Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders.

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Differential Effects of Race, Socioeconomic Status, and Insurance on Disease-Specific Survival in Rectal Cancer.

BACKGROUND: National Comprehensive Cancer Network guideline adherence improves cancer outcomes. In rectal cancer, guideline adherence is distributed differently by race/ethnicity, socioeconomic status, and insurance. OBJECTIVE: This study aimed to determine the independent effects of race/ethnicity, socioeconomic status, and insurance status on rectal cancer survival after accounting for differences in guideline adherence. DESIGN: This was a retrospective study. SETTINGS: The study was conducted using the California Cancer Registry. PATIENTS: This study included patients aged 18 to 79 years diagnosed with rectal adenocarcinoma between January 1, 2004, and December 31, 2017, with follow-up through November 30, 2018. Investigators determined whether patients received guideline-adherent care. MAIN OUTCOME MEASURES: ORs and 95% CIs were used for logistic regression to analyze patients receiving guideline-adherent care. Disease-specific survival analysis was calculated using Cox regression models. RESULTS: A total of 30,118 patients were examined. Factors associated with higher odds of guideline adherence included Asian and Hispanic race/ethnicity, managed care insurance, and high socioeconomic status. Asians (HR, 0.80; 95% CI, 0.72-0.88; p < 0.001) and Hispanics (HR, 0.91; 95% CI, 0.83-0.99; p = 0.0279) had better disease-specific survival in the nonadherent group. Race/ethnicity were not factors associated with disease-specific survival in the guideline adherent group. Medicaid disease-specific survival was worse in both the nonadherent group (HR, 1.56; 95% CI, 1.40-1.73; p < 0.0001) and the guideline-adherent group (HR, 1.18; 95% CI, 1.08-1.30; p = 0.0005). Disease-specific survival of the lowest socioeconomic status was worse in both the nonadherent group (HR, 1.42; 95% CI, 1.27-1.59) and the guideline-adherent group (HR, 1.20; 95% CI, 1.08-1.34). LIMITATIONS: Limitations included unmeasured confounders and the retrospective nature of the review. CONCLUSIONS: Race, socioeconomic status, and insurance are associated with guideline adherence in rectal cancer. Race/ethnicity was not associated with differences in disease-specific survival in the guideline-adherent group. Medicaid and lowest socioeconomic status had worse disease-specific survival in both the guideline nonadherent group and the guideline-adherent group. See Video Abstract at http://links.lww.com/DCR/B954 . EFECTOS DIFERENCIALES DE LA RAZA, EL NIVEL SOCIOECONMICO COBERTURA SOBRE LA SUPERVIVENCIA ESPECFICA DE LA ENFERMEDAD EN EL CNCER DE RECTO: ANTECEDENTES: El cumplimiento de las guías de la National Comprehensive Cancer Network mejora los resultados del cáncer. En el cáncer de recto, el cumplimiento de las guías se distribuye de manera diferente según la raza/origen étnico, nivel socioeconómico y el cobertura médica.OBJETIVO: Determinar los efectos independientes de la raza/origen étnico, el nivel socioeconómico y el estado de cobertura médica en la supervivencia del cáncer de recto después de tener en cuenta las diferencias en el cumplimiento de las guías.DISEÑO: Este fue un estudio retrospectivo.ENTORNO CLINICO: El estudio se realizó utilizando el Registro de Cáncer de California.PACIENTES: Pacientes de 18 a 79 años diagnosticados con adenocarcinoma rectal entre el 1 de enero de 2004 y el 31 de diciembre de 2017 con seguimiento hasta el 30 de noviembre de 2018. Los investigadores determinaron si los pacientes recibieron atención siguiendo las guías.PRINCIPALES MEDIDAS DE RESULTADO: Se utilizaron razones de probabilidad e intervalos de confianza del 95 % para la regresión logística para analizar a los pacientes que recibían atención con adherencia a las guías. El análisis de supervivencia específico de la enfermedad se calculó utilizando modelos de regresión de Cox.RESULTADOS: Se analizaron un total de 30.118 pacientes. Los factores asociados con mayores probabilidades de cumplimiento de las guías incluyeron raza/etnicidad asiática e hispana, seguro de atención administrada y nivel socioeconómico alto. Los asiáticos e hispanos tuvieron una mejor supervivencia específica de la enfermedad en el grupo no adherente HR 0,80 (95 % CI 0,72 - 0,88, p < 0,001) y HR 0,91 (95 % CI 0,83 - 0,99, p = 0,0279). La raza o el origen étnico no fueron factores asociados con la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. La supervivencia específica de la enfermedad de Medicaid fue peor tanto en el grupo no adherente HR 1,56 (IC del 95 % 1,40 - 1,73, p < 0,0001) como en el grupo adherente a las guías HR 1,18 (IC del 95 % 1,08 - 1,30, p = 0,0005). La supervivencia específica de la enfermedad del nivel socioeconómico más bajo fue peor tanto en el grupo no adherente HR 1,42 (IC del 95 %: 1,27 a 1,59) como en el grupo adherente a las guías HR 1,20 (IC del 95 %: 1,08 a 1,34).LIMITACIONES: Las limitaciones incluyeron factores de confusión no medidos y la naturaleza retrospectiva de la revisión.CONCLUSIONES: La raza, el nivel socioeconómico y cobertura médica están asociados con la adherencia a las guías en el cáncer de recto. La raza/etnicidad no se asoció con diferencias en la supervivencia específica de la enfermedad en el grupo que cumplió con las guías. Medicaid y el nivel socioeconómico más bajo tuvieron peor supervivencia específica de la enfermedad tanto en el grupo que no cumplió con las guías como en los grupos que cumplieron. Consulte Video Resumen en http://links.lww.com/DCR/B954 . (Traducción- Dr. Francisco M. Abarca-Rendon).

Health Information Source Characteristics Matter: Adapting the Dissemination of an HPV Vaccine Intervention to Reach Latina and Vietnamese Women.

Latina and Vietnamese women are disproportionately burdened by human papillomavirus (HPV)-associated cervical cancer and underutilize the HPV vaccine, which is an effective cancer prevention measure. To inform the adaptation of a National Cancer Institute's evidence-based cancer control program, HPV Vaccine Decision Narratives, and because of the rapidly changing information concerning consumption patterns of young adults, we elicited preferences and characteristics associated with women's interest in various health information sources, specifically for HPV vaccination. We conducted 50 interviews with young Latina and Vietnamese women at two Planned Parenthood health centers in Southern California. Interview questions were guided by the Channel Complementarity Theory and focused on understanding the multiple communication channels women turn to for health, and the characteristics that motivate their use. Our results showed that Latina and Vietnamese women turn to many sources, from online and social media to school health classes, mothers, and doctors. Specific characteristics that motivate women's online use of health information included immediacy and access, convenience and credibility. When receiving HPV vaccine information, privacy, avoiding information overload, interpersonal engagement, and receiving health information from trusted sources was important. Our study advances the prevention literature by elevating the role of platform delivery considerations and emphasizing preferences to effectively reach Latina and Vietnamese women, who are disproportionately burdened by HPV cancers and are less aware of HPV vaccine prevention. These results can be used to further inform the dissemination of this cancer control program. Adaptation of the program should include changes to its delivery, such that trusted sources are used, and dissemination is coordinated to send a consistent message across multiple communication methods.

Physical Activity, Nutrition, and Obesity among Pacific Islander Youth and Young Adults in Southern California: An Exploratory Study.

This exploratory study aimed to assess obesity, physical activity, and nutrition among Pacific Islander youth and young adults in Southern California. A total of 129 Tongan, Samoan, and Marshallese participated in the study, including relatively similar proportions of males and females and age groups. We calculated Body Mass Index (BMI), dietary intake by a food frequency questionnaire (FFQ), and 7-day physical activity levels with accelerometers. Overall, 84% of Tongan, 76% of Samoan, and 24% of Marshallese participants were overweight or obese, with mean BMI of 31.2 and 34.3 kg/m2 (for Tongan males and females), 32.3 and 33.4 kg/m2 (Samoan males and females), and 25.3 and 22.1 kg/m2 (Marshallese males and females). We found moderate- and vigorous-intensity physical activity (MVPA) fell below current guidelines at 38 min/day, with over 87% engaging in light-intensity PA and large sedentary times. Daily percent of energy from saturated fat, fiber/1,000 kcal and dairy intake were higher in Tongans compared to Samoans and Marshallese. Despite promising outcomes from this study, high prevalence of overweight, low physical activity levels, and high caloric intake put Pacific Islander youth and young adults at risk for a variety of health concerns and future efforts should focus on further research as well as community-wide prevention and amelioration efforts.

A Narrative Engagement Framework to Understand HPV Vaccination Among Latina and Vietnamese Women in a Planned Parenthood Setting.

Disparities in cervical cancer and human papillomavirus (HPV) vaccination persist among Vietnamese and Latina women. Through a partnership with Planned Parenthood of Orange and San Bernardino Counties (PPOSBC) in Southern California, we conducted in-depth interviews with young adult Latina ( n = 24) and Vietnamese ( n = 24) women, and PPOSBC staff ( n = 2). We purposively sampled vaccinated women to elicit HPV vaccine decision narratives to uncover rich data on motivators, cultural values, and implicit vaccine attitudes. Unvaccinated women were interviewed to identify barriers. Women were also asked to discuss their observations of men's HPV vaccine attitudes. Narrative engagement theory guided the study privileging the meaning women ascribed to their experiences and conversations related to vaccine decision making. Vaccine decision narratives included (a) mother-daughter narratives, (b) practitioner recommendation of HPV vaccination, (c) independence narratives among Vietnamese women, (d) HPV (un)awareness narratives, and (d) school exposure to HPV knowledge. Barriers to vaccinating included trust in partner HPV status, and family silence and stigma about sexual health. Participants conveyed the importance of including messages aimed at reaching men. Practitioners described insurance barriers to offering same day vaccination at PPOSBC health center visits. Narrative communication theory and methodology address health equity by privileging how Vietnamese and Latina women ascribe meaning to their lived experiences and conversations about HPV vaccination. Identifying authentic and relatable vaccine decision narratives will be necessary to effectively engage Vietnamese and Latina women. These findings will guide the process of adapting an existing National Cancer Institute research-tested HPV vaccine intervention.

Eliminating tobacco disparities among native Hawaiian Pacific Islanders through policy change: the role of community-based organizations.

Although cigarette smoking in the general U.S. population has decreased considerably over the past several decades, prevalence rates among Native Hawaiian Pacific Islanders (NHPI) have remained elevated by comparison with other groups. The aggregation of NHPI smoking data with that of Asians has drawn attention away from the serious smoking problems that NHPIs experience, thus, limiting funding, programs, and policies to reduce tobacco-related health disparities in their communities. In California, community-based organizations (CBOs) have played a major role in supporting the state's comprehensive tobacco control program, which is arguably one of the most successful in the nation. In this commentary, we describe the tobacco control activities of five NHPI-serving CBOs in Southern California and how they have provided anti-tobacco education for thousands of Native Hawaiians, Chamorros, Marshallese, Samoans, Tongans, and other Pacific Islander subgroups, and used advocacy and coalition building to promote smoke-free environment policies in their communities. The concerted efforts of the CBOs and their community members have made vital contributions to the reduction of tobacco-related disparities for NHPI populations in California.

What promotes cervical cancer screening among Chamorro women in California?

Pacific Islander women represent a significant at-risk population for cervical cancer, yet little is known about the modifiable factors associated with routine Pap testing. Therefore, the aims of this paper are to report and discuss the known and unknown factors associated with cervical cancer screening among Chamorro women in California. This cross-sectional study explored the factors associated with receipt of regular Pap testing among Chamorro women age 18 years and older in California. A self-administered survey was designed and distributed to women in order to understand their knowledge, beliefs and behaviors regarding routine receipt of Pap tests. Only about two-thirds of women had received a Pap test within the past 2 years, which is below the U.S. average of 72 %. Significant predictors included younger age, health insurance coverage, knowledge of screening frequency, and medically correct beliefs regarding risk groups. These factors, however, accounted for less than 16 % of the variance in Pap testing behavior. We discuss the poor predictive value of existing demographic and theoretical variables, and discuss potentially new areas of research that can aid in the development of future intervention studies. Study limitations and implications are also discussed.

Culturally-specific physical activity measures for Native Hawaiian and Pacific Islanders.

INTRODUCTION: Physical activity is an important contributor to the health disparities experienced by Native Hawaiian and Pacific Islander (NHPI) populations. A culturally-specific measurement instrument that minimizes interpretation bias is necessary to obtain accurate assessments of this lifestyle behavior. The purpose of this study was to 1) create two versions of the Pacific Islander Physical Activity Questionnaire (PIPAQ-short and PIPAQ-long) for United States NHPI, and 2) pilot test the PIPAQ instruments and two objective physical activity monitors to evaluate cultural-appropriateness and acceptability. METHODS: Forty NHPI adults (20M, 20F) aged 21-65 years attended focus group discussions addressing cultural perspectives related to physical activity. Feedback from participants, community leaders and physical activity experts guided cultural modifications to existing questionnaires to create PIPAQ-short and PIPAQ-long with accompanying showcards. Pilot testing of both PIPAQs and two objective physical activity monitors, the Actiheart and ActiTrainer, was carried out in another sample of 32 NHPI adults (17M, 15F) aged 18-63 years. Participants were instructed to wear one monitor for ≥10 hours/day for 7 consecutive days. At the follow-up visit, participants completed PIPAQ-short and PIPAQ-long, and a written and verbal exit interview to provide feedback on both subjective and objective instruments. RESULTS: The majority of participants felt PIPAQ-long provided a more accurate reflection of activity levels, compared to PIPAQ-short. The Actiheart was the preferred monitor due to higher comfort and lower participant burden. Self-reported duration of physical activities was most difficult to recall, compared to activity type, frequency and intensity. CONCLUSION: Both PIPAQ instruments and the Actiheart monitor have demonstrated cultural acceptability and appropriateness for NHPI adults. Future studies will investigate the validity and reliability of both PIPAQ instruments in larger samples of NHPI adults.

Effects of family functioning and self-image on adolescent smoking initiation among Asian-American subgroups.

PURPOSE: This study examined differences in smoking prevalence and differences in associations between family functioning, self-image and adolescent smoking behavior among four Asian-American subgroups. METHODS: Statistical analyses were conducted on responses about their smoking behaviors from 1139 students who self-identified as Chinese-Americans, Filipino-Americans, Korean-Americans, and Vietnamese-Americans. RESULTS: Significant differences in the prevalence of ever-tried smoking and 30-day smoking were found across subgroups, but there were no overall gender differences. Korean-American adolescents reported the highest lifetime smoking and 30-day smoking rates, followed by Vietnamese- and Filipino-Americans. Chinese-Americans reported the lowest smoking rates. There were also differences in the associations between smoking and family functioning and self-image across the four subgroups. High family functioning was inversely associated with smoking for Chinese- and Korean-American adolescents, but not for Filipino- and Vietnamese-Americans. On the other hand, high self-image was associated with decreased risk of smoking for Filipino- and Vietnamese-Americans, but not for the other two subgroups. CONCLUSION: Findings of this study demonstrate that family functioning and self-image varied across Asian-American subgroups. This suggests the need to understand etiological differences between the groups as well as potential implications for prevention cessation programs.

Tongan-American women's breast cancer knowledge, attitudes, and screening behaviors.

OBJECTIVE: Breast cancer is the most common cancer for many Pacific Islander American populations, but virtually nothing is known about the cancer risks and screening behaviors of many specific ethnic subgroups. This paper examines the breast cancer risk, knowledge, attitudes, and screening behaviors of Tongan-American women. DESIGN: Research activities were conducted in 3 phases: determination of cancer proportional ratios using data from the California Cancer Registry, exploratory focus groups conducted with 22 women, and self-administered surveys from 303 women (for a response rate of 92%). SETTING AND PARTICIPANTS: Survey respondents were Tongan-American women aged 40 years and older, residing in Los Angeles and Orange Counties. RESULTS: The breast is the most common cancer site for Tongan women, followed by the cervix and uterus, lung and bronchus, and stomach. The proportion of all cancers accounted for by breast cancer is lower among Tongan women (0.8) compared to White women. We found low rates for all types of breast cancer screening: only 40% of respondents had ever performed a breast self-examination (BSE); 26% ever received a clinical breast exam (CBE); and 25% ever received a mammogram. Many misperceptions existed about breast cancer causes, signs, and symptoms as well as the role of screening in detecting pre-symptomatic cancers. CONCLUSIONS: Much emphasis needs to be placed on improving early breast cancer screenings among Tongan-American women, including comprehensive community education, culturally tailored and linguistically appropriate materials, and improved access to low-cost screening sites.