Developing and Evaluating a School-Based Tobacco and E-Cigarette Prevention Program for Deaf and Hard-of-Hearing Youth.

School-based programs are an important tobacco prevention tool. Yet, existing programs are not suitable for Deaf and Hard-of-Hearing (DHH) youth. Moreover, little research has examined the use of the full range of tobacco products and related knowledge in this group. To address this gap and inform development of a school-based tobacco prevention program for this population, we conducted a pilot study among DHH middle school (MS) and high school (HS) students attending Schools for the Deaf and mainstream schools in California (n = 114). American Sign Language (ASL) administered surveys, before and after receipt of a draft curriculum delivered by health or physical education teachers, assessed product use and tobacco knowledge. Thirty-five percent of students reported exposure to tobacco products at home, including cigarettes (19%) and e-cigarettes (15%). Tobacco knowledge at baseline was limited; 35% of students knew e-cigarettes contain nicotine, and 56% were aware vaping is prohibited on school grounds. Current product use was reported by 16% of students, most commonly e-cigarettes (12%) and cigarettes (10%); overall, 7% of students reported dual use. Use was greater among HS versus MS students. Changes in student knowledge following program delivery included increased understanding of harmful chemicals in tobacco products, including nicotine in e-cigarettes. Post-program debriefings with teachers yielded specific recommendations for modifications to better meet the educational needs of DHH students. Findings based on student and teacher feedback will guide curriculum development and inform next steps in our program of research aimed to prevent tobacco use in this vulnerable and heretofore understudied population group.

How can we help African American substance users stop smoking? client and agency perspectives.

Research is needed to better understand barriers to smoking cessation and sustained abstinence among racial/ethnic minority polydrug users. We conducted community dialogue groups involving 49 clients in substance use treatment programs with predominantly ethnic minority clientele and individual dialogues/interviews with seven program providers (stakeholders). Most clients were African American, under 40 years old, women, current smokers, and high school graduates. Smoking cessation services in these programs were considered inadequate and community programs insufficiently culturally tailored and economically and geographically inaccessible. Participants discussed individual "willpower" and choice; agency tobacco-related programs and policies; the relationships between smoking, smoking cessation, and treatment goals; and steps needed to reshape agency services and policies to provide greater support for smoking cessation in this at-risk population.

A Breast Cancer Education Program for D/deaf Women.

Barriers to obtaining breast cancer prevention knowledge and breast cancer screening have been noted among D/deaf women. A randomized controlled trial (RCT) is described that tested a culturally and linguistically tailored breast cancer education program conducted among a racially/ethnically diverse sample of 209 D/deaf women age 40 years or older. The study focused on D/deaf women with no more than a secondary education, a population at relatively high risk for incomplete breast health knowledge and services. This population's inadequate breast cancer knowledge and screening practices and the value of the education program were confirmed. Knowledge increased from -baseline to 12-month follow-up in the intervention group, and in some instances the control group; increased intention to get a mammogram was observed in the intervention group. Possible reasons for the few significant intervention/control group differences at 12 months were examined. Materials from the RCT are available online.

Bilingual Cancer Genetic Education Modules for the Deaf Community: Development and Evaluation of the Online Video Material.

Health information about inherited forms of cancer and the role of family history in cancer risk for the American Sign Language (ASL) Deaf community, a linguistic and cultural community, needs improvement. Cancer genetic education materials available in English print format are not accessible for many sign language users because English is not their native or primary language. Per Center for Disease Control and Prevention recommendations, the level of literacy for printed health education materials should not be higher than 6th grade level (~ 11 to 12 years old), and even with this recommendation, printed materials are still not accessible to sign language users or other nonnative English speakers. Genetic counseling is becoming an integral part of healthcare, but often ASL users are not considered when health education materials are developed. As a result, there are few genetic counseling materials available in ASL. Online tools such as video and closed captioning offer opportunities for educators and genetic counselors to provide digital access to genetic information in ASL to the Deaf community. The Deaf Genetics Project team used a bilingual approach to develop a 37-min interactive Cancer Genetics Education Module (CGEM) video in ASL with closed captions and quizzes, and demonstrated that this approach resulted in greater cancer genetic knowledge and increased intentions to obtain counseling or testing, compared to standard English text information (Palmer et al., Disability and Health Journal, 10(1):23-32, 2017). Though visually enhanced educational materials have been developed for sign language users with multimodal/lingual approach, little is known about design features that can accommodate a diverse audience of sign language users so the material is engaging to a wide audience. The main objectives of this paper are to describe the development of the CGEM and to determine if viewer demographic characteristics are associated with two measurable aspects of CGEM viewing behavior: (1) length of time spent viewing and (2) number of pause, play, and seek events. These objectives are important to address, especially for Deaf individuals because the amount of simultaneous content (video, print) requires cross-modal cognitive processing of visual and textual materials. The use of technology and presentational strategies is needed that enhance and not interfere with health learning in this population.

D/deaf Breast Cancer Survivors: Their Experiences and Knowledge.

D/deaf cancer patients and survivors, including D/deaf women diagnosed with breast cancer, have been largely overlooked in the research literature. To gain preliminary information we included 29 D/deaf breast cancer survivors in a larger program of community-academic research aimed at evaluating and addressing the breast cancer educational needs of D/deaf women. Seven D/deaf breast cancer survivors completed in-depth signed (American Sign Language) interviews and another 22 survivors completed a written/signed survey. Both studies revealed significant gaps in breast cancer knowledge among these women despite their having multiple contacts with medical providers, communication challenges in clinical settings, and inadequate access to support and advocacy services during diagnosis, treatment, and recovery. Research is needed to develop tailored cancer control programs for this population and to identify strategies for disseminating to health care providers and organizations information about the challenges D/deaf people face in obtaining needed services.

Bilingual approach to online cancer genetics education for Deaf American Sign Language users produces greater knowledge and confidence than English text only: A randomized study.

INTRODUCTION: Deaf American Sign Language-users (ASL) have limited access to cancer genetics information they can readily understand, increasing risk for health disparities. We compared effectiveness of online cancer genetics information presented using a bilingual approach (ASL with English closed captioning) and a monolingual approach (English text). HYPOTHESIS: Bilingual modality would increase cancer genetics knowledge and confidence to create a family tree; education would interact with modality. METHODS: We used a parallel 2:1 randomized pre-post study design stratified on education. 150 Deaf ASL-users ≥18 years old with computer and internet access participated online; 100 (70 high, 30 low education) and 50 (35 high, 15 low education) were randomized to the bilingual and monolingual modalities. Modalities provide virtually identical content on creating a family tree, using the family tree to identify inherited cancer risk factors, understanding how cancer predisposition can be inherited, and the role of genetic counseling and testing for prevention or treatment. 25 true/false items assessed knowledge; a Likert scale item assessed confidence. Data were collected within 2 weeks before and after viewing the information. RESULTS: Significant interaction of language modality, education, and change in knowledge scores was observed (p = .01). High education group increased knowledge regardless of modality (Bilingual: p < .001; d = .56; Monolingual: p < .001; d = 1.08). Low education group increased knowledge with bilingual (p < .001; d = .85), but not monolingual (p = .79; d = .08) modality. Bilingual modality yielded greater confidence creating a family tree (p = .03). CONCLUSIONS: Bilingual approach provides a better opportunity for lower educated Deaf ASL-users to access cancer genetics information than a monolingual approach.

Health Effects of Vanpooling to Work.

Shared commutes to work, such as vanpooling, benefit the environment and provide economic gain for riders in terms of fuel costs, parking fees, and personal vehicle wear and tear. Although ride sharing is commonly believed to promote health through stress reduction, published evidence on this topic is limited, and findings vary. This study explored the perceived health and well-being of vanpoolers using a qualitative, descriptive design. Five focus groups of vanpoolers and two individual interviews with drivers were conducted (N=40 participants). Stress, change in sleep patterns, and interpersonal relationships emerged as major themes. Employee insights about the impact of vanpooling on work productivity and how employer commitment to the vanpool program influences the vanpool experience also were important findings.

Can a minimal intervention reduce secondhand smoke exposure among children with asthma from low income minority families? Results of a randomized trial.

We report on the results of a low-intensity behavioral intervention to reduce second hand smoke (SHS) exposure of children with asthma from low income minority households in Los Angeles, California. In this study, 242 child/adult dyads were randomized to a behavioral intervention (video, workbook, minimal counseling) or control condition (brochure). Main outcome measures included child's urine cotinine and parental reports of child's hours of SHS exposure and number of household cigarettes smoked. Implementation of household bans was also considered. No differences in outcomes were detected between intervention and control groups at follow-up. Limitations included high attrition and low rates of collection of objective measures (few children with urine cotinine samples). There continues to be a need for effective culturally and linguistically appropriate strategies that support reduction of household SHS exposure among children with asthma in low income, minority households.

Breast cancer knowledge and practices among D/deaf women.

BACKGROUND: Limited scientific evidence is available regarding D/deaf women's breast cancer knowledge and early detection practices, as well as about how to increase D/deaf women's breast cancer control practices. OBJECTIVE/HYPOTHESIS: To assess baseline breast cancer knowledge and practices among a sample of D/deaf women recruited into a randomized controlled trial of a breast cancer education program developed for this population. METHODS: A written and signed (American Sign Language) survey was administered to a racially/ethnically diverse sample of 209 D/deaf women, 40+ years old, with lower levels of education, recruited in California between October 2008 and May 2009. RESULTS: There were misconceptions about breast cancer risk factors, screening, and treatment; only 64.2% of respondents correctly identified the purpose of mammography. Mammography in the prior 2 years was reported by 57.3% of the sample, by 69.8% of White women, and by 43.5% of women from other racial/ethnic groups. Rates also varied by education, having seen a physician in the prior year, and type of insurance. CONCLUSIONS: This study underscores significant gaps in breast cancer screening knowledge and practices, communication issues in health care settings, and unmet needs for tailored health information and materials in this population. Challenges faced in conducting the research needed to develop and test such programs are noted.

Tobacco prevention education in schools for the deaf: the faculty perspective.

We report results of a survey of tobacco education practices and perspectives among faculty at four Schools for the Deaf participating in the trial of a tailored tobacco prevention curriculum. Few faculty (20.4%) included tobacco use among the three most important health problems facing their students, although 88.8% considered tobacco education to be worthwhile. Despite perceived unmet needs among their students, classroom or school-wide attention to tobacco prevention was limited. Only 13.9% reported delivering tobacco programming in the prior year, most often reporting lack of deaf-friendly curriculum and materials (60.9%), time (47.8%), and training (43.5%) as barriers to program delivery. Perceptions, attitudes, and institutional issues, including lack of tailored curriculum, were seen as contributing to the limited focus on this important health problem.

Development and testing of an antitobacco school-based curriculum for deaf and hard of hearing youth.

A tobacco use prevention curriculum tailored for deaf/hard of hearing youth was tested using a quasi-experimental design. Two schools for the deaf received the curriculum; two served as noncurriculum controls. Surveys assessed changes in tobacco use, tobacco education exposure, and tobacco-related attitudes and knowledge among students in grades 7-12 over 3 school years (n = 511-616). Current (past month) smoking decreased significantly at one intervention school (23% to 8%,p = .007), and current smokeless tobacco use at the other (7.5% to 2.5%, p = .03). Tobacco education exposure and antitobacco attitudes and knowledge increased significantly at one or both intervention schools. At one control school, reported tobacco education exposure decreased (p < .001) and antitobacco attitudes increased (p = .01). The results indicate that the curriculum increased perceived tobacco education exposure and significantly affected tobacco-related practices, attitudes, and knowledge.

Exploring the uncertainties of early detection results: model-based interpretation of mayo lung project.

BACKGROUND: The Mayo Lung Project (MLP), a randomized controlled clinical trial of lung cancer screening conducted between 1971 and 1986 among male smokers aged 45 or above, demonstrated an increase in lung cancer survival since the time of diagnosis, but no reduction in lung cancer mortality. Whether this result necessarily indicates a lack of mortality benefit for screening remains controversial. A number of hypotheses have been proposed to explain the observed outcome, including over-diagnosis, screening sensitivity, and population heterogeneity (initial difference in lung cancer risks between the two trial arms). This study is intended to provide model-based testing for some of these important arguments. METHOD: Using a micro-simulation model, the MISCAN-lung model, we explore the possible influence of screening sensitivity, systematic error, over-diagnosis and population heterogeneity. RESULTS: Calibrating screening sensitivity, systematic error, or over-diagnosis does not noticeably improve the fit of the model, whereas calibrating population heterogeneity helps the model predict lung cancer incidence better. CONCLUSIONS: Our conclusion is that the hypothesized imperfection in screening sensitivity, systematic error, and over-diagnosis do not in themselves explain the observed trial results. Model fit improvement achieved by accounting for population heterogeneity suggests a higher risk of cancer incidence in the intervention group as compared with the control group.

Alcohol and other substance use among deaf and hard of hearing youth.

Little research has focused on alcohol and illicit drug use among deaf and hard of hearing youth. Findings are reported from survey data collected among high school students at two phases of a program of research primarily focusing on tobacco use [Phase 1: (1999/2000) n = 226, Phase 2: (2004) n = 618). Evidence of considerable ever (lifetime) drinking (59.1%, 42.6%) and other substance use (21.1%, 18.9%) was found. Gender, age, race/ethnic, grade, school type (mainstream vs. school for the deaf), age when deafened, and aspects of self-perception were examined for their possible association with substance use. Current use rates are reported, and study findings are discussed in relation to national data. Understanding these use patterns is critical to developing interventions for this culturally and linguistically unique population.

Low-income women with abnormal breast findings: results of a randomized trial to increase rates of diagnostic resolution.

BACKGROUND: Timely diagnostic resolution of abnormal breast findings represents a critical step in efforts to reduce breast cancer morbidity and mortality. Yet, follow-up rates among resource poor populations are not optimal. Efforts to mitigate this disparity are needed. We report results of a randomized trial assessing the effectiveness of a patient support and navigation intervention in increasing timely diagnostic resolution of abnormal breast findings among indigent women. METHODS: Women (n = 1,708) diagnosed with a breast abnormality at two public hospitals were randomized to an intervention or control group. The intervention, delivered through telephone, involved one call from a professional health worker and multiple calls from a lay health worker. The outcome, timely diagnostic resolution, defined as receipt of a definitive diagnosis (malignant or benign) within 6 months of the index referral, was assessed through medical chart audit. RESULTS: Intent-to-treat analyses revealed no significant effect of the intervention on timely diagnostic resolution. Diagnostic resolution rates were 55% and 56%, respectively, in the intervention and control arms. The significant predictors were method of abnormality identification (odds ratio = 1.50) and location of first scheduled appointment (odds ratio = 0.62). CONCLUSIONS: The intervention was not effective in creating change within the County health system. Achieving optimum diagnostic follow-up may require more intensive interventions than the one tested. In addition, system-level rather than patient-level interventions may hold more promise. IMPACT: There are no randomized trials reported in the literature testing interventions to increase diagnostic follow-up of breast abnormalities. Future research might test patient and system-level interventions that can be sustained beyond the study period.

Do deaf and hard of hearing youth need antitobacco education?

Little research has focused on tobacco use among deaf and hard of hearing youth. Findings are reported from a first-ever tobacco-related survey, completed by 226 California middle and high school students using either a written questionnaire or the Interactive Video Questionnaire, an interactive multimedia computer video technology. Rates for current smoking (3.1%), ever smoking (45.1%), and multiple types of tobacco use (10.6%) were found to be lower than among high school students generally; mainstreamed students were likelier to have ever tried smoking than their deaf school peers (57.8% vs. 31.8%). No statistically significant associations were found between ever smoking and race/ethnicity, gender, school performance, or prelingual vs. postlingual deafening; a quarter of the sample experienced occasional peer pressure to use tobacco products. Tobacco use covariates, exposure to cigarette marketing and antismoking programming, and tobacco education needs of deaf and hard of hearing youth are discussed.

Understanding tobacco use among Filipino American men.

Although lung cancer is the top cancer killer among Filipino American men, data on tobacco-related knowledge and attitudes, cessation efforts, and preferences for smoking cessation programs among this population are lacking. We interviewed a community sample of 318 Filipino American men (110 current, 108 former, and 100 never-smokers, all immigrants) aged 40-75 years in Los Angeles County in English and Tagalog, to gain a better understanding of their tobacco use as a first step toward developing a culturally tailored smoking cessation program. In our sample, smokers had lower levels of education and income compared with nonsmokers and were less acculturated based on language use and English fluency. Smokers were more likely than nonsmokers to agree that smoking can alleviate stress, depression, and boredom, and that it is part of social interactions, growing up, being a man, and looking mature. These beliefs were summarized in a Smoking Beliefs Scale (Cronbach's alpha = .84), which predicted current smoking in a multivariate analysis, together with perceived risk of getting smoking-related diseases and peer norms. The most preferred smoking cessation intervention formats were educational small group sessions with other Filipino men (32%), followed by one-on-one consultations by a health professional (26%), video (20%), pamphlet (17%), and toll-free telephone number (6%). More than half of the current smokers requested these smoking cessation activities in Tagalog (34%) or a combination of Tagalog and English (24%). Based on these findings, we make specific recommendations for a smoking cessation program for Filipino men.

The UCLA tobacco control program.

Tobacco use, the most preventable cause of death in our society and a growing international epidemic, should be well understood by all students preparing to enter the field of public health. Despite its importance, however, tobacco does not always enjoy the prominence it deserves in public health education. We report here on efforts to expand the focus on tobacco in the University of California Los Angeles School of Public Health through a program supported by the Association of Schools of Public Health/American Legacy Foundation's Scholarship, Training, and Education Program for Tobacco Use Prevention funding mechanism. We describe steps to increase tobacco content in required and elective courses; offer elective courses on tobacco; implement a pre-doctoral scholarship program featuring coursework, fieldwork, and exposure to tobacco issues at national meetings; and establish a tobacco-focused workshop series. We outline program successes, structural barriers to achieving some programmatic goals, and the program's early termination.

Is tobacco use a problem among deaf college students?

College students' tobacco use poses a significant public health problem. Effective intervention requires understanding of this behavior among race/ethnic, cultural, and linguistic collegiate subgroups, including deaf and hard of hearing collegians. Findings from a first-ever tobacco-related survey among this understudied population are reported. The authors used written questionnaires and the Interactive Video Questionnaire, a multimedia computer technology developed for use with the deaf and hard of hearing, to interview 241 volunteers on seven California college campuses. They found lower self-reported current smoking prevalence (14.5%) relative to collegians in the general population, but considerable ever smoking (65.1%) and multiple types of tobacco use (37.3%). The authors report on factors associated with tobacco use and on students' exposure to cigarette marketing, gaps experienced in receipt of antitobacco messages and services, and students' antitobacco intervention recommendations. Limitations of the research are described, including possible underreporting of participants' tobacco use.

Do children with asthma and their parents agree on household ETS exposure? Implications for asthma management.

The adverse consequences of passive smoking have spurred efforts to reduce environmental tobacco smoke (ETS) exposure among children, particularly in the home. For children with asthma, teaching them to avoid tobacco smoke at home is an important element of patient self-management. This strategy assumes that children can accurately assess household smoking behaviors and the level of their own exposure in the home. This study compared child and parental assessments of household smoking behaviors in an urban, low-income and largely ethnic minority sample of asthmatic children and their parents. While there was general parent-child agreement on the smoking status of household members, there was less agreement on duration of household smoking and the child's exposure to ETS. Objective validation measures (cotinine, nicotine) suggest that parents were better able than their children to assess hours of indoor smoking. Children's assessment of the extent of exposure to ETS may be problematic, with important implications for asthma patient self-management efforts.

Household smoking behavior and ETS exposure among children with asthma in low-income, minority households.

Environmental tobacco smoke (ETS) exposure was measured among 242 children with asthma who live in homes where at least one person smokes. Subjects were identified through clinics, schools, community agencies, and hospitals serving low-income, medically underserved communities in Los Angeles. Parents were surveyed about smoking behaviors in the household, children's ETS exposure, and attitudes towards smoking and smoking behavior change. Validation measures included urine cotinine for the child with asthma and passive air nicotine monitors placed in the subjects' homes. Overall reported levels of household smoking and ETS exposure were low, with a significant amount of household smoking taking place outside rather than inside the home. Over 47% of the respondents reported absolute restrictions against smoking in the home, and these restrictions were associated with lower reported levels of smoking, ETS exposure, and air nicotine and urine cotinine concentrations.