Protecting our Khmer daughters: ghosts of the past, uncertain futures, and the human papillomavirus vaccine.

OBJECTIVES: The FDA approved the first human papillomavirus (HPV) vaccine in 2006. Research into parental decision-making and concerns about HPV vaccination highlights questions about parenting and parents' role in the crafting of their daughters' future sexuality. In contrast to much of this literature, we explore narratives from interviews with Cambodian mothers of HPV vaccine-age eligible daughters who experienced genocide and came to the USA as refugees. DESIGN: We conducted in-depth, in-person interviews with 25 Cambodian mothers of HPV vaccine-age eligible daughters. Interviews were conducted in Khmer and translated into English for analysis. We followed standard qualitative analysis techniques including iterative data review, multiple coders, and 'member checking.' Five members of the research team reviewed all transcripts and two members independently coded each transcript for concepts and themes. RESULTS: Interview narratives highlight the presence of the past alongside desires for protection from uncertain futures. We turn to Quesada and colleagues' concept structural vulnerability to outline the constraints posed by these women's positionalities as genocide survivors when faced with making decisions in an area with which they have little direct knowledge or background: cervical cancer prevention. CONCLUSION: Our study sheds light on the prioritization of various protective health practices, including but not exclusive to HPV vaccination, for Khmer mothers, as well as the rationalities informing decision-making regarding their daughters' health.

Clinical perspectives on colorectal cancer screening at Latino-serving federally qualified health centers.

PURPOSE: Colorectal cancer is the second most common cause of cancer death in the United States, and rates of screening for colorectal cancer are low. We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (operating 17 clinics) about barriers to utilization of screening services for colorectal cancer. METHOD: We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving Federally Qualified Health Center networks in Oregon. All interviews were recorded, transcribed, and coded, and themes were grouped by influences at three levels: the patient, the organization, and the external environment. RESULTS: Estimated proportions of eligible patients who are underscreened for colorectal cancer ranged from 20% to 70%. Underscreening was thought to occur among low-income, underinsured, and undocumented patients and patients having multiple health concerns. Limited funding to pay for follow-up testing in patients with positive screens was cited as the key factor contributing to underscreening. CONCLUSIONS: We identified health care provider perceptions about the underutilization of screening services for colorectal cancer; our findings may inform future efforts to promote guideline-appropriate cancer screening.

Understanding HPV vaccine uptake among Cambodian American girls.

Cervical cancer incidence rates vary substantially among racial/ethnic groups in the United States (US) with women of Southeast Asian descent having the highest rates. Up to 70 % of cervical cancers could be prevented by widespread use of the human papillomavirus (HPV) vaccine. However, there is a lack of information about HPV vaccine uptake among Southeast Asian girls in the US. We conducted a telephone survey of Cambodian women with daughters who were age-eligible for HPV vaccination. Survey items addressed HPV vaccination barriers, facilitators and uptake. Our study group included 86 Cambodian mothers who lived in the Seattle metropolitan area. The proportions of survey participants who reported their daughter had initiated and completed the HPV vaccine series were only 29 and 14 %, respectively. Higher levels of vaccine uptake were significantly associated with mothers having heard about the HPV vaccine from a health professional and having received a recent Pap test. Commonly cited barriers to HPV vaccination included lack of knowledge about the HPV vaccine, not having received a physician recommendation for HPV vaccination and thinking the HPV vaccine is unnecessary in the absence of health problems. Linguistically and culturally appropriate HPV educational programs should be developed and implemented in Cambodian American communities. These programs should aim to enhance understanding of disease prevention measures, increase knowledge about the HPV vaccine and empower women to ask their daughter's doctors for HPV vaccination.

Perceptions of under and overutilization of cervical cancer screening services at Latino-serving community health centers.

We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (FQHCs) about patients' utilization of screening services for cervical cancer. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving FQHCs in Oregon. The clinic personnel we interviewed observed both under and overutilization of cervical cancer screening services. Clinic personnel estimated that 20-60 % of eligible patients were underscreened for cervical cancer, with 30 % the most commonly cited percentage. Underscreening was thought to occur among low-income, underinsured, and undocumented patients. Overscreening for cervical cancer was estimated to occur in 10-50 % of eligible patients, with 10 % the most frequently cited proportion. Overscreening was thought to occur among women younger than age 21 and women with a recent pregnancy. Our findings may inform future efforts to promote guideline-appropriate cancer screening and coordinated follow-up care.

Evaluation of a hepatitis B lay health worker intervention for Cambodian Americans.

Cambodian Americans have high rates of chronic hepatitis B virus (HBV) infection. However, only about one-half of Cambodian Americans have been serologically tested for HBV. We conducted a randomized controlled trial to evaluate the impact of a lay health worker (LHW) intervention on HBV testing and knowledge levels among Cambodian Americans. The study group included 250 individuals who participated in a community based survey in metropolitan Seattle and had not been tested for HBV. Experimental group participants received a LHW intervention addressing HBV and control group participants received a LHW intervention addressing physical activity. Trial participants completed a follow-up survey 6 months after randomization. Over four-fifths (82 %) of randomized individuals participated in a LHW home visit and the follow-up survey response rate was 80 %. Among participants with follow-up data, 22 % of the experimental group and 3 % of the control group reported HBV testing (p < 0.001). The experimental and control group testing difference remained significant in an intent-to-treat analysis. The experimental group was significantly more likely than the control group to know that Cambodians have higher rates of HBV infection than whites, HBV cannot be spread by eating food prepared by an infected person, HBV cannot be spread by sharing chopsticks, and HBV cannot be spread by shaking hands. Our findings indicate LHW interventions are acceptable to Cambodian Americans and can positively impact both HBV testing and knowledge levels.

Factors associated with hepatitis B testing among Cambodian American men and women.

Cambodian Americans have an elevated risk of liver cancer. This health disparity is attributable to high rates of hepatitis B virus (HBV) infection. Our study examined factors associated with HBV testing among Cambodian men and women. A population-based survey was conducted in the Seattle area. The Health Behavior Framework guided our survey instrument development. We attempted to interview a man and a woman in each household. The sample included 300 men and 367 women. About one-half of the male (45%) and female (54%) respondents had been tested for HBV. Two factors were independently associated with testing among men and women: a doctor had recommended testing and had asked a doctor for testing. Knowing that someone who looks and feels healthy can spread HBV was independently associated with testing among men. Low levels of HBV testing remain a public health problem among Cambodians. Interventions should improve patient-provider communication by encouraging providers who serve Cambodians to recommend HBV testing, as well as by empowering Cambodians to ask for testing.

Physical activity among Cambodian Americans: an exploratory study.

Available data indicate that Asian Americans as a group have lower levels of physical activity than non-Latino whites. However, few studies have focused on physical activity among Asian American sub-groups. Our objectives were to describe levels of physical activity, as well as individual and environmental correlates of physical activity among Cambodian Americans. We conducted a telephone survey of Cambodians living in three geographic areas (Central California, Northern California, and the Pacific Northwest) during 2010. Physical activity levels were assessed using the International Physical Activity Questionnaire (IPAQ) short version. Survey items addressed demographic characteristics, knowledge about the health benefits of physical activity, social norms and supports with respect to physical activity, the availability of neighbourhood recreational facilities, and neighbourhood characteristics. Our study group included 222 individuals. Only 12% of the study group reported low levels of physical activity, 40% reported moderate levels, and 48% reported high levels. Physical activity was strongly associated with the availability of neighborhood recreational facilities such as parks, but not with neighborhood characteristics such as heavy traffic. Our results suggest that a majority of Cambodian Americans are adherent to current physical activity guidelines. Neighborhood recreational facilities that provide opportunities for leisure-time physical activity are associated with higher levels of physical activity in Cambodian communities. Future research should assess the reliability and validity of the IPAQ in a Cambodian American study group.

Hepatitis B knowledge and practices among Cambodian Americans.

BACKGROUND: Liver cancer occurs more frequently among Americans of Southeast Asian descent than any other group. This health disparity can be attributed to high rates of hepatitis B virus (HBV) infection. We examined HBV awareness, knowledge about HBV transmission, HBV testing levels, and HBV vaccination levels among Cambodian Americans. METHODS: A population-based survey was conducted in metropolitan Seattle during 2010. The study sample included 667 individuals. We created a composite knowledge score (0-9) by summing the number of correct answers to survey items addressing HBV transmission. Data were analyzed using Generalized Estimating Equations. RESULTS: Seventy-eight percent of the study group had heard of HBV (before it was described to them). The proportions who knew that HBV cannot be spread by eating food prepared by an infected person, can be spread during childbirth, and can be spread during sexual intercourse were only 33%, 69%, and 72%, respectively. The mean knowledge score was 5.5 (standard deviation 1.7). Fifty percent of the survey respondents had been tested and 52% had been vaccinated. HBV awareness, higher knowledge scores, and vaccination were all associated (p<0.05) with younger age, higher educational level, younger age at immigration, and greater English proficiency. DISCUSSION: Our study findings confirm the need for Khmer language HBV programs for less acculturated and educated members of the Cambodian community. Such programs should aim to increase HBV testing rates, HBV vaccination rates among individuals who remain susceptible to infection, and levels of knowledge about routes of hepatitis B transmission.

To be healthy and to live long, we have to exercise: psychosocial factors related to physical activity among Cambodian Americans.

Regular physical activity produces various health benefits; however, relatively few adults in the United States (US) get enough physical activity. Little is known about physical activity behaviors, and barriers and facilitators to physical activity among Cambodian-Americans. Cambodian Americans were recruited from community venues to participate in one-on-one interviews and focus groups. A total of 20 adults (10 women and 10 men) participated in one-on-one interviews and 37 adults (23 women and 14 men) participated in one of four focus groups. Fifteen of the 20 interviews and all the focus groups were conducted in Khmer. Participants were generally born in Cambodia and over two-thirds had a high school education or less. About one-half of the participants met or exceeded the 2008 US Department of Health and Human Services physical activity guidelines. Commonly reported types of physical activity were walking, running, and working out at the gym. Barriers to physical activity included lack of time, inconvenient work hours, and family responsibilities. Perceived benefits of physical activity included improved health, improved appearance, and reductions in stress. Sweating caused by physical activity was thought to produce a variety of health benefits. Data from this qualitative study could be used to inform the development of culturally-relevant physical activity survey measures and culturally-relevant physical activity interventions for Cambodian Americans.

Chumnguh thleum: understanding liver illness and hepatitis B among Cambodian immigrants.

Cambodian immigrants are over 25 times more likely to have evidence of chronic hepatitis B infection than the general US population. Carriers of HBV are over 100 times more likely to develop liver cancer than non-carriers. Liver cancer incidence is the second leading cancer for Cambodian men and the sixth for Cambodian women. Despite this, this underserved population has received very little attention from health disparities researchers. Culturally and linguistically appropriate interventions are necessary to increase hepatitis B knowledge, serologic testing, and vaccination among Cambodian Americans. Eight group interviews were held with Cambodian American men (48) and women (49). Focus group discussion revealed unanticipated information about sociocultural influences on participants' understanding about hepatitis B transmission, disease course, and prevention and treatment informed by humoral theories underlying Khmer medicine, by biomedicine, and by migration experiences. Our findings reveal the value of qualitative exploration to providing cultural context to biomedical information--a formula for effective health promotion and practice.

HPV vaccine knowledge and beliefs among Cambodian American parents and community leaders.

BACKGROUND: The cervical cancer incidence rate among Cambodian American women is 15.0 per 100,000, compared to 7.7 per 100,000 among non-Latina white women. HPV infection has been identified as a universal risk factor for cervical cancer. The HPV vaccine was recently approved in the United States for females aged 9-26 years. There is little information about HPV vaccination knowledge and beliefs in Southeast Asian communities. METHODS: We conducted 13 key informant interviews with Cambodian community leaders, as well as four focus groups with Cambodian parents (37 participants). Two of the focus groups included fathers and two of the focus groups included mothers. Interview and focus group questions addressed HPV vaccine barriers and facilitators. RESULTS: Participants had limited knowledge about HPV infection and the HPV vaccine. Barriers to HPV vaccination included a lack of information about the vaccine, as well as concerns about vaccine safety, effectiveness, and financial costs. The most important facilitators were a health care provider recommendation for vaccination and believing in the importance of disease prevention. DISCUSSION: Future cervical cancer control educational programs for Cambodians should promote use of the HPV vaccine for age-eligible individuals. Health care providers who serve Cambodian communities should be encouraged to recommend HPV vaccination.