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Keywords:

  • AANCART;
  • cancer;
  • Asian;
  • Cambodian;
  • qualitative research

Abstract

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

Census data indicate that Cambodian Americans are economically disadvantaged and linguistically isolated. In addition, cancer registry data show that Southeast Asians experience several cancer-related health disparities (e.g., markedly elevated risks of cervical and liver cancer). The Seattle regional Asian American Network for Cancer, Awareness, Research, and Training (AANCART) site has implemented a community-based cancer awareness program for Cambodian immigrants in collaboration with a Cambodian community coalition. Our cancer awareness program has the following goals: to assist individuals and organizations in advocating for a healthy community, to provide information within a cultural context, and to deliver information in ways that are useful and meaningful to the community. The program was guided by a community assessment that included the use of published data as well as information from qualitative interviews, focus groups, and quantitative surveys. Examples of community awareness activities include group presentations at community-based organizations (e.g., during English as a second language classes), health fair participation (including at nontraditional venues such as a farmers' market serving Cambodians), and educational displays in neighborhood locations (e.g., at Cambodian video stores). In addition, the Seattle AANCART site has both inventoried and developed culturally appropriate Khmer language cancer education materials and disseminated materials through the ETHNOMED website. Our approach recognizes that limited English language proficiency may preclude many Cambodians from understanding publicly disseminated information, and Cambodian immigrants are often isolated and tend to stay close to their own neighborhoods. Cancer 2005. © 2005 American Cancer Society.

A major objective of the Asian American Network for Cancer, Awareness, Research, and Training (AANCART) is to increase cancer awareness among Asian American communities. The Seattle AANCART regional site is a collaboration between Fred Hutchinson Cancer Research Center and Harborview Medical Center (a county hospital delivering comprehensive medical services to inner city residents), and primarily targets Cambodian Americans. Our cancer awareness program has the following goals: to assist individuals and organizations in advocating for a healthy community; to provide information within a cultural context; and to deliver information in ways that are useful and meaningful to the Cambodian community. This brief report summarizes a presentation at the fifth AANCART Academy, held in Sacramento during 2004, and focuses on our collaboration with the Cambodian community.

COMMUNITY COALITION

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

To ensure that the Seattle AANCART activities incorporate community values, attitudes, and symbols, our regional site works closely with a coalition of Cambodian Americans. This coalition includes representation from the following groups and organizations: Asian Counseling and Referral Service, Cambodian Women's Association, Harborview Medical Center, International Community Health Services, Khmer Community of Seattle–King County, Refugee Federation Service Center, and Refugee Women's Alliance. Coalition members have input into the selection and development of all AANCART activities and facilitate the implementation of community-based health education.

COMMUNITY ASSESSMENT

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

Our health education program was informed by published data, earlier qualitative studies addressing hepatitis B / liver cancer and women's health issues, previous quantitative surveys of Cambodian women in Seattle, and focus groups conducted shortly after AANCART received funding from the National Cancer Institute (NCI).1–7 The U.S. Census data for 1990 indicated that Cambodian Americans are economically disadvantaged (43% lived below the federal poverty level) and linguistically isolated (only 73% spoke English fluently or very well).1 In addition, information from the California Cancer Registry shows that Southeast Asians have a markedly increased risk of two malignancies, cervical cancer and liver cancer, when compared with all other racial/ethnic groups. (The incidence of invasive cervical cancer is 35.2 per 100,000 among Southeast Asian women vs. 7.5 among non-Latina white women. Similarly, the incidence rates for liver cancer among Southeast Asian and non-Latino white men are 39.4 and 3.1 per 100,000, respectively.)2

The earlier qualitative study addressing hepatitis B found that Cambodians recognize illnesses that are described in terms of symptom complexes, but do not refer to diseased organs; therefore, an educational pamphlet about hepatitis B that includes the term rauk tlaam (the literal translation of liver disease), for example, would be meaningless to many Cambodian immigrants.3 Our qualitative study of women's health showed that Cambodian Americans have a complex traditional model of reproductive health and disease; it also showed that Cambodians are unfamiliar with Western concepts of cancer as well as early detection.4 Quantitative survey data found low levels of screening participation among Cambodian women: nearly one-quarter (24%) of survey respondents had never received Papanicolaou (Pap) testing, one-third (33%) of those age 40 and older had never received a mammogram, and only 38% had been serologically tested for hepatitis B infection.5–7 Our focus groups confirmed that Seattle's Cambodian community has many competing health and social service needs, and that Cambodians generally stay close to their neighborhoods because of language barriers and transportation difficulties. Table 1 gives examples of how data were used to plan our community awareness program.

Table 1. Use of Community Assessment Data for Program Planning
Data sourceFindingProgram feature(s)
U.S. CensusOnly a minority of Cambodian Americans speak EnglishHealth education sessions are translated into Khmer by a Cambodian outreach worker
Health fairs are staffed by Cambodian staff and community coalition members
California Cancer RegistrySoutheast Asians have high rates of cervical and liver cancerEmphasis has been placed on education about hepatitis B testing and immunization as well as Pap testing
Qualitative studiesCambodians have traditional models for considering health and illnessEducational materials and presentations recognize traditional models, and explain medical terms as well as preventive concepts in ways that are understandable to the community
Cambodians are unfamiliar with biomedical terminology and preventive concepts
Quantitative surveysVery few Cambodian women can read EnglishKhmer language cancer education materials have been developed
Cambodian women have low rates of cancer screening participationAvailable Khmer language materials have been inventoried
Educational materials focus on screening procedures
Educational presentations systematically address cancer screening tests
AANCART focus groupsThe Cambodian community has many competing health and social service needsEducational presentations address community concerns as well as cancer-related topics
Cambodians stay close to their own neighborhoods because of language barriers and transportation difficultiesEducation is provided in neighborhood settings

COMMUNITY-BASED HEALTH EDUCATION

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

The Seattle AANCART site has provided a ‘grass-roots’ health education program of community presentations. These presentations are given in neighborhood settings such as the community centers of public housing complexes. In general, education is given during regularly scheduled social events and classes for Cambodian immigrants. For example, forums have included a senior lunch program for older Cambodians as well as English as a second language classes (conducted by organizations represented on the community coalition). Presenters have all volunteered their time and have included physicians, nurses, and pharmacists. The presentations are translated into Khmer by a Cambodian interpreter. Approximately one-half of the presentations have focused on cancer-related issues such as diet and cancer, smoking cessation, hepatitis B, Pap testing, and breast cancer screening. However, we have also made presentations addressing the broader health and social services needs of the community; these needs were identified by coalition members. For example, we addressed health insurance issues, diabetes, and hypertension.

We have regularly participated in traditional health fairs targeting Asian American groups. These health fairs have included the International District Health Fair (held in the geographic area of Seattle where Asians first settled), White Center Jubilee Days (White Center has the greatest concentration of Cambodian residents in the city), and the New Holly Park Health Fair (held at a public housing area with a large proportion of Southeast Asian residents). We have also used nontraditional forums to provide cancer education in a health fair setting. For example, we have regularly staffed a table at the Columbia City Farmers Market; this flower, fruit, and vegetable market is held in an area of South Seattle with many Cambodian residents, occurring weekly during the summer months. Finally, educational displays have been placed in neighborhood settings (e.g., at the Khmer Community of Seattle–King County office and Cambodian video stores).

HEALTH EDUCATION MATERIALS

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

The Seattle AANCART site completed a systematic inventory of available Khmer language cancer education materials. The main focus was health education materials related to cancer control. However, during the process, health education materials related to other medical issues (e.g., tuberculosis) were also collected and inventoried. The following topics were considered relevant to cancer education during the inventory process: regular physical exams; breast, cervical, colorectal, and prostate cancer screening; hepatitis B testing and immunization; tobacco cessation; and diet and nutrition. The inventory is organized by type of material (e.g., videos) as well as topic (e.g., breast cancer screening), and provides the title of each material as well as contact information for the organization that supplied the pamphlet, video, or poster.

Seattle's AANCART site has developed several Khmer language educational materials. These materials focus on hepatitis B / liver cancer and cervical cancer and all incorporate images from Angkor Wat. For example, three Pap testing pamphlets were developed. One of these pamphlets, entitled New Traditions to Preserve Health, uses testimonials and accompanying facts as well as a question-and-answer format to address barriers to cervical cancer screening, identified during our previous qualitative study of women's health issues. The other two pamphlets, Pap Tests: A Healthy Habit for Life and Having a Pelvic Exam and Pap Test, were adapted from NCI publications (National Institutes of Health Publications 98–3213 and 99–3416) and translated into Khmer.

ETHNOMED (ethnomed.org) is an electronic database, maintained by members of the Seattle AANCART group that contains information on medical and cultural information relevant to clinicians and other healthcare providers who serve refugee and immigrant groups. The database aims to bridge cultural and linguistic barriers to effective healthcare delivery. We have used ETHNOMED to disseminate the inventory as well as Khmer language health education materials (e.g., a Khmer language motivational video addressing cervical cancer screening entitled The Preservation of Traditions).

CONCLUSION

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

The Seattle regional AANCART site has successfully implemented a community-based cancer education program for Cambodian Americans. This ongoing effort has been made possible by actively collaborating with community leaders as well as groups and organizations that serve Cambodian families. Our approach recognizes that low levels of acculturation to Western norms of preventive medicine, scant knowledge of biomedicine, and limited English language proficiency may preclude many Cambodians from receiving and understanding publicly disseminated information.8 For example, use of the English language media would be an ineffective method of disseminating information to Cambodian Americans. The community awareness program also recognizes that Cambodian Americans are often isolated from the general U.S. society, tend to stay close to their own neighborhoods, and need individualized assistance in adapting to a Western preventive care orientation.

Acknowledgements

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES

The authors thank the Cambodian community coalition members' contributions to our community awareness program: Jenny Ap, Leta Chhor, Lynn Chhor, Leng Lim, Boriphal Mar, Ly Sieng Ngo, Roeun Sam, Lyvan Sawn, and Sophorn Sim.

REFERENCES

  1. Top of page
  2. Abstract
  3. COMMUNITY COALITION
  4. COMMUNITY ASSESSMENT
  5. COMMUNITY-BASED HEALTH EDUCATION
  6. HEALTH EDUCATION MATERIALS
  7. CONCLUSION
  8. Acknowledgements
  9. REFERENCES
  • 1
    United States Department of Commerce. We the Asian Americans. Washington, DC: United States Department of Commerce, 1993.
  • 2
    Perkins CI, Morris CR, Wright WE, Young JL. Cancer incidence and mortality in California by detailed race/ethnicity, 1988–92. Sacramento: California Department of Health Services, 1995.
  • 3
    Jackson JC, Rhodes LA, Inui TS, Buchwald D. Hepatitis B among the Khmer: issues of translation and concepts of illness. J Gen Intern Med. 1997; 12: 9298.
  • 4
    Jackson JC, Taylor VM, Chitnarong K, et al. Development of a cervical cancer control intervention for Cambodian American women. J Community Health. 2000; 25: 359377.
  • 5
    Taylor VM, Schwartz SM, Jackson JC, et al. Cervical cancer screening among Cambodian American women. Cancer Epidemiol Biomarkers Prev. 1999; 8: 541546.
  • 6
    Tu SP, Yasui Y, Kuniyuki A, et al. Breast cancer screening among Cambodian American women. Cancer Detect Prev. 2000; 24: 549563.
  • 7
    Taylor VM, Jackson JC, Chan N, Kuniyuki A, Yasui Y. Hepatitis B knowledge and practices among Cambodian women in Seattle, Washington. J Community Health. 2002; 27: 151163.
  • 8
    McPhee SJ, Birg JA, Ha NT, Jenkins CNH, Fordham D, Le B. Pathways to early cancer detection: health is gold. Health Educ Q (Suppl). 1996; 23: 6075.