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Author(s): Cuaresma, Charlene F; Sy, Angela U; Nguyen, Tung T; Ho, Reginald CS; Gildengorin, Ginny L; Tsoh, Janice Y; Jo, Angela M; Tong, Elisa K; Kagawa-Singer, Marjorie; Stewart, Susan L | Abstract: BACKGROUND:Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i. METHODS:A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months. RESULTS:Among 304 participants (77% women, 86% had g 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening. CONCLUSIONS:This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.

BACKGROUND Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Korean American men and women. Although CRC screening is effective in reducing the burden of this disease, studies have shown that Korean Americans have low screening rates. METHODS The authors conducted a 2-arm cluster randomized controlled trial comparing a brochure (print) with a brochure and lay health educator (LHE) outreach (print + LHE) in increasing CRC screening rates among Korean American individuals. Self-administered written surveys at baseline and at 6 months assessed knowledge of CRC and its screening, ever screening, and being up to date with screening. RESULTS A total of 28 LHEs recruited 348 participants aged 50 to 75 years from their social networks. Significant percentages of participants reported not having health insurance (29.3%) or a usual source of care (35.6%). At 6 months postintervention, the print + LHE participants had a greater increase in knowledge compared with those in the print arm (P = .0013). In multivariable analyses, both groups had significant increases in ever screening (print plus LHE: odds ratio [OR], 1.60 [95% confidence interval (95% CI), 1.26-2.03] and print: OR, 1.42 [95% CI, 1.10-1.82]) and being up to date with screening (print plus LHE: OR, 1.63 [95% CI, 1.23-2.16] and print: OR, 1.40 [95% CI, 1.04-1.89]). However, these increases did not differ significantly between the study arms. Having insurance and having seen a provider within the past year were found to be positively associated with screening. CONCLUSIONS Compared with a brochure, LHE outreach yielded greater increases in knowledge but resulted in similar increases in CRC screening in a Korean American population with barriers to health care access. More work is needed to appropriately address logistical and system barriers in this community. Cancer 2017. © 2017 American Cancer Society.

BACKGROUND Asian Americans have lower colorectal cancer (CRC) screening rates than non-Hispanic white individuals. Hmong Americans have limited socioeconomic resources and literacy. The current randomized controlled trial was conducted to determine whether bilingual/bicultural lay health educator (LHE) education could increase CRC screening among Hmong Americans. METHODS A cluster randomized controlled trial was conducted among Hmong Americans in Sacramento, California. LHEs and recruited participants were randomized to intervention or control groups. The intervention group received CRC education over 3 months delivered by an LHE. The control group received education regarding nutrition and physical activity delivered by a health educator. The outcomes were changes in self-reported ever-screening and up-to-date CRC screening after 6 months. RESULTS All 329 participants were foreign-born with mostly no formal education, limited English proficiency, and no employment. The majority of the participants were insured and had a regular source of health care. The intervention group experienced greater changes after the intervention than the control group for ever-screening (P = .068) and being up-to-date with screening (P 4 times the odds of receiving screening, both ever-screening and up-to-date screening. A higher CRC knowledge score mediated the intervention effect for both screening outcomes. CONCLUSIONS A culturally and linguistically appropriate educational intervention delivered by trained LHEs was found to increase CRC screening in an immigrant population with low levels of education, employment, English proficiency, and literacy. Cancer 2016. © 2016 American Cancer Society.

Background: In the United States, Korean immigrants experience a disproportionately high burden of chronic hepatitis B (HBV) viral infection and associated liver cancer compared with the general population. However, despite clear clinical guidelines, HBV serologic testing among Koreans remains persistently suboptimal. Methods: We conducted a cluster-randomized trial to evaluate a church-based small group intervention to improve HBV testing among Koreans in Los Angeles. Fifty-two Korean churches, stratified by size (small, medium, large) and location (Koreatown versus other), were randomized to intervention or control conditions. Intervention church participants attended a single-session small-group discussion on liver cancer and HBV testing, and control church participants attended a similar session on physical activity and nutrition. Outcome data consisted of self-reported HBV testing obtained via 6-month telephone follow-up interviews. Results: We recruited 1,123 individuals, 18 to 64 years of age, across the 52 churches. Ninety-two percent of the sample attended the assigned intervention session and 86% completed the 6-month follow-up. Sample characteristics included were as follows: mean age 46 years, 65% female, 97% born in Korea, 69% completed some college, and 43% insured. In an intent-to-treat analysis, the intervention produced a statistically significant effect (OR = 4.9, P < 0.001), with 19% of intervention and 6% of control group participants reporting a HBV test. Conclusion: Our intervention was successful in achieving a large and robust effect in a population at high risk of HBV infection and sequelae. Impact: The intervention was fairly resource efficient and thus has high potential for replication in other high-risk Asian groups. Cancer Epidemiol Biomarkers Prev; 24(9); 1341–9. ©2015 AACR.

Filipino colorectal cancer (CRC) screening rates fall below Healthy People 2020 goals. In this study, the authors explore whether a lay health educator (LHE) approach can increase CRC screening among Filipino Americans ages 50 to 75 years in Hawai'i.A cluster randomized controlled trial from 2012 through 2015 compared an intervention, which consisted of LHEs delivering 2 education sessions and 2 telephone follow-up calls on CRC screening plus a CRC brochure versus an attention control, in which 2 lectures and 2 follow-up calls on nutrition and physical activity plus a CRC brochure were provided. The primary outcome was change in self-reported ever receipt of CRC screening at 6 months.Among 304 participants (77% women, 86% had 10 years of residence in the United States), the proportion of participants who reported ever having received CRC screening increased significantly in the intervention group (from 80% to 89%; P = .0003), but not in the control group (from 73% to 74%; P = .60). After covariate adjustment, there was a significant intervention effect (odds ratio, 1.9; 95% confidence interval, 1.0-3.5). There was no intervention effect on up-to-date screening.This first randomized controlled trial for CRC screening among Hawai'i's Filipinos used an LHE intervention with mixed, but promising, results. Cancer 2018;124:1535-42. © 2018 American Cancer Society.

Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Korean American men and women. Although CRC screening is effective in reducing the burden of this disease, studies have shown that Korean Americans have low screening rates.The authors conducted a 2-arm cluster randomized controlled trial comparing a brochure (print) with a brochure and lay health educator (LHE) outreach (print + LHE) in increasing CRC screening rates among Korean American individuals. Self-administered written surveys at baseline and at 6 months assessed knowledge of CRC and its screening, ever screening, and being up to date with screening.A total of 28 LHEs recruited 348 participants aged 50 to 75 years from their social networks. Significant percentages of participants reported not having health insurance (29.3%) or a usual source of care (35.6%). At 6 months postintervention, the print + LHE participants had a greater increase in knowledge compared with those in the print arm (P = .0013). In multivariable analyses, both groups had significant increases in ever screening (print plus LHE: odds ratio [OR], 1.60 [95% confidence interval (95% CI), 1.26-2.03] and print: OR, 1.42 [95% CI, 1.10-1.82]) and being up to date with screening (print plus LHE: OR, 1.63 [95% CI, 1.23-2.16] and print: OR, 1.40 [95% CI, 1.04-1.89]). However, these increases did not differ significantly between the study arms. Having insurance and having seen a provider within the past year were found to be positively associated with screening.Compared with a brochure, LHE outreach yielded greater increases in knowledge but resulted in similar increases in CRC screening in a Korean American population with barriers to health care access. More work is needed to appropriately address logistical and system barriers in this community. Cancer 2017;123:2705-15. © 2017 American Cancer Society.

Korean Americans experience many challenges to obtaining adequate health care coverage and access to needed services. Because a large proportion of Korean Americans attend churches on a regular basis, churches may be a promising venue where health programs can be delivered. In order to gain an in-depth understanding of Korean American churches with respect to conducting future health intervention research, we conducted exploratory interviews and focus groups with 58 leaders from 23 Korean American churches and three community organizations. From these interviews and focus groups, we found that Korean churches and church leaders seek to meet a variety of social and health needs of their congregation and their surrounding community. Several leaders have stated that assisting with social and medical needs of their members is an important component of their current ministry. They described profound health needs of their congregations and have suggested various ways in which the university can partner with the local churches to help address these needs through research. Additionally, they described various resources churches can provide to researchers such as: their personal assistance, church volunteer base, church facility, and church network and contacts. Our findings suggest that Korean churches have a high potential to serve an important role in the health of Korean Americans. On the basis of the promising results of the present study, we are planning to conduct a cross sectional survey of Korean church leaders and members in Los Angeles County to substantiate our findings in a larger representative sample.

Background Korean Americans have one of the lowest screening rates for colorectal cancer. Although physician recommendation is one of the most important predictors of cancer screening across populations, only few Korean American patients receive such a recommendation. Methods We interviewed 14 Korean American physicians in Los Angeles area who primarily serve Korean Americans to explore why they are reluctant to recommend colorectal cancer screening to their Korean patients. Results Physicians identified barriers attributable to themselves (i.e., lack of knowledge, fear of medicolegal liability), their patients (i.e., patient’s unfamiliarity with the concept of screening), and the health care system (i.e., lack of referral network, poor reimbursement). Discussion Our results suggest the need for multi-faceted interventions directed at the physicians, their patients, and the health care system. Further research is needed to validate our results and to assess the extent to which they apply to physicians from other racial/ethnic groups.

Background : Although Korean American women have one of the lowest rates of mammography screening, only few interventions have been developed for them. We developed a theory-based Korean-language print intervention to increase annual mammography screening with the goal to disseminate it through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Methods : Korean American staff and patients at a community clinic advised on the content and layout of the brochure. We pilot tested the intervention from July to September 2005 at a community clinic in Koreatown, Los Angeles County that provides free mammograms through the NBCCEDP. The proportion of Korean American women who received a repeat mammogram during the intervention period was compared to the pre-intervention period using a NBCCEDP database. Results : We found a non-significant 6 percentage point increase in repeat screening from 32% to 38%. A debriefing survey with a subsample of 59 women revealed that only 32% recalled receipt of the brochure and a subsequent investigation revealed that only about 60% had identical address information in the NBCCEDP records and in their charts. Conclusions : Although dissemination of print information through NBCCEDP is very feasible, the reach and effectiveness of the intervention was limited due to incorrect or outdated address information.

Use of colorectal cancer screening is extremely low among Korean Americans. The objective of this study was to gather information on predictors, facilitators, barriers, and intervention preferences with respect to colorectal cancer screening that may inform the development of future interventions for underserved Korean Americans.We developed a questionnaire guided by the Health Behavior Framework and administered it to a convenience sample of 151 Korean Americans aged 40-70 recruited through a community based organization in Los Angeles.In our sample in which 60% of the subjects did not have health insurance, only 17% reported having received a stool blood test within the past year or sigmoidoscopy or colonoscopy within the past 5 years. Having received a physician recommendation was significantly associated and having symptoms of the disease was marginally associated with the outcome variable. Although 64% of respondents reported having a primary care physician, only 29% received a screening recommendation from a physician. Barriers to colorectal cancer screening were lack of health insurance and inability to afford testing, not knowing where to go for testing, language barrier, and fear of being a burden to the family. Intervention preferences included educational seminars, media campaigns, and print materials.Our findings point to the need for a multi-faceted approach that includes educational seminars at community venues, a media campaign, and physician education to increase colorectal cancer screening in this underinsured Korean American population.

Background: Little is known about interest in faith-based health promotion programs among Asian American populations. Among the Christian denominations, the Seventh-day Adventist (SDA) church is known to place a strong doctrinal emphasis on health. Objectives: To understand appropriate ways to develop and implement health promotion programs and to conduct research among Korean American SDAs. Methods: We collaborated with the North American Division of Korean SDA Churches which sponsors annual week-long religious retreats for their church members. We developed and administered a 10-page questionnaire at their 2009 retreat in order to assess socio-demographic and church characteristics, religiosity, perceived relationship between health and religion, and interest and preferences for church-based health promotion programs. Results: Overall, 223 participants completed our survey (123 in Korean and 100 in English). The sample consisted of regular churchgoers who were involved in a variety of helping activities, and many holding leadership positions in their home churches. The vast majority was interested in receiving health information at church (80%) in the form of seminars, cooking classes and workshops (50-60%). Fewer respondents were interested in support groups (27%). Some interests and preferences differed between English and Korean language groups. Conclusion: Korean American SDA church retreat participants from a large geographic area are very interested in receiving health information and promoting health at their churches and can potentially serve as “agents of influence” in their respective communities.

In Los Angeles County, Koreans surpass all other groups with respect to liver cancer incidence and mortality. An estimated 80%-85% of all liver cancer is etiologically related to chronic hepatitis B viral infection. Hepatitis B serologic testing of adult immigrants from highly endemic areas such as Asia is recommended as the first step in the control of hepatitis B infection and associated morbidities including liver cancer.To collect pilot data to obtain an initial understanding of hepatitis B serologic testing and vaccination rates and associated knowledge and beliefs in a community sample of Korean adults (N=141, 85% foreign born, mean age 45 years) in the greater Los Angeles area.Cross-sectional survey.Five Korean Christian churches and one Korean-serving primary care clinic.The hepatitis B serologic testing rate in our sample was 56%. Approximately one quarter of those tested reported that they were either chronic carriers or were immune as a result of a previous infection. Of those who remained susceptible to future infections, only 38% reported having been vaccinated. Constructs from our conceptual model, the Health Behavior Framework, were significant predictors of serologic testing, including hepatitis B knowledge, barriers to testing, and receipt of a physician's recommendation to get tested.Findings suggest that intervention research is urgently needed to increase hepatitis B awareness and testing among Korean American adults with subsequent vaccination and followup as indicated.

Asians experience the highest liver cancer incidence and mortality rates of all racial/ethnic groups in the U.S. Approximately 80% of liver cancers are etiologically related to chronic infection with the hepatitis B virus (HBV), which is endemic in Asia. It is therefore recommended that Asian adults first be tested for HBV to identify, counsel, and monitor virus carriers and that only those found susceptible be referred for vaccination. In light of the rapid growth and high interracial marriage rates of the U.S. Asian population, prevention and control of HBV infection through testing and vaccination is a critical public health priority. Koreans have the highest liver cancer incidence and mortality rates in Los Angeles County, home to the largest concentration of Koreans in the U.S. To date, no intervention studies have focused on HBV prevention and control among Korean adults. Therefore, we conducted a cluster randomized trial to test the effectiveness of a culturally-tailored small group intervention in increasing HBV serologic testing rates in a community sample of Korean adults in Los Angeles. The sample was recruited through churches, given the large proportion of Korean Americans that attend church. Methods: Study Design. A 2-group design, with cluster randomization at the church level, was used. Churches (N=50) were stratified by size (small: 50-200 members, medium: 201-900 members, large: 900+ members) and geographic location (Koreatown vs. outside Koreatown). Randomization was conducted within each stratum. The intervention consisted of a 1-hour discussion session on HBV, using an interactive, nondidactic format, aided by PowerPoint materials and take-home materials. The control group received a 1-hour discussion session, using a similar format, on nutrition and physical activity (NPA) as well as take-home materials. Lay health educators served as facilitators for the discussions in both study conditions. Church members were recruited on site, in conjunction with routine weekend church services, and invited to participate in a discussion on cancer prevention. Participants had no advance knowledge of their church's study condition assignment. Eligibility criteria included: Korean ethnicity, age 18-64 years, and no prior history of HBV testing. Individuals previously tested, but unaware of their results, were also eligible. Baseline surveys were administered in person, by interviewers, immediately prior to discussion sessions. Subjects were contacted by telephone 6 months post-intervention to assess study outcomes. Theoretical Framework. The Health Behavior Framework (HBF) guided the interventions and data collection instruments.1 The HBF is a comprehensive conceptual framework that includes individual, health system, community, and societal level variables that can influence health behavior. The focus of this trial was primarily on modifying individual (e.g., knowledge, health beliefs) and community level (e.g., social norms) constructs. Data Collection Instruments. Data collection instruments assessed HBF constructs including demographics, cultural factors and knowledge, beliefs, barriers, and supports related to HBV and NPA. To assess the effect of answering a lengthy survey (testing effect) on HBV testing, approximately half the sample completed an abbreviated baseline interview. Results: Recruitment. To date (7/31/10) 1,826 individuals have been screened at 50 churches, and 1174 (64%) were eligible for the study participation. Ninety-four percent (N = 1105) of those eligible were enrolled into the trial (target enrollment =1200). The vast majority of participants completed baseline interviews in Korean (98%) and attended their assigned session (92%). Among participants due for 6-month follow-up (N = 972), the retention rate in both study conditions was 86%. Demographic Characteristics of Sample. Nearly all participants were born in Korea (97%), with an average stay in the U.S. of 16 years and a mean age of 45.5 years. Participants were well-educated (54% have a college degree or more) with a wide range of incomes (25% earn less than $30,000 and 23% earn more than $80,000). Still, only 42% were insured and only 49% indicated that they had a usual place where they sought health care. Knowledge and Beliefs Regarding HBV. Results of HBV baseline survey items from participants assigned to complete the full-length baseline interview (N = 557) illustrate gaps in knowledge related to HBV. For example, while 77% were aware that HBV can be spread by an infected individual who feels and appears healthy, only 45% knew that the virus can be sexually transmitted. Fifty-two percent believed HBV can be transmitted via sharing food and eating utensils and 40% believed that it can be transmitted via coughing or sneezing. Health beliefs that may influence testing likelihood were also identified. Only 58% believed that Koreans were more susceptible to HBV than Caucasians. A majority of participants (82%) believed that HBV can be treated, but only 49% were aware that infection can last a lifetime. Perceived efficacy of HBV testing in preventing future liver problems was high (93%). Additionally, 47% believed that people avoid those infected with HBV, suggesting a stigma in the community related to HBV. Intervention Effect. We investigated the effect of the intervention on receipt of HBV serologic testing in the overall study sample, and within strata defined by church size and location. We employed intent-to-treat analyses in which individuals lost to follow-up were counted as untested. A statistically significant intervention effect was detected in the overall sample (OR=4.6, p Discussion: This study illustrates the need for liver cancer prevention and control efforts in the Korean American community, and the viability of the church as an intervention setting. Although participants were from Korea, where HBV is endemic, baseline data revealed significant gaps in knowledge related to the virus. Our small-group intervention was successful in increasing HBV testing rates. However, a significant intervention effect was not detected in large or Koreatown churches. This could be due to the fact that free HBV testing events (sponsored by a community organization) were conducted in control churches in these two strata during our study period. While the intervention produced a fairly large and statistically significant effect size, the absolute HBV testing rate in the intervention group was only 20%. This has implications for the value of such an intervention when applied at the population level. Further efforts are needed to test interventions that can substantially increase HBV testing among high-risk groups. Reference: 1. Bastani, R., Glenn, B.A., Taylor, V.M., Chen, M.S., Nguyen, T.T., Stewart, S. L., Maxwell, A.E. (2010). Integrating theory into community interventions to reduce liver cancer disparities: The Health Behavior Framework, Preventive Medicine, 50 (1-2):63-7. Epub 2009 Aug 27 Citation Information: Cancer Prev Res 2010;3(12 Suppl):CN03-02.

Objective To test an intervention to increase adherence to diagnostic follow-up tests among Asian American women. Methods Korean American women who were referred for a diagnostic follow-up test (mainly diagnostic mammograms) and who had missed their follow-up appointment were eligible to participate in the study. Women from two clinics (n = 176) were randomly allocated to a usual care control arm or a peer navigator intervention arm. A 20-min telephone survey was administered to women in both study arms six months after they were identified to assess demographic and socio-economic characteristics and the primary outcome, self-reported completion of the recommended follow-up exam. Results Among women who completed the survey at six-month follow-up, self-reported completion of follow-up procedures was 97% in the intervention arm and 67% in the control arm (p