Association Between COVID-19 and Planned and Postponed Cancer Screenings Among American Indian Adults Residing in California and Oklahoma, March-December 2020.

OBJECTIVE: Little is known about how the COVID-19 pandemic affected cancer screenings among American Indian people residing in California and Oklahoma, 2 states with the largest American Indian populations. We assessed rates and factors associated with cancer screenings among American Indian adults during the pandemic. METHODS: From October 2020 through January 2021, we surveyed 767 American Indian adults residing in California and Oklahoma. We asked participants whether they had planned to obtain screenings for breast cancer, cervical cancer, and colorectal cancer (CRC) from March through December 2020 and whether screening was postponed because of COVID-19. We calculated adjusted odds ratios (AORs) for factors associated with reasons for planned and postponed cancer screening. RESULTS: Among 395 participants eligible for breast cancer screening, 234 (59.2%) planned to obtain the screening, 127 (54.3%) of whom postponed it. Among 517 participants eligible for cervical cancer screening, 357 (69.1%) planned to obtain the screening, 115 (32.2%) of whom postponed it. Among 454 participants eligible for CRC screening, 282 (62.1%) planned to obtain CRC screening, 80 of whom (28.4%) postponed it. In multivariate analyses, women who lived with a child (vs did not) had lower odds of planning to obtain a breast cancer screening (AOR = 0.6; 95% CI, 0.3-1.0). Adherence to social distancing recommendations was associated with planning to have and postponement of cervical cancer screening (AOR = 7.3; 95% CI, 0.9-58.9). Participants who received (vs did not receive) social or financial support had higher odds of planning to have CRC screening (AOR = 2.0; 95% CI, 1.1-3.9). CONCLUSION: The COVID-19 pandemic impeded completion of cancer screenings among American Indian adults. Interventions are needed to increase the intent to receive evidence-based cancer screenings among eligible American Indian adults.

"You Don't Know If It's the Truth or a Lie": Exploring Human Papillomavirus (HPV) Vaccine Hesitancy among Communities with Low HPV Vaccine Uptake in Northern California.

BACKGROUND: Vaccine hesitancy, delaying or refusing to vaccinate despite the availability of vaccines, impedes the progress of achieving optimal HPV vaccine coverage. Little is known about the sources of human papillomavirus (HPV) vaccine hesitancy among racially/ethnically and geographically diverse communities. The purpose of this paper is to explore HPV vaccine hesitancy among rural, Slavic, and Latino communities that reside in counties with low HPV vaccine uptake rates. METHODS: Key informant interviews and focus groups were conducted with rural, Slavic, and Latino communities that reside within counties in California that have low HPV vaccine up to date rates (16-25%). Qualitative data were transcribed verbatim and analyzed using inductive and deductive thematic analysis. RESULTS: A total of seven focus groups and 14 key informant interviews were conducted with 39 individuals from seven California counties. Salient themes that contributed to HPV vaccine hesitancy included the following: social media and the anti-vaccination movement; a strong belief in acquiring immunity naturally; prior vaccine experiences; and vaccine timing concerns. Participants suggested the provision of culturally appropriate, in-language, in-person easy to understand HPV vaccine education to mitigate HPV vaccine hesitancy. CONCLUSIONS: Our findings can inform future interventions to increase HPV vaccine uptake among hesitant communities.

Tobacco and marijuana use during the COVID-19 pandemic lockdown among American Indians residing in California and Oklahoma.

INTRODUCTION: American Indian (AI) people experience a disproportionate tobacco and marijuana burden which may have been exacerbated by the COVID-19 pandemic. Little is known about the tobacco and marijuana habits of American Indian individuals during the COVID-19 pandemic. The objective of this study is to examine tobacco and marijuana use as well as change in use during the COVID-19 pandemic among the American Indian community. METHODS: This cross-sectional study analyzes survey data from a convenience sample of American Indian individuals residing in California and Oklahoma and included adults with and without cancer that resided in both rural and urban areas (n=1068). RESULTS: During October 2020 - January 2021, 36.0% of participants reported current use of tobacco products, 9.9% reported current use of marijuana products, and 23.7% reported increased use of tobacco and/or marijuana in the past 30 days, with no difference between those with cancer and those without cancer. Tobacco use was associated with marital status, age, employment status, COVID-19 exposure, COVID-19 beliefs, and alcohol consumption. Marijuana use was associated with COVID-19 beliefs, alcohol consumption, and income level. Increased tobacco and/or marijuana use was associated with baseline use of those products. Nearly a quarter of participants reported increased use of tobacco and/or marijuana products during the COVID-19 pandemic. CONCLUSIONS: We observed high rates of tobacco use during the COVID-19 pandemic, consistent with other studies. Research is needed to examine whether tobacco and marijuana use will decrease to pre-pandemic levels post-pandemic or if these behaviors will persist post-pandemic. Given these findings, there is a pressing need to increase access to evidence-based tobacco and marijuana treatment services in the AI population post COVID-19 pandemic.

Implementation and evaluation of a multilevel intervention to increase uptake of the human papillomavirus vaccine among rural adolescents.

PURPOSE: Geographic disparities exist in uptake of the human papillomavirus vaccine (HPV). In 2020, the National Immunization Survey-Teen reported that adolescents living in nonmetropolitan statistical areas (MSAs) had lower HPV vaccination coverage (≥ 1 dose) compared to adolescents living in MSA principal cities. This paper describes the implementation and evaluation of a multilevel pilot intervention study to increase uptake of the HPV vaccine among adolescent patients ages 11-17 of a rural health clinic. METHODS: This parent, primary care team, and clinic multilevel pilot intervention was guided by evidence-based approaches to increase HPV vaccinations, formative research, and input from the community. HPV vaccination initiation and completion rates were analyzed at baseline and 23 months follow-up. FINDINGS: The proportion of adolescent patients ages 11-17 who had initiated the HPV vaccine series was significantly greater at follow-up compared to baseline, (82.7% compared to 52.4%), χ2 (1, n = 498) = 49.2, P < .0001. The proportion of adolescent patients ages 11-17 who had completed the HPV vaccine series was also significantly greater at follow-up compared to baseline, (58.0% compared to 27.0%), χ2 (1, n = 498) = 50.8, P < .0001. CONCLUSIONS: The multilevel intervention significantly increased HPV initiation and completion rates among adolescent patients ages 11-17 at this rural health clinic. This study demonstrates the feasibility of utilizing a multilevel intervention to address low HPV vaccination rates among rural adolescents and the potential of employing this strategy for a large-scale randomizing-controlled trial.

Sociodemographic factors associated with HPV awareness/knowledge and cervical cancer screening behaviors among caregivers in the U.S.

BACKGROUND: Family caregivers may be at a higher risk for several chronic diseases, including cancer. Cervical cancer is one of the most common causes of cancer death among women. Despite family caregivers' vulnerability, the status of their HPV awareness, knowledge, and preventive health behaviors, including cervical cancer screening, has been understudied. Thus, this study aimed to examine the sociodemographic factors associated with HPV awareness and knowledge and adherence to the cervical cancer screening guidelines among caregivers in the U.S. METHODS: Nationally representative cross-sectional survey data were obtained from the Health Information National Trends Survey (HINTS 5, 2017-2020). Female caregivers aged 21-65 were included (N = 1190). Weighted multivariable logistic regression was performed to identify factors associated with HPV awareness (heard of HPV), knowledge (HPV can cause cervical cancer), and adherence to the United States Preventive Service Task Force 2018 cervical cancer screening guidelines by sociodemographic factors (age, race/ethnicity, education, household income, marital status,) and the intensity of caregiving. RESULTS: An estimated 79% of female caregivers were aware of HPV and 84% adhered to the cervical cancer screening guidelines. Caregivers who were older than 50 (OR = 3.62, 1.91-6.85, adherence of aged 21-50 vs. 51-65), Hispanics of race/ethnicity compared with Black/African Americans (OR = 3.14, 1.31-7.52, adherence of Black/African Americans vs. Hispanics), with a high school education or less (OR = 2.34, 1.14-4.82, adherence of Some college or more vs. High school education or less), and with intense caregiving duty (spending 35 h/week or more on caregiving) compared with light-duty (OR = 2.34, 1.10-5.00, adherence of 5-14 h vs. 35 h or more, weekly) had poor adherence to the cervical cancer screening guidelines. Caregivers who were older, racial minorities (Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Multiple races), and less educated showed lower HPV awareness (Heard of HPV) than their counterparts. CONCLUSIONS: There are caregiving populations whose HPV awareness and cervical cancer screening adherence are low. To improve their awareness and knowledge of HPV and support their cervical cancer screening behaviors, we need to consider interventions that target those specific populations.

Understanding Human Papillomavirus Vaccine Promotions and Hesitancy in Northern California Through Examining Public Facebook Pages and Groups.

Human papillomavirus (HPV) vaccination coverage among adolescents is lower in rural regions and remains under the 80% coverage goal by Healthy People 2030. Through both sentiment analysis and topic modeling, this research examines how local health agencies and groups in nine Northern California counties promote HPV vaccines through Facebook and how target populations react to promotion posts in comments that elucidate their sentiments and hesitancy toward HPV vaccination. In January 2021, we identified 2,105 public Facebook pages and 1,065 groups related to health within the counties and collected a total of 212 posts and 505 comments related to the HPV vaccine. The posts were published between 2010 and 2021, with the majority (83%) published after 2017. There were large variations of Facebook activities across counties. We categorized four counties with HPV vaccination initiation rates below 40% as low-coverage counties and five counties with rates above 40% as high-coverage counties. In general, low-coverage counties had fewer Facebook activities in comparison to high coverage. Results showed that, on average, comments about the HPV vaccine exhibited more positive emotion, more negative emotion, and more anger than the posts. Overall, thematic topics that emerged from posts centered around awareness and screening of HPV and cervical cancer, STI testing services, information sources, and calls to action for health services. However, comment topics did not correspond to posts and were mostly related to vaccine hesitancy, discussing vaccine risks, safety concerns, and distrust in vaccine science, citing misinformation. When comparing high- versus low-coverage counties, posts expressed similar sentiments; however, comments within high-coverage counties expressed more anger than in low-coverage counties. Comments from both high- and low-coverage counties expressed concerns with vaccine safety, risks, and injury. It is important to note that commenters exchanged information sources and tried to address misinformation themselves. Our results suggest that the promotion of HPV vaccines from public Facebook pages and groups is limited in frequency and content diversity. This illustrates problems with generalized social media vaccination promotion without community tailoring and addressing specific hesitancy concerns. Public health agencies should listen to the thoughts of targeted audiences reflected through comments and design relevant messages to address these concerns for HPV vaccination promotion.

Patient and clinician factors associated with uptake of the human papillomavirus (HPV) vaccine among adolescent patients of a primary care network.

BACKGROUND: Human papillomavirus (HPV) vaccination rates for adolescents remain relatively low. The purpose of this study is to examine patient and clinician factors associated with HPV vaccination among patients, ages 11-17, of a large community-based primary care network. METHODS: Electronic health records and administrative data from a large primary care network from January 2017 - June 2018 for patients ages 11-17 (n = 10,682) and the 198 primary care clinicians that saw them were analyzed. Mixed effects logistic regression models examined the association of patient and clinician factors with HPV vaccine uptake. RESULTS: Most patients (63.0%) had at least one dose of the HPV vaccine, and 37.7% were up to date. In adjusted analyses, patients who received the tetanus, diphtheria, and pertussis (Tdap) vaccine (OR = 2.8, 95% CI: 2.1-3.9) compared to those who did not receive the vaccine and patients with five or more medical visits (OR = 1.9, 95% CI: 1.6-2.2) had the greatest odds of being up to date with the HPV vaccine series. Compared to White patients, African American/Black (OR = 0.8, 95% CI: 0.6 - 1.0) and Alaskan Native/American Indian (OR = 0.5, 95% CI: 0.3-0.9) patients were less likely to be up to date. Boys were also less likely to be up to date with the HPV vaccine series compared to girls (OR = 0.7, 95% CI: 0.7-0.8). Additionally, patients with family/general practice primary care clinicians were less likely to have their patients up to date than those with pediatricians (OR = 0.8, 95% CI: 0.6 - 1.0). CONCLUSION: HPV vaccine uptake varied by patient characteristics, heath care utilization and primary care clinician specialty. These findings may inform future evidence-based interventions aimed at increasing HPV vaccine uptake among adolescents by targeting patient sub-groups and reducing missed opportunities for vaccination.

"There's Always Next Year": Primary Care Team and Parent Perspectives on the Human Papillomavirus Vaccine.

Acceptance of the human papillomavirus (HPV) vaccination among parents and clinicians is high, but uptake remains low. Little is known about organizational and primary care team factors that influence the uptake of the HPV vaccine. Interviews with clinicians, clinic support staff, and parents of adolescent patients were conducted to better understand the interrelationships among the people and the organizational processes that influence HPV vaccine uptake at the point of care. Between July 2016 and February 2017, semi-structured interviews of 40 participants (18 clinicians, 12 clinic support staff, and 10 parents of adolescent patients) in a primary care network were conducted. Organizational structures and processes, such as electronic provider reminders, availability of "vaccination only" appointments, and knowledgeable primary care team members contributed to HPV vaccine uptake. Consistently high support of HPV vaccination was found among key informants; however, rather than refuse HPV vaccination, parents are opting to delay vaccination to a future visit. When parents express the desire to delay, clinicians and care team members described often recommending addressing HPV vaccination at a future visit, giving parents the impression that receiving the vaccine was not time-sensitive for their child. Discordance in HPV vaccination recommendations among providers and clinic support staff may contribute to delayed HPV vaccination. Strong, high-quality HPV vaccine recommendations are needed from all primary team members. Clinic interventions to accelerate HPV vaccine uptake may benefit from a team-based approach where every member of the primary care team is delivering the same consistent messaging about the importance of timely HPV vaccination.

High frequency of the PNPLA3 rs738409 [G] single-nucleotide polymorphism in Hmong individuals as a potential basis for a predisposition to chronic liver disease.

BACKGROUND: An exploratory study was performed to determine the prevalence of the patatin-like phospholipase domain-containing protein 3 (PNPLA3) rs78409 [G] allele among the Hmong as a risk factor for nonalcoholic fatty liver disease (NAFLD). NAFLD/nonalcoholic steatohepatitis is the world's most common chronic liver disease and is expected to replace viral hepatitis as the leading cause of cirrhosis and potential precursor to hepatocellular carcinoma (HCC). Of all populations in California, the Hmong experience the highest risk of death from HCC and the highest prevalence of metabolic syndrome risk factors among Asians that predispose them to NAFLD. Here a genetic explanation was sought for the high rates of chronic liver disease among the Hmong. The literature pointed to the PNPLA3 rs738409 [G] allele as a potential genetic culprit. METHODS: Cell-free DNA was isolated from 26 serum samples previously collected in community settings. Quantitative polymerase chain reaction-based single-nucleotide polymorphism (SNP) genotyping was performed with a validated TaqMan SNP genotyping assay, and results were analyzed with TaqMan Genotyper software. RESULTS: The PNPLA3 rs738409 [C>G] variant occurred at a frequency of 0.46 (12 of 26; 95% confidence interval, 0.27-0.67). This carrier rate would rank the Hmong as the third highest population in the 1000 Genomes Project. CONCLUSIONS: Although this small sample size limits the generalizability, the high frequency rates of this allele along with the presence of metabolic syndrome risk factors warrant further studies into the etiology of NAFLD among the Hmong. Cancer 2018;124:1583-9. © 2018 American Cancer Society.

Time, trust, and transparency: Lessons learned from collecting blood biospecimens for cancer research from the Asian American community.

BACKGROUND: Biospecimens from racially diverse groups are needed to advance cancer research. The Asian American Cancer Education Study was developed to increase the number and proportion of blood biospecimen donations from Asian Americans for cancer research. METHODS: The authors' targeted approach included 2 types of community engagement, in-reach (within institution to Asian American patients with cancer) and outreach (external to institution to the general Asian American community). Participants received in-language biospecimen education followed by the opportunity to donate blood biospecimens. Outreach participants donated through our community biospecimen blood drives, and in-reach participants consented to donating an extra tube of blood during their routine blood draws as a patient. Donated blood biospecimens were spun down to serum and plasma to be stored in a biorepository or were sent to the laboratory to test for cancer-related risk factors. RESULTS: Three hundred eighty-eight Asian Americans donated 1127 blood biospecimens for cancer research. Four hundred twenty tubes of plasma and serum are currently being stored at the cancer center's biorepository, 39 tubes have been used for cancer genomic research, and 668 tubes were used to characterize cancer-related risk factors. CONCLUSIONS: Building upon the past decade of the National Cancer Institute-funded Asian American Network for Cancer Awareness, Research, and Training's foundation of trust and service among Asian Americans, researchers were able to leverage relationships not only to introduce the idea of biospecimen contribution to the community but to also exceed expectations with regard to the quantity of blood biospecimens collected from Asian Americans. Cancer 2018;124:1614-21. © 2018 American Cancer Society.

Increasing Hepatitis B Testing and Linkage to Care of Foreign-Born Asians, Sacramento, California, 2012-2013.

OBJECTIVE: Without medical intervention, about one-quarter of the 1.4-2.2 million Americans chronically infected with the hepatitis B virus (HBV) will die of HBV-associated conditions, including liver failure and hepatocellular carcinoma. We report on a program in Sacramento County, California, that offered HBV screening to at-risk adults, referred infected individuals to care, and vaccinated uninfected adults who were susceptible to HBV infection (i.e., individuals who tested negative for hepatitis B surface antigen and who were never vaccinated against HBV). METHODS: We engaged organizations linked to Chinese, Hmong, Korean, and Vietnamese communities to cosponsor HBV screenings of Asian Americans as part of the Hepatitis Testing and Linkage to Care initiative, which promoted viral hepatitis B and hepatitis C screening, posttest counseling, and linkage to care at 34 U.S. sites. We held 28 hepatitis B community screening events throughout Sacramento County, California, in collaboration with these groups from September 2012 to September 2013. RESULTS: We screened 1,004 Asian American adults (i.e., 283 Koreans, 242 Chinese, 233 Vietnamese, 223 Hmong, and 23 people from other Asian communities) for HBV, of whom 98% were foreign born and 87% had a language preference other than English. Of the 76 participants who tested positive for HBV (31 Hmong, 23 Vietnamese, 17 Chinese, two Koreans, and three from other Asian communities), we provided posttest counseling to 51 participants. CONCLUSION: By collaborating with community groups and addressing barriers to screening, we highlighted the importance of disaggregating chronic HBV infection rates by Asian ethnicity and sex vs. aggregated Asian American rates. Future HBV screening initiatives should target Hmong and Vietnamese men.

Impact of a biospecimen collection seminar on willingness to donate biospecimens among Chinese Americans: results from a randomized, controlled community-based trial.

BACKGROUND: Biospecimen collection from diverse populations can advance cancer disparities research, but is currently underrepresented. METHODS: We partnered with a community-based clinic serving Cantonese-speaking Chinese Americans to develop and revise an educational seminar on biospecimen collection. Through a randomized controlled trial (n = 395), the intervention seminar was compared with a control seminar (cancer prevention) on change in willingness to donate biospecimens. RESULTS: At baseline, many were willing to donate a biospecimen (saliva, urine, hair, toenails, blood, unused cancerous tissue) whether healthy or hypothetically had cancer. Also, many would donate because future generations would benefit, and few had concerns about donation. In logistic regression analyses, there was an intervention effect for willingness to donate: urine if had cancer [OR, 2.2; 95% confidence interval (CI), 1.3-3.7], toenails if healthy (OR, 2.1; 95% CI, 1.4-3.2) or had cancer (OR, 2.3; 95% CI, 2.0-2.7), hair if healthy (OR, 1.8; 95% CI, 1.3-2.5) or had cancer (OR, 2.8; 95% CI, 1.9-4.0), and unused cancerous tissue (OR, 1.8; 95% CI, 1.2-2.9). There was also an intervention effect for donating because future generations would benefit (OR, 2.0; 95% CI, 1.4-3.0), and this attitude was a strong independent predictor for willingness to donate all biospecimens, whether healthy or had cancer (OR, 2.9-4.2). CONCLUSION: Cantonese-speaking Chinese American participants of an educational seminar on biospecimen collection showed greater increases in willingness to donate biospecimens and donating for the benefit of future generations, than participants who attended a control seminar. IMPACT: Donating for the benefit of future generations is a theme that should be incorporated in messages that encourage biospecimen donation for Chinese Americans.

Twenty years post-NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials.

BACKGROUND: The National Institutes of Health (NIH) Revitalization Act of 1993 mandated the appropriate inclusion of minorities in all NIH-funded research. Twenty years after this act, the proportion of minority patients enrolled in cancer clinical trials remains persistently low. Clinical trials are vehicles for the development and evaluation of therapeutic and preventive agents under scientifically rigorous conditions. Without representation in trials, it is projected that disparities in the cancer burden for minorities will increase. METHODS: For this review article, the authors counted the frequency with which minorities were the primary focus of National Cancer Institute-sponsored clinical trials, examined citations from the PubMed database focusing on the search terms "NIH Revitalization Act of 1993" and "enhancing minority accrual to cancer clinical trials," and supplemented the review with their expertise in NIH-funded research related to minority accrual in cancer clinical trials. RESULTS: The reporting and analyses of data based on minorities in clinical trials remain inadequate. Less than 2% of the National Cancer Institute's clinical trials focus on any racial/minority population as their primary emphasis. The current review of the literature indicated that the percentage of authors who reported their study sample by race/ethnicity ranged from 1.5% to 58%, and only 20% of the randomized controlled studies published in a high-impact oncology journal reported analyzing results by race/ethnicity. Proportionately greater population increases in minorities, accompanied by their persistent and disproportionate cancer burden, reinforce the need for their greater representation in clinical trials. CONCLUSIONS: Renewing the emphasis for minority participation in clinical trials is warranted. Policy changes are recommended.

Engaging diverse populations about biospecimen donation for cancer research.

Clinical research increasingly relies upon the availability of appropriate genetic materials; however, the proportion of biospecimens from racial/ethnic minority patients and healthy controls are underrepresented, which preclude equitable research across all patient groups for cancer treatment. National Cancer Institute-funded Community Network Program Centers in California, Florida, and New York collaborated with local community partners to conduct three independent formative research studies with diverse (African American, Asian American, Hispanic, and White) participants to explore their knowledge, attitudes, and beliefs about biobanking, and their experiences with the donation of biospecimens. Our findings demonstrated similarities in overall low knowledge and understanding about the use of biospecimens for research. This was exacerbated for non-English speakers. Racial and ethnic groups differed with regard to a number of factors that are obstacles for participation, e.g., continuing medical mistrust (African Americans), lack of benefit (Hispanics), apprehension about the physical toll of donating (Vietnamese), usage of biospecimen for research (Hmong and Chinese), and suspicion of exploitation by corporate entities (Whites). However, participants uniformly reported general interest and willingness to participate in biobanking for altruistic purposes, particularly to benefit future generations. This interest was framed with a strong admonition that donations should be accompanied by transparency about study sponsorship and ownership, distribution and use of biospecimens, and study information that fit participants' backgrounds and experiences. This cross-cultural regional analysis offers significant insights into the similarities and variations in opinions and perceptions about biobanking and the collection of biospecimens for use in cancer research.

Increasing hepatitis B screening for hmong adults: results from a randomized controlled community-based study.

BACKGROUND: Hepatitis B-linked liver cancer disproportionately affects Hmong Americans. With an incidence rate of 18.9 per 100,000, Hmong Americans experience liver cancer at a rate that is 6 to 7 times more than that of non-Hispanic Whites. Serologic testing for the hepatitis B virus (HBV) is a principal means to prevent liver cancer-related deaths through earlier identification of those at risk. METHODS: Academic researchers and Hmong leaders collaborated in the design, conduct, and evaluation of a 5-year randomized controlled trial testing a lay health worker (LHW) intervention to promote HBV testing among 260 Hmong adults through in-home education and patient navigation. RESULTS: Intervention group participants were more likely to report receiving serologic testing for HBV (24% vs. 10%, P = 0.0056) and showed a greater mean increase in knowledge score (1.3 vs. 0.3 points, P = 0.0003) than control group participants. Multivariable modeling indicated that self-reported test receipt was associated with intervention group assignment [OR 3.5; 95% confidence interval (CI) 1.3-9.2], improvement in knowledge score (OR 1.3 per point; 95% CI 1.02-1.7), female gender (OR 5.3; 95% CI 1.7-16.6), and having seen a doctor in the past year at baseline (OR 4.8; 95% CI 1.3-17.6). The most often cited reason for testing was a doctor's recommendation. CONCLUSIONS: LHWs were effective in bringing about HBV screening. Doctor visits and adherence to doctors' recommendations were pivotal. Participation of health care providers is essential to increase HBV testing. IMPACT: LHWs can significantly increase HBV screening rates for Hmong but their doctors' recommendation is highly influential and should be pursued.