we conducted a pilot study using both qualitative and quasi-experimental designs to investigate whether a school-based intervention entitled, SunSafe In the Middle School Years (SunSafe), could be adapted for use in a multiethnic high school in Honolulu, HI. We used qualitative research methods to incorporate information from discussions with students, parents, teachers and community members to adapt the program. Discussion themes provided strategies that were integrated into the existing SunSafe program. The adapted SunSafe intervention was then delivered to 250, 10th grade students. The curriculum consisted of a 30-minute presentation, modeling of sun protection apparel, and a QA Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B56.