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Research Articles

apanicolaou Testing Among Vietnamese Americansesults of a Multifaceted Intervention

ung T. Nguyen, MD, Stephen J. McPhee, MD, Ginny Gildengorin, PhD, Thoa Nguyen, Ching Wong,y Q. Lai, MD, MPH, Hy Lam, Jeremiah Mock, MSc, PhD, Thien-Nhien Luong, MPH, Ngoc Bui-Tong, MHA,uyet Ha-Iaconis

ackground: Vietnamese-American women have the highest incidence of cervical cancer of any ethnicgroup, and they underutilize Papanicolaou (Pap) tests.

esign: Development and implementation of a multifaceted intervention using community-basedparticipatory research (CBPR) methodology and evaluated with a quasi-experimentalcontrolled design with cross-sectional pre-intervention (2000) and post-intervention(2004) telephone surveys. Data were analyzed in 2005.

etting: Santa Clara County, California (intervention community) and Harris County, Texas(comparison community).

articipants: Vietnamese-American women aged 18 and older (n �1566 at pre-intervention and 2009 atpost-intervention).

ntervention: A community–academic coalition developed and implemented six components: Vietnam-ese-language media campaign, lay health worker outreach, Vietnamese Pap clinic, patientregistry/reminder system, restoration of a government-funded low-cost screening program,and continuing medical education for Vietnamese physicians.

utcomeeasure:

Pap test receipt.

esults: Overall response rate was 56%. Pap test receipt increased in the intervention (77.5% to84.2%, p �0.001), but not in the comparison community (73.9% to 70.6%, p �0.05). Inmultivariate analyses, the intervention was associated with increased Pap test receipt(odds ratio [OR]�2.02, 95% confidence interval [CI]�1.37–2.99). Other factorsassociated with increased Pap testing included longer U.S. residence, having healthinsurance, having a regular site of care, having a respectful physician, having anon-Vietnamese or a female Vietnamese physician, and recalling exposure to Vietnam-ese-language media about Pap testing. Factors associated with reduced likelihood ofPap test receipt were age 65 years and older, never married, less than high schooleducation, and income below poverty level.

onclusions: A multifaceted CBPR intervention was associated with increased Pap test receipt amongVietnamese-American women in one community.(Am J Prev Med 2006;31(1):1-9) © 2006 American Journal of Preventive Medicine

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ietnamese-American women have the highestrate of cervical cancer of any ethnic group,1,2

yet they underutilize cervical cancer screen-ng.3–5 Their Papanicolaou (Pap) test receipt has

rom the Suc Khoe La Vang! Vietnamese Community Health Pro-otion Project, Division of General Internal Medicine (Nguyen TT,cPhee, Gildengorin, Nguyen T, Wong, Lai, Lam), and Department

f Psychiatry (Mock), University of California-San Francisco, Sanrancisco, California; Public Health Department (Luong) and Santa

lara Valley Health and Hospital System, Ambulatory and Commu-ity Health Services (Bui-Tong), Santa Clara County, San Jose, w

m J Prev Med 2006;31(1)2006 American Journal of Preventive Medicine • Published by

een associated with sociodemographic factors, be-iefs, access to care, and physician characteristics.4,5

Community-based participatory research (CBPR) in-olves community members in project design, imple-entation, and interpretation6–8 to address health

isparities in a culturally appropriate manner6,9,10 and

alifornia; and American Cancer Society, Silicon Valley/Centraloast Unit, California Division (Iaconis), Campbell, CaliforniaAddress correspondence and reprint requests to: Tung T. Nguyen,D, UCSF Medical Center, Box 0320, 400 Parnassus Avenue, A-405,

an Francisco CA 94143-0320. E-mail: tung.nguyen@ucsf.edu.

The full text of this article is available via AJPM Online at

ww.ajpm_online.net.

10749-3797/06/$–see front matterElsevier Inc. doi:10.1016/j.amepre.2006.03.005

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o produce sustainable community-based solutions.11

revious interventions to address Pap test receiptmong Vietnamese Americans have not usedBPR.12,13 This article reports quantitative results of aBPR project to increase Pap testing and build com-unity capacity. Baseline data and CBPR outcomes are

eported elsewhere.4,14

ethodsntervention

oalition building and community action plan. In 1999, theietnamese Community Health Promotion Project (VCHPP),community–academic research organization, formed a co-

lition with ten other organizations in Santa Clara CountySCC), California. The Vietnamese REACH for Health Initia-ive (VRHI) Coalition (the Coalition) developed a logic

odel based on the Pathways model to describe barriers toervical cancer screening. In the model, healthy behaviorsccur after the negotiation of complex pathways.15,16 Com-unity members negotiate a community pathway influenced

y socioeconomic status, beliefs, knowledge, attitudes, socialeinforcement, exposure to information, and access to healthare. Medical providers negotiate a medical pathway influ-nced by their knowledge, attitudes, beliefs, and incentives.hese pathways interact through cultural concordance, pa-

ient education, and system capacity.16 Since many factorsere involved, the Coalition formulated an intervention with

ix components.14

ommunity pathway: media campaign. The media campaignan for 27 months from 2002 to 2004 through Vietnamese-anguage television, radio, and print media along with theistribution of education materials. Media companies, com-unity members, and the Coalition assisted in the develop-ent and distribution of materials. Vietnamese physicians,oalition members, cancer survivors, and others appeared infteen 30- to 60-second television advertisements about the

mportance of cervical cancer screening guidelines, where tobtain Pap tests, and how to ask for one. Radio advertise-ents (audio tracks of TV ads) were broadcast weekly.ewspaper advertisements (images of TV ads) ran weekly in

ix newspapers and were supplemented by ten newspaperrticles. Distribution of materials with screening messages atealth fairs, physicians’ offices, and other venues included000 culturally appropriate annual calendars, 16,000 silkoses, and 25,000 copies of a Vietnamese-language cervicalancer booklet. Details can be found at www.healthisgold.org.

ommunity pathway: lay health worker outreach. The Coali-ion recruited and trained five community-based organiza-ions (CBOs), which recruited 50 Vietnamese-Americanomen as lay health workers (LHWs). Each LHW recruited0 Vietnamese-American women who were randomized intoHW outreach (LHWO) or comparison group. Overall, 1005omen participated. Over 3 to 4 months, each LHW con-ucted two small-group sessions to educate the LHWO groupbout Pap testing. Comparison-group participants re-eived one educational session after the post-LHWO surveyas completed. Details and results have been reported

lsewhere.17,18 s

American Journal of Preventive Medicine, Volume 31, Num

edical pathway: continuing medical education. The Coali-ion and the Vietnamese Physician Association of Northernalifornia organized continuing medical education (CME)

eminars on cervical cancer. Of 192 members, 48, 56, and 55hysicians attended the three annual seminars, respectively,ach lasting 1 hour. Pre- and post-CME surveys showedignificant increases in physician knowledge about survivalates for early- and late-stage cervical cancer, recommenda-ions about screening intervals, and options for evaluatingbnormal results.19

edical pathway: Breast and Cervical Cancer Control Pro-ram (BCCCP) restoration. The Breast and Cervical Cancerontrol Program, a federal program providing free screening

or low-income women, no longer existed in SCC in 1999.oalition members testified at legislative briefings, collectednd forwarded 2748 petitions, and met with state legislatorsnd health officials. In 2003, the program was re-establishednd grew to 15 sites, six with Vietnamese-speaking providers.

athway interactions: Vietnamese Pap clinic and patient navi-ator. The Coalition and the county medical system estab-ished a weekly clinic staffed by a Vietnamese female physiciano provide Pap tests at discounted rates, and a bilingual stafferson helped women to navigate by telephone. From 2001 to003, 1257 people received telephone assistance, and 462eceived a Pap test during 71 clinic sessions, with 90 obtainingne at other sites.

athway interactions: Pap registry/reminder system. Primaryare physicians with large Vietnamese patient populationsere recruited for a reminder system. In 1 year, 28 physiciansnrolled 4180 women at the time of a Pap test. Reminderards were sent on the 1-year anniversary to remind women tobtain repeat Pap testing.

valuation

ross-sectional pre- and post-intervention surveys were ad-inistered using a computer-assisted telephone interviewing

CATI) system to Vietnamese-American women in the inter-ention and control communities in 2000 and in 2004. Theniversity of California-San Francisco Institutional Reviewoard approved study protocols.The survey included questions previously developed with

ommunity input in English, translated and back-translated,ilot tested, and fielded in multiple surveys along with newuestions.3,4,12,13,20 A multidisciplinary multilingual team re-iewed all questions and their translations. The new surveysere tested in pilot interviews for comprehension and cul-

ural appropriateness and changed as needed.4 Researchersnd the surveying organization, Public Research Institute,rained and monitored bilingual interviewers.

ntervention and Comparison Communities. The interven-ion community, SCC, is home to 102,841 Vietnamese livingn a metropolitan area with churches, pagodas, stores, restau-ants, and CBOs.21 Vietnamese media capacity included threeadio stations, two daily television programs, and 13 publica-ions. Harris County (HC), Texas was chosen as the compar-son community because it has the largest Vietnamese-Amer-can community (population 58,248) outside California, hadimilar ethnic media capacity (five radio stations, one televi-

ion station, and four publications), and was distant enough

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o minimize media contamination. The two Vietnamese com-unities were also similar in gender ratios, age, birthplace,

inguistic isolation, educational attainment, and per capitancome.21 Neither county had a BCCCP site in 2000. Vietnam-se physicians numbered 110 in HC and 150 in SCC.

ampling and Response Rates. Genesys Sampling Systemsrovided random samples of listed telephone numbers with7 Vietnamese surnames. Listed surname sampling is stan-ard in this population, with the 37 surnames accounting forost Vietnamese Americans.4 Eligible participants wereomen aged �18 years, resident in either county, and

elf-identified as Vietnamese. In households with more thanne eligible respondent, one woman was randomly selected.ther than the maximum number of call attempts (8 in 2000,

2 in 2004), recruitment was similar for both surveys.Using a baseline Pap receipt rate of 70%, an effect size of

%, power of 80%, and significance level of 0.05, the sampleize was calculated at 750 per community per survey. Theverall response rate (number of respondents/number ofouseholds reached and eligible) was 56% (63% pre- and9% post-intervention in SCC, 54% pre- and 50% post-ntervention in HC). Both communities had the same groupf female interviewers for each survey. Over 95% of partici-ants responded in Vietnamese at both sites for both surveys.

ariables. Community pathway measures included sociode-ographic and health status. Household poverty level was

etermined using 1999 or 2003 income scales from the U.S.epartment of Agriculture.22 Beliefs and knowledge about

ervical cancer were measured by asking respondents howikely they were to get cervical cancer and about its causes.ccess measures included health insurance status, regularlace of care, regular physician, and physician’s gender andthnicity. Pathway interactions were measured by askingarticipants if they preferred a Vietnamese-speaking or aemale physician for a Pap test, if they would feel moreomfortable with a female present during the test, if theyelieved that people were treated unfairly due to ethnicity ornglish proficiency, if they trusted healthcare providers, if

hey felt their doctors treated them with respect, and if theynderstood their physicians’ explanations. To assess exposureo intervention activities, respondents were asked if they hadeen/heard a Vietnamese-language newspaper article, book-et, or television, radio, or newspaper advertisement concern-ng cervical cancer in the previous 6 months.

Outcome measures included Pap awareness, defined as anffirmative response to the question, “Have you ever heard ofPap test?” After an explanation of the test, Pap test receiptas measured by asking, “Have you ever had a Pap test?”ecency of Pap test (receipt within 12 months) was measuredy asking, “How long has it been since you had your last Papest?” Planning was measured by asking, “Are you planning toave a Pap test in the next 12 months?”

tatistical Analysis. All data were analyzed in 2005 using SAS,ersion 8.2 (SAS Institute, Inc., Cary NC, 2001). Descriptivetatistics were calculated for each variable by site (county) andime period. Women who had a hysterectomy were excludedrom the analysis of Pap testing. Initial analyses used chi-quare and Student’s t tests to examine differences betweenites and between pre- and post-intervention within each site.

ssuming a normal distribution and identity link function, a 2

uly 2006

inear model was constructed with site, time, and site-by-timenteractions.23,24 These models were used for cervical cancernowledge, Pap test screening, and media exposure variableso test for differences in the change from pre- to post-ntervention between the two sites.

Logistic regression analyses were used to identify factorselated to the outcome variables of Pap test receipt andecency. To identify fairly full stepwise models, a backwardlimination method was employed with an exclusion criterionf p �0.20. All models included variables measuring siteSCC�1, HC�0), time (post-intervention�1, pre-interven-ion�0), and site � time interaction to test for an interven-ion effect. Exploratory analyses included interaction termssite � other covariates), but these were not significant andere excluded from the models. Variables included in theodel using this approach are listed in the multivariateodel results. Covariates in the final models but not listedith odds ratio included employment, exposure to smoking,nderstanding of physician’s explanations, trust in healthcareroviders, perception that people are treated unfairly due toace/ethnicity or language, perceived likelihood of develop-ng cervical cancer, preference for female physician or Viet-amese physician performing the Pap test, preference ofnother woman in the room for the Pap test, and reportaving seen a Vietnamese television advertisement or a Viet-amese booklet concerning cervical cancer in the last 6onths. The final models included all variables statistically

ignificantly different at baseline between the two sitesshown in Tables 1, 2, and 3) except for having seen aietnamese calendar and knowing that smoking caused cer-ical cancer. A significance level of 0.05 was used for alltatistical tests.

esults

here were significant differences in sociodemographicnd healthcare measures within each community fromre- to post-intervention and between intervention andomparison communities (Table 1). Exposure to Viet-amese-language television or radio advertisements in-reased in both communities, with increases being signif-cantly greater in SCC compared to HC (Table 2).

Knowledge of the Pap test rose in SCC (76% to 94%,�0.001), but declined in HC (72% to 67%, p �0.05)

Table 3). Knowledge about screening recommenda-ions by age (60% to 82%, p �0.001) and by sexualnitiation (33% to 56%, p �0.001) increased in SCC.here was little change in knowledge about the causesf cervical cancer.In bivariate analyses (Table 4), Pap test receipt

ncreased in SCC (77.5% to 84.2%, p �0.001) but notn HC (73.9% to 70.6%, p �0.05). Pap test recency alsoncreased in SCC (64.9% to 70.4%, p �0.05) but not in

C (59.2% to 53.1%, p �0.05). More women in SCCeported physician offering of a Pap test over time59.2% vs 68.5%, p �0.001). Among women who neverad the test, more planned to obtain one in SCC41.3% to 53.6%, p �0.05) but not in HC (43.1% to

7.1%, p �0.001).

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Multivariate model results (Table 5) show that thentervention term (site � time) was significantly associ-ted with ever having received a Pap (OR [odds ra-io]�2.02, 95% CI [confidence interval]�1.37–2.99).actors associated with lower likelihood of test receiptere age �65 years, never having been married, less

han high school education, and household incomeelow poverty. Longer U.S. residency, having health

nsurance, and having a regular place of care weressociated with increased Pap test receipt. Compared toomen with no regular physician, those with femaleietnamese, female non-Vietnamese, or male non-Viet-amese physicians were more likely to have obtained aap test. Women who reported that their physician

able 1. Characteristics of Vietnamese-American women by

Sociodemographic characteristics

Intervention community

Pre-intervention(n � 798)

ge (years) 45.2 � 14.3 (18–90) 46.9

ears in the United States 11.8 � 8.4 (0–82) 13.8peaks English poorly or not at all 38 4ess than high school education 42 3nemployed 43 5ever married 9 1ousehold income below poverty

level22 2

ealth and access to health careGood-to-excellent health 73 5Had hysterectomy 6Someone in household smokes

cigarettes32 3

Has health insurance 69 8Has usual place for health care 93 8Has a regular physician at a

usual place for health care85 9

Regular physician is a woman 30 3Regular physician is Vietnamese 86 8

ttitudes toward healthcare systemPhysician treats respondent with

respect94 9

Physician explains things in away respondent canunderstand

84 8

Can trust physicians to do whatis best for the patient

79 7

Thinks healthcare system nevertreats people unfairly basedon their race or ethnicity

69 7

Thinks healthcare system nevertreats people unfairly basedon language

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p values are for chi-square test for the pre–post comparison in eachp value for the differences at pre- or post-intervention between intep � 0.05;*p � 0.01;**p � 0.001 (all bolded).D, standard deviation.

reated them with respect were more likely to have (

American Journal of Preventive Medicine, Volume 31, Num

btained a test. Exposure to radio advertisementsOR�1.5, CI�1.17–1.80) or newspaper articlesOR�1.8, CI�1.46–2.27) was associated with testeceipt.

Along with longer U.S. residence, self-reported goodealth, having health insurance, and having a regularlace of care, the intervention term was also significantlyssociated with Pap test recency (OR�1.67, CI�1.19–.34). Variables associated with lower likelihood of Papest recency were age �65 years, never married, limitednglish proficiency, and unknown household income.ap test recency and Pap test receipt were associated with

he same physician characteristics. Exposure to newspaperdvertisements (OR�1.4, CI�1.10–1.76) and articles

pre-intervention (2000) and post- intervention (2004)

Clara County Comparison community Harris County

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esults show that the multifaceted intervention de-igned and implemented by the VRHI Coalition wasuccessful in increasing cervical cancer screeningmong Vietnamese-American women. The effect size of0% is comparable to other community-based interven-ions.13,26 Although there are variations in the measure-

ent of CBPR effectiveness, changes in health behav-ors are ultimately important.25,27 This is one of the firsteports of a significant community-wide change inehavior resulting from an CBPR project, as a recentystematic review of CBPR projects found only 12rticles reporting results of completed interventionsnd only two with improved outcomes.27 Other CBPReasures such as capacity building, system change,

ustainability, and dissemination for this project haveeen described elsewhere.14

Knowledge deficits and cultural beliefs are impor-ant targets of health promotion. Although thereere knowledge changes following the intervention,o knowledge measure was associated with Pap testeceipt. Respondents continued cultural behaviorsuch as deferring to physicians, since less than halfad asked for a Pap test.28 The most importanteterminants of Pap test receipt and recency were

he intervention, physician characteristics, andealthcare access. These findings suggest that cultur-

able 2. Exposure to media education elements (%) by site,

Media exposure

Intervention communitSanta Clara County

Pre-intervention(n � 798)

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% answe

ith respect to cervical cancerand the Pap test, in the past6 months, have you

. . seen a Vietnamese-language television ad?

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. . seen a Vietnamesenewspaper article?

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. . seen a Vietnamese bookletabout cervical cancer?

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. . seen a red and goldVietnamese calendar urgingwomen to get Pap tests?

12 31**

p � 0.01;*p � 0.001 (all bolded).values are for chi-square test for the pre–post comparison (post-i

omparison (Harris pre-intervention column) between interventioninear model for intervention community change relative to compar

lly appropriate interventions can succeed in chang- f

uly 2006

ng health behaviors even if they are not successful inhanging cultural barriers.

Of equal importance are system barriers such asccess to health care. Interventions to improve accessave the largest effect on screening among the under-erved.29 The relationship among access, physicianharacteristics, and Pap test receipt in this study illus-rates the importance and complexity of healthcareccess in an ethnic minority population. Confirminghe importance of financial and logistic access, Viet-amese-American women with health insurance and aegular place of care were more likely to obtainests.3,13,20,30,31 The community identified access as a

ajor barrier, and therefore the Coalition included twontervention components to address financial access. As

catalyst for system change, the Coalition focused onietnamese-American issues, but the resulting im-roved financial access benefited all eligible countyesidents. Such success may not have been possible in araditional research approach, which often dictates aingle intervention. In addition, a CBPR approachncluded community members and policy advocates,ithout whom there may be no policy change.Culturally accessible care, however, is more nuanced.

espect is an important component of interpersonalelationships in Vietnamese culture. Women who re-orted having a physician who treated them respect-

e-intervention (2000) and post-intervention (2004)

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ndicating that ethnic concordance did not automati-

able 3. Cervical cancer awareness and knowledge (%) amo2000) and post-intervention (2004)

Intervention cSanta Clara

Pre-intervention(n � 798)

warenesseard of cervical cancer 91hink “almost certain” or “very likely”to develop cervical cancera

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eard of Pap test 76orrect knowledgeomen aged �18 should have Pap tests 60irgins should have Pap tests 33PV infection causes cancer 16

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values are for chi-square test for the pre–post comparison (post-omparison (Harris pre-intervention column) between the interventior a linear model for the intervention community change relative tOnly women who reported not having a hysterectomy.p � 0.05;*p � 0.01;**p � 0.001 (all bolded).PV, human papilloma virus; Pap, Papanicolaou test.

able 4. Pap testing (%) among Vietnamese-American wom2004)a

Intervention commSanta Clara Cou

Pre-intervention(n � 746)

Pinter(n �

ver had a Pap test 77.5 84.2*ad a Pap test in last year 64.9 70.4*ad a Pap test in last year if everhad one

84.2 83.8

ver asked doctor to perform a Paptest

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octor ever offered a Pap test 59.2 68.5*lanning to get next Pap test innext 12 months (if have hadone)

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values are for chi-square test for the pre–post comparison in each clara) change relative to comparison community (Harris) change.

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American Journal of Preventive Medicine, Volume 31, Num

ally lead to appropriate care.20,32 Many male Vietnam-se physicians are older, trained in Vietnam, and lessikely to have Western preventive care training.28

etnamese-American women by site at pre-intervention

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omen with female Vietnamese or female non-Viet-amese physicians were equally likely to receive screen-

ng, confirming that, for the Pap test, physician genderoncordance is more important than ethnic concor-ance.20,31,33,34 This finding indicates that effectivereventive care can still be delivered to Asian Ameri-ans in areas without large numbers of ethnic-concor-ant physicians.Commitment to a community-driven agenda in

BPR often means designing the research to fit com-unity needs, which here dictated a multifaceted inter-

ention. Since it is difficult to evaluate which compo-ent had the most impact, a multidimensionalpproach could be considered a research limitation.35

owever, more complex strategies are more effective inhanging screening behaviors among the under-erved.29 In addition, some components were evaluatedeparately and found to be effective.17,19

Of the 12 CBPR studies with quantitative evaluations,ve were quasi-experimental and four were random-

zed controlled trials.27 Thus, the quasi-experimentalesign is appropriate for the evaluation of this CBPR

able 5. Multivariate logistic models for factors associated w

ntervention (site � pre–post)ge, years (ref � 40–64)18–39�65

ears in United States (5-year increments)oor or no English fluency (ref � fluent)ever married marital status (ref � married)ess than high school education (ref � at least high school)ousehold income (ref � above poverty)Below poverty levelUnknownood/excellent health status (ref � poor/fair)ave any health insurance (ref � none)ave usual place of care (ref � none)ave a regular doctor (ref � none)Female, VietnameseFemale, non-VietnameseMale, VietnameseMale, non-Vietnameseoctor treats with respect (ref � no)ave heard Vietnamese radio ad in the last 6 months aboutave seen Vietnamese newspaper ad in last 6 months aboutave seen Vietnamese newspaper article in last 6 months ab

otes: Variables included but not significant in either model incxplanations, trust in healthcare providers, perception that people arf developing cervical cancer, preference for female physician or Vioman in the room for the Pap test, and report having seen a Vietnamancer in last 6 months.Only those who reported not having a hysterectomy.Hosmer-Lemeshow p � 0.34.Hosmer-Lemeshow p � 0.40.Indicates that variable was removed from final model.I, confidence interval; OR, odds ratio; Pap, Papanicolaou test; ref,

ntervention, particularly the media campaign. Some a

uly 2006

ffects of the media campaign were captured in thentervention term, but exposure to radio and newspa-er advertisements was independently associated withap test receipt. Other communities without capacity to

mplement all six components could focus on changingnowledge and behavior through education by usingelatively inexpensive ethnic media sources. Materialseveloped by this project are accessible to others atww.healthisgold.org.The main limitations of the survey included the

elatively low response rate of 56% and the use ofelf-report of test receipt. The response rate is notnusual for a telephone-based survey in this popula-ion.13,36 Although there are ethnic differences in thealidity of self-reports,37 this bias should affect interven-ion and comparison samples similarly. Another limita-ion is the small number of communities and theironrandomized selection. Randomized controlled tri-ls are not always feasible or ethically appropriate inBPR.27 There are few large Vietnamese communities

n the United States, and the cost of conducting CBPRn more than one community would be prohibitive. In

p test receipt and Pap test recency

Ever had a Papa,b

n � 3081

Had a Pap inlast 12 monthsa,c

n � 2862OR (95% CI) OR (95% CI)

2.02 (1.37–2.99) 1.67 (1.19–2.34)

0.8 (0.64–1.01) 1.0 (0.81–1.20)0.5 (0.37–0.68) 0.5 (0.41–0.72)1.2 (1.16–1.34) 1.1 (1.03–1.15)

—d 0.8 (0.66–0.99)0.1 (0.12–0.21) 0.2 (0.18–0.32)0.6 (0.50–0.77) —d

0.8 (0.60–0.96) 0.8 (0.67–1.03)1.3 (0.74–2.26) 0.8 (0.62–0.97)

—d 1.2 (1.00–1.45)1.4 (1.12–1.72) 1.5 (1.28–1.88)2.0 (1.35–3.10) 2.6 (1.76–4.00)

2.0 (1.36–2.93) 1.8 (1.32–2.56)3.8 (1.88–7.87) 2.7 (1.65–4.54)1.2 (0.90–1.64) 1.1 (0.87–1.49)1.9 (1.12–3.17) 2.1 (1.38–3.23)1.9 (1.29–2.71) 2.4 (1.64–3.57)

al cancer (ref � no) 1.5 (1.17–1.80) —d

al cancer (ref � no) —d 1.4 (1.10–1.76)rvical cancer (ref � no) 1.8 (1.46–2.27) 1.3 (1.06–1.70)

employment, exposure to smoking, understanding of physician’sted unfairly due to race/ethnicity or language, perceived likelihoodese physician performing the Pap test, preference of anotherelevision advertisement or a Vietnamese booklet concerning cervical

nce.

ith Pa

cerviccervicout ce

ludee trea

etnamese t

ddition, a CBPR approach requires that the interven-

Am J Prev Med 2006;31(1) 7

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ion community be closely related to the researchrganization. Although there were significant differ-nces at baseline between the communities, these wereddressed in the multivariate analyses. Nonetheless,here may have been unmeasured confounders. Al-hough the Vietnamese populations were different inize, they were comparable in other respects.21 Finally,imilar to most CBPR projects, only one health disparityn one ethnic group was addressed, and thus the results

ay not be generalizable to other settings.There is an abundance of data showing that a variety

f interventions are effective in addressing some as-ects of health disparities.35 Proponents of CBPR argue

hat interventions not grounded in the community willot lead to lasting changes. CBPR requires extensiveommitment in personnel, time, and resources, but isnherently valued by the communities suffering fromhe disparities. Effectiveness of studies such as thisrovides another building block in the justification forhe commitment of resources to this approach inealth promotion research.

his research was funded by the Centers for Disease Controlnd Prevention (CDC) (cooperative agreements U50/CU917412 and U50/CCU922156). Its contents are solely

he responsibility of the authors and do not necessarilyepresent the views of the CDC. The Asian American Networkor Cancer Awareness, Research and Training also supportedhis research through the National Cancer Institute (cooper-tive agreement U01/CA86322) (SJM and TTN). TTN waslso supported by an American Cancer Society Cancer Con-rol Career Development Award. This project would not haveeen possible without the contributions of the Vietnamese-merican community in Santa Clara County, California, and

he members of the Vietnamese REACH for Health Initiativeoalition, whose past and current chairs include Thien-Nhienuong, MPH, Tuyet Ha-Iaconis, and Ngoc Bui-Tong, MHA.e acknowledge the important contribution of the latehristopher N.H. Jenkins to the development of this projectnd the work of Kieuly Dang, MPH, Hiep Doan, MD, Tramam, MPH, and Kim H. Nguyen, MPH, during the course of

his project.No financial conflicts were reported by the authors of this

aper.

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