Asian Tobacco Education and Cancer Awareness Research Special Population Network

A Model for Reducing Asian American Cancer Health Disparities


  • Grace X. Ma PhD,

    Corresponding author
    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
    • Department of Public Health, Center for Asian Health, College of Health Professions, Temple University, 1700 N Broad Street, Suite 304A, Philadelphia, PA 19122-0843
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    • Fax: (215)-787-5436

  • Yin Tan MD, MPH,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
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  • Jamil I. Toubbeh PhD,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
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  • Rosita L. Edwards MA,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
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  • Steven E. Shive PhD, MPH,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
    2. Department of Health, East Stroudsburg University, East Stroudsburg, Pennsylvania
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  • Philip Siu MD,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
    2. Chinese Health Information Center and Chinese Medical Services
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  • Ping Wang MD,

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
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  • Carolyn Y. Fang PhD

    1. Center for Asian Health, Department of Public Health, Temple University, Philadelphia, Pennsylvania
    2. Division of Population Science, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Asian Americans are the fastest growing and the second largest foreign-born ethnic group in the United States. Cancer is a leading cause of death among Asian Americans. The Asian Tobacco Education and Cancer Awareness Research (ATECAR) Special Population Network, Center for Asian Health, aimed to reduce or eliminate cancer health disparities in these diverse, underserved populations in Pennsylvania, New Jersey, Delaware, and New York. The ATECAR logic model was adapted from a variety of conceptual frameworks to develop and implement the network's multifaceted cancer health disparities research, training, awareness, and outreach programs. The model was the basis for the developmental phases of the network that included (1) needs assessment, infrastructure, and partnership building; (2) intervention research, training, and mentorship; and (3) evaluation, dissemination, and diffusion. Community involvement occurred at every operational level to ensure program and network sustainability. Between 2000 and 2005, the ATECAR network consisted of 88 partners, representing a cross-section of Asian communities, academia, cancer centers, and health service agencies, ensuring a viable infrastructure for the network's multidimensional cancer health disparities programs. ATECAR's research covered tobacco control, cancer prevention and intervention, and clinical trials. More than 22 research projects were conducted and their results disseminated in peer-reviewed journals. ATECAR also trained 76 junior researchers and special population investigators and 1014 community professionals in disparity issues. ATECAR's multimedia cancer awareness education program reached over 116,000 Asians. The ATECAR network's achievements have had a profound impact on Asian Americans and established a trend toward reducing cancer health disparities, especially among underserved Asian Americans. Cancer 2006. © 2006 American Cancer Society.

Asian Americans are the fastest growing and the second largest foreign-born ethnic group in the U.S., increasing by 48% between 1990 and 2000 and representing 4.2% of the population.1 There are increasingly large populations of Asian Americans on the East Coast. In Pennsylvania and New Jersey, the increase during this period was 75%.1 New York is one of three states that have the largest populations of Asians.2 Nationally, Chinese represent the largest subgroup, comprising 23% of all Asian Americans.2 Between 1990 and 2000, this subgroup increased by 70% in Pennsylvania and New Jersey.3 The most recent immigrants in the eastern region of the U.S. are Vietnamese and Cambodians, and these subgroups increased 90% and 107%, respectively.3, 4 For the purpose of this article, the term ‘Asian American’ refers to people with ethnic–racial ties to East and Southeast Asia.

While overall health insurance status has improved in the U.S. since the mid-1980s, more than 30% of Asian Americans are uninsured and medically underserved.5 Koreans and Vietnamese have even higher uninsured rates.6 Southeast Asians, as a group, have higher poverty levels than the general population. The household income of 53% of Hmong, 41% of Cambodians, and 33% of Laotians falls below $15,000 per year, compared with 22% of non-Hispanic whites.7

The health status of Asian Americans may also be adversely affected by language barriers. The percentage of persons 5 years or older who do not speak English varies by subgroup: 61% of Vietnamese, 51% of Chinese, and 24% of Filipinos are not fluent in English. The majority of Asian Americans older than 65 years of age cannot communicate well in English.8 Even with the assistance of interpreters, the multiple languages and dialects of different Asian groups make communication difficult.9

Asian American Health and Cancer Disparities

While some health indicators suggest that Asian Americans are considered healthy relative to other subsets of the general population, these indicators do not reflect the diversity in these populations with regard to health status. For example, Asian Americans have higher incidence of tuberculosis (TB) and hepatitis B virus (HBV) infection than the general population.10 The incidence of TB, for example, is 41.6/100,000, compared with 2.8/100,000 for white non-Hispanics and 22.4 for African-Americans.9, 11, 12 Asian Americans account for ∼50% of HBV infections and 50% of deaths caused by HBV-induced liver failure in the U.S.13

Cancer is the leading cause of death for Asian American women, with an average age-adjusted cancer death rate of 66/100,000; for males, cancer is the second leading cause of death, with an average age-adjusted death rate of 97/100,000.14, 15 Certain types of cancer are more common among Asians: for example, they have the highest incidence rates of stomach cancer (male, 23/100,000; female, 13/100,000) and the highest death rate for this cancer among females (8/100,000) and males, the second highest (13/100,000); women have the third highest breast cancer incidence rate (97/100,000); and the incidence of cervical cancer among Vietnamese women is five times that of white women.16 Asians also have high rates for lung and bronchus, colon and rectum, and prostate cancers.17, 18

Tobacco Use Among Asian Americans

Although tobacco use is decreasing among the general U.S. population, its prevalence is on the rise among Asian Americans. Recent studies on tobacco use among adult Asian males have shown a prevalence ranging between 33% (Cambodians) and 39% (Chinese).19 A study of Asian smoking behavior in the eastern U.S. showed a prevalence range of 24% to 43%, which was the highest among U.S. racial/ethnic groups.20 Ma et al.20 noted that despite a high prevalence of lung cancer, for example, the majority of Asian smokers face substantial challenges in quitting smoking.21 Further, despite the efficacy of interventions in reducing tobacco use in the general population, few studies have targeted Asian Americans.22–25

Cancer Awareness and Knowledge in Asian Communities Prior to the ATECAR Special Populations Network

While a few tobacco control and cancer prevention programs targeting Asians in the western region of the U.S. have been established,26 similar efforts targeting Asian communities of the East Coast did not exist prior to the establishment of the Asian Tobacco Education and Cancer Awareness Research (ATECAR) network at Temple University in 2000. ATECAR, a comprehensive, innovative, and community-based, is part of the NCI-funded special populations network (SPN) initiative. The Asian community of the eastern U.S. was culturally and linguistically shielded from most programs that had served the population at large.27–32 To illustrate, in the heavily populated area of southeastern Pennsylvania and New Jersey, ATECAR identified 142 smoking cessation programs, none of which was culturally or linguistically adapted to any Asian group. A study conducted in 2000 by ATECAR20, 33, 34 showed that 70% of study participants thought their communities were either ‘not at all’ or ‘not very’ active in Asian tobacco use prevention, while 80% thought organizations in their communities ‘do not’ or ‘do little’ work on Asian tobacco-related issues.

Rationale for Establishing the ATECAR Special Population Network

A number of factors provided the rationale for establishing the ATECAR SPN. Among these were national and state initiatives and priorities such as Healthy People 2010,10 the Pennsylvania State Health Improvement Plan,35 and others that specifically addressed tobacco use and cancer health disparities among Asian Americans and Pacific Islanders (AAPI). The latter include the summit on cancer concerns for AAPIs, and the AAPI blueprint for tobacco control guidelines and recommendations36, 37 that stressed the need for comprehensive prevention and health promotion programs for the target populations and the establishment of an infrastructure for viable long-term, culturally competent research and education programs in tobacco and cancer control.

Although the overall ATECAR SPN goals and objectives were consistent with those of the NCI SPN, ATECAR established a long-term mission for the SPN and expanded the NCI objectives to reflect the special and urgent needs of its target populations in an expanded geographic region. For example, ATECAR expanded its goals and objectives to encompass a range of topics about cancer and cancer health disparities that included breast and cervical cancer, hepatitis B liver cancer, and stomach and colorectal cancers. ATECAR also explored and established viable patterns of health communication with a variety of Asian groups; developed and implemented hands-on training to junior researchers; and widened the range and sources of financial support for itself and the community. The revised mission also encompassed an expanded perspective of Asian cancer health issues to include questions regarding disparities and policies that govern the provision of services to underserved Asians. The concept of sustainability of established infrastructures and partnerships also evolved as a function of ATECAR's model of community engagement. The expanded geographic area of ATECAR included Delaware and New York City.


Conceptual Frameworks Informing ATECAR Research and Practice

The ATECAR SPN's logic model was adapted from a variety of conceptual frameworks to inform components of its multifaceted research, training, demonstration, media health communication, and community-based programs. These included the PRECEDE-PROCEED model,38 community-based participatory research (CBPR) principles,39, 40 the health belief model (HBM),41 and social cognitive theory (SCT)42 model.

ATECAR Special Population Network Logic Model

The original ATECAR operational model reflected the three developmental phases of the ATECAR SPN, as shown in Figure 1. It consisted of interrelated components and subcomponents that included needs assessment, infrastructure and partnership building, community outreach and education for cancer awareness, intervention research, professional training and mentorship, evaluation research, and dissemination and diffusion—components that lead to cancer health disparities reduction.

Figure 1.

Asian Tobacco Education and Cancer Awareness Research (ATECAR) logic model.

Application of Conceptual Frameworks

Application of these conceptual frameworks within the logic model allowed ATECAR to carry out the various phases of the SPN project. ATECAR used the PRECEDE-PROCEED model as an integrative framework for program planning and development. The model has been used extensively in community-based health promotion plans, and has been shown to be a robust conceptual educational framework for planning, implementing, and evaluating health programs.41 The model rests on the principle that success in achieving change is enhanced by active participation of the intended audience.41 CBPR underscores the indispensable role of the community in all phases of the research process.40 ATECAR used this approach successfully in developing, pilot testing, implementing, and evaluating its Asian community-wide tobacco and cancer control research and training programs.

PRECEDE-PROCEED and CBPR became the theoretical basis upon which the ATECAR SPN established the Asian community cancer coalition (ACCC), an essential building block in a sustainable community-based tobacco and cancer control program. The ACCC was the first coalition of its kind in the eastern U.S. and comprises more than 50 community-based organizations. The ACCC provided new opportunities for research, training, patient navigation, leadership, and regional activism for lifestyle change.

The ATECAR logic model was also used in developing a variety of strategies to enhance community capacity building. Among these were ATECAR's innovative small grants and technical support programs to encourage ACCC, and local and regional lay community members to initiate research that fulfilled specific community needs.

Program Evaluation

ATECAR designed a comprehensive, multifaceted evaluation system that incorporated an assessment of process, impact, and outcomes to measure the overall effort and effectiveness of all ATECAR programs. This was a dynamic monitoring system whose aim was to ensure implementation of program objectives and program responsiveness to target population needs. An NCI SPN Phase II progress review identified the ATECAR evaluation system as a ‘Best Practice’ and recommended its dissemination to other SPN programs.43 ATECAR process evaluations examined procedures and efforts in implementing ATECAR pro grams and activities. It facilitated early detection of problems associated with implementation so that timely adjustments could be made, and enabled tracking of the process of community mobilization.

Impact and outcome evaluations measured the effectiveness of ATECAR cancer awareness programs and other cancer health disparity intervention programs in which changes (e.g., in knowledge, attitudes, and behavior) were to be assessed prior to or following interventions.


Infrastructure and Cancer Coalition Capacity Building

ATECAR's infrastructure was based on establishing a long-term, sustainable, collaborative partnership that consisted of a steering committee, the ACCC Advisory Board, and academic and other institutional partners. ATECAR assumed a leadership role in establishing and maintaining a regional network focused on cancer health disparity issues. The sustainability of infrastructure and partnership building was enhanced by ATECAR's multiethnic, multilingual, and interdisciplinary research team that functioned within a structure—the Center for Asian Health—to which Asians could relate.

By 2005, ATECAR's collaborating partners included 88 community-based organizations, research and training institutions, community clinics and hospitals, cancer centers, CIS, and governmental and private entities (e.g., American Legacy Foundation, American Cancer Society). ACCC organizational membership increased from 7 in 2000 to more than 50 in 2005; the number of other partners increased from 6 to 38. During this 5-year period, ATECAR developed collaborative agreements and joint plans with all network partners. These partnerships and agreements formed the basis of ATECAR's CBPR that encompassed cancer health disparities research, training, and education programs. The partnerships also provided research opportunities for minority junior researchers to develop pilot studies in health disparities and to participate in ATECAR's intervention research programs.

The ATECAR infrastructure helped foster cohesiveness and effectiveness of the network to address cancer health disparities in general, and through increased awareness among Asian Americans, to remove barriers that prevented access to services, thus enhancing sustainability of the overall effort.

Asian Cancer Health Disparities Research

Reduction of cancer health disparities represents the core of ATECAR's research efforts. ATECAR's research focused on 3 broad cancer health disparity subjects: tobacco control, cancer prevention and intervention, and clinical trials education research. Research activities included population-based assessments, development of behavioral and clinical interventions, and community randomized intervention trials. During the SPN, ATECAR developed and conducted 22 research projects (Table 1). Examples of these projects are discussed below.

Table 1. ATECAR Cancer Health Disparities Research Projects
  1. Project status stands as of December, 2004.

Tobacco Disparity Research Projects
1. Comprehensive baseline epidemiological study on smoking and cancer risks for Asian Americans
2. Asian youth smoking intervention/cessation with cultural adaptation—ACT NOT (Asian-youth choose tobacco-free/not on tobacco)
3. Theory-based Asian adult brief smoking cessation intervention trial
4. Clinical, motivational, behavioral and pharmacological interventions for Chinese adult smokers
5. Culturally appropriate smoking intervention for Vietnamese American smokers
6. Culturally Appropriate smoking intervention for underserved Korean American smokers
7. U.S.–China tobacco study
8. Research-based community tobacco prevention and intervention for youth and adults
9. Secondhand smoke-free project for Asian families and community
Cancer Health Disparity Research Projects
10. A study on knowledge, attitudes, and behavior to Hepatitis B screening among Vietnamese Americans
11. A study on barriers and cultural beliefs to Hepatitis B screening among Vietnamese Americans and feasibility of a culturally tailored intervention
12. Study on knowledge, attitudes, and behavior to Hepatitis B screening among Chinese Americans in NYC
13. Study on barriers and cultural beliefs to Hepatitis B screening among Chinese Americans and feasibility of a culturally tailored intervention
14. Knowledge, attitudes, and behaviors to breast cancer early detection among Chinese Women
15. A study on barriers and cultural beliefs to breast cancer and early detection among Chinese Women and feasibility of a culturally tailored intervention
16. A community intervention study to increase cervical cancer screening among Korean American women
17. A study of barriers and cultural beliefs to cervical cancer screening among Korean Women and feasibility of a culturally tailored intervention
18. Cervical cancer intervention pilot study among Vietnamese women
19. Breast cancer prevention, treatment and navigation for Asian women
20. Hepatitis B and liver cancer prevention and intervention program
21. Cancer care disparities among Asian patients
Clinical Trials Education Research Projects
22. Clinical Trials Education for Underserved Asians

Comprehensive needs assessment study

A study of 1374 multiethnic Asian Americans was conducted in the target communities to collect data to guide health policy and planning for a variety of cancer prevention and smoking cessation programs. It identified cancer-related concerns in the communities, determined rates of smoking among defined age groups, identified secondhand smoke issues, and assessed the relative impact of tobacco advertizing. The study also gathered information on community awareness of tobacco and cancer prevention resources, knowledge and attitudes about tobacco, risk factors, and cancer research among Asian populations in the eastern region of the United States. Study results were disseminated through publications in scientific journals and at conferences.20, 33, 44–48

Culturally tailored cervical cancer intervention for Vietnamese women

This intervention study used a quasi-experimental research design, with a pretest–posttest and a 6-month follow-up. Vietnamese women were assigned to either an intervention or comparison group. Results indicated that the major barriers to screening were “language,” “don't know where to go,” and “no health problem/no sign of disease symptoms.” The 6-month follow-up assessment showed a significant increase between intervention and control groups in screening rates.49 Specifically, the results revealed a significant increase in receipt of Pap tests among all participants in the intervention group at 6-month follow-up (from 32% to 100%, P < .001). No significant increase was found in the control group (from 35% to 52%, P < .049) (67.6% vs. 17%). The conversion rate of baseline noncompliant (those who reported not having a Pap test in the past 12 months) to 6-month follow-up compliant was 100% for intervention and 36% for control group (Table 2). The intervention group also showed significant increases (P < .05) in knowledge about the causes of cervical cancer such as HPV from baseline to 6-month follow-up (from 17.6% to 44.1% with 26.5% increase), multiple sexual partners (from 5.9% to 41.2% with 35.3% increase), early age sexual involvement (from 2.9% to 35% with 32.4% increase), and smoking (from 8.8% to 41.2% with 32.4% increase).49

Table 2. Screening Rates of Cervical Cancer Intervention Trial in Vietnamese Women
IncreaseIntervention groupControl group
Ever had a Pap 17%32.4%100%67.6%35%52%
Had Pap test 36% (Those had No Pap past 12 M)0100%100%036%

Breast cancer among Chinese women

This was a cross-sectional study of Chinese women recruited from Chinese community-based organizations in metropolitan Philadelphia. Results indicated that 53% of participants had ever performed a breast self-examination (BSE), 53.2% had ever had a clinical breast examination (CBE), and 67.9% had ever had a mammogram. Knowledge and self-efficacy were significant predictors of BSE ever performance. Education and preference for a Chinese-speaking physician for CBE or mammogram were significant predictors of ever having a CBE (34%).50

Hepatitis B among Chinese Americans

This study of Chinese residents in New York City provided insights into knowledge about and screening for HBV. Results showed that 61.9% of participants had heard of HBV, 53.2% had heard there was screening for HBV, and 53.2% had heard of a vaccination for HBV. 62.8% reported they had never been screened for HBV, while 68.9% reported they had never received HBV vaccination. Lack of knowledge of screening facilities, lack of physician's recommendation, and feeling well/healthy were significantly associated with not obtaining screening.60

Culturally appropriate smoking cessation program for Asian youth

Focus groups with Asian adolescent smokers and nonsmokers and Asian adult professionals were conducted to develop a smoking cessation program tailored to Asian youth. Results from the intervention indicated an 18.2% quit rate at 3-month follow-up among program participants. Among participants who continued to smoke, there was a reduction in reported weekend and weekday cigarette consumption.52

Culturally enhanced smoking cessation study among Chinese and Korean smokers

A culturally tailored, theory-driven smoking cessation intervention for Chinese and Korean smokers was conducted. The intervention consisted of behavioral and nicotine replacement therapy. Participants were assessed at baseline and 1 week, 1 month, and 3 months postbaseline. Results suggested that a theory-based, individualized smoking cessation intervention could be effective in modifying smoking-related perceptions and attitudes as well as behavior. For example, 57% of smokers reported having quit at 1-week follow-up, and ∼60% reported quitting smoking between baseline and 3-month follow-up.51

Clinical trials education and promotion for underserved Asians

The goals of ATECAR clinical trials education research were to increase knowledge and participation of Asian Americans in cancer clinical trials (e.g., NLST, STAR, and SELECT). This program was accomplished through ATECAR's academic and clinical partners and the ACCC. In collaboration with Cancer Information Services, ATECAR provided intensive clinical trials education to Asian community leaders, service professionals, and healthcare providers who served Asian populations. In addition, community-based education was conducted through mass media campaign and group education to lay community people in Asian languages. For example, Cancer Clinical Trials Series articles were published in The Epoch Times, a Chinese newspaper with a mass distribution of 12,000 per issue and a Chinese readership that covers a large geographic area that includes metropolitan Philadelphia, South Jersey, the Delaware and Lehigh valleys, and the Washington D.C. metropolitan area. Limited funds did not permit a full scale evaluation of this program; in its stead, an evaluation survey was conducted among a subset of the readership. Results indicated that the large majority of respondents found the series helpful and 82% indicated a strong interest in calling ATECAR for more information on clinical trials focused on breast and lung cancer.44 Intensive group education to lay community people was also focused on a subset of the Asian community, namely Chinese Americans. Pre and postevaluation data on this group was collected and is currently in the process of data entry and analysis.

Training of Minority Junior Researchers and Community Partners

Training of minority junior researchers

Recruitment and training of junior researchers in community-based Asian cancer health disparities was one of ATECAR's strategic objectives. The Asian Junior Investigator Training and Mentorship (AJITM) was a collaborative effort between the Center for Asian Health and ATECAR academic and clinical partners. This effort formed a sustainable training base for graduate students, interns, and pre- and postdoctoral fellows from a variety of disciplines (e.g., medicine, public health, psychology, epidemiology, occupational health). To date, 76 Asian junior researchers have been trained through this program, 18 of whom have become special population investigators with leadership roles in developing, conducting, and managing pilot projects. The AJITM Program was designed to enhance trainees' exposure to Asian community-based research under the mentorship of experienced senior ATECAR researchers. The program offered four tracks:

  • 1Cancer Research Leadership Training: This track provided doctoral or postdoctoral fellows opportunities to develop, lead, and seek support for CNP pilot studies from a variety of sources (e.g., K awards, R21 or other sources).
  • 2Cancer Research Doctoral Fellowship Program: This program, supported primarily by ATECAR grant, provided fellows a wide range of experience in research and research-related activities that included, among other: literature search, review and critique; data collection; intervention curriculum development; evaluation tool development; preparation of peer-reviewed scientific papers; dissemination of research findings at national conference; conduct of community-based workshops on cancer topics and IRB protocol preparation.
  • 3Short-Term Internship Training: This time-limited and individually-tailored program was designed for graduates and undergraduate students who have shown interest in acquiring hands-on experience in Asian community cancer research that included curriculum development on a community cancer-related health issue, evaluation tool development, or a master's thesis development and implementation.
  • 4Cultural Competency Enhancement Training: All individuals involved in ATECAR or CAH activities have been provided this training to enable them to become more responsive to the health needs of Asian Americans.

Training and capacity building for community partners

This program was designed for community health practitioners and partners to enhance their capacity in developing and implementing community cancer control programs. The goal of this program was to institutionalize ATECAR's cancer health disparities programs and ensure program sustainability. ACCC partners have benefited from ATECAR's 85 training workshops. To date, 1014 professionals have been trained in a range of topics including cultural competency, smoking prevention and intervention, cancer health disparities, cancer control strategies for Asian populations, clinical trials, project evaluation, and hands-on grant-writing skills.

Community Cancer Awareness Education and Outreach

ATECAR's success in reaching Asian communities has been documented by Ma et al.53 The authors documented unrecognized community needs that served as the basis for collective action to increase cancer awareness, knowledge about cancer prevention, and early detection and utilization of health care services. One of ATECAR's successful efforts was its cancer and tobacco awareness and education program, which included an array of field-tested strategies—multimedia campaigns, live presentations, structured and hands-on training, culturally adapted educational materials and displays, special events awards, and outreach activities that involved ACCC members. Highlights of these efforts are presented in the following paragraphs.

Media education campaign

Research on culturally appropriate, community-based, educational media campaigns has demonstrated their efficacy in increasing cancer screening and decreasing smoking rates among minority ethnic populations.23, 54, 55 ATECAR's multimedia approach combined TV, radio, ethnic newspapers, advertizing, posters, websites, and pamphlets in Asian languages. ATECAR also elicited the support of and worked closely with CIS and ACCC member agencies in planning, executing, and evaluating media initiatives.56 The multimedia campaigns have reached more than 116,400 Asians. An example of the multimedia campaign is the collaboration with CIS, Pan Asia Radio, and ATECAR to produce a series of 30-min, multilingual radio programs on cancer control issues (tobacco control, breast cancer, cervical cancer, and healthy lifestyles). These programs increased calls to CIS 1-800-4-CANCER by 84%. Another example is the ATECAR Link, a regular column published in local and regional widely read Asian newspapers. The column is designed to disseminate health messages, cancer health disparities research findings, and available health service resources. To date, 103 ATECAR Link articles have been published.

Community outreach

ATECAR also reached Asian communities through health fairs and cultural gatherings to promote tobacco and cancer control messages. ATECAR disseminated Asian-language tobacco and cancer educational materials, recruited Asian lay people to participate in cancer intervention research projects, and conducted tobacco prevention and smoking cessation research projects. ATECAR cancer awareness efforts reached progressively larger numbers of people in Asian communities over a 5-year period (see Figs. 2–4).

Figure 2.

Center for Asian Health overall people reached Year 1 through Year 4.

Figure 3.

Center for Asian Health number of people attending educational training workshops, Year 1 through Year 5.

Figure 4.

Center for Asian Health material distribution, Year 1 through Year 5.

Outreach efforts were also enhanced by supporting ACCC community partners through the ATECAR small innovative grants program using leveraged funds. The purpose of this program was to mobilize and increase Asian community participation and capacity in tobacco and cancer control. To date, 26 community-initiated projects have been funded by government agencies and private foundations.

Asian-language educational materials

One of the major factors contributing to cancer health disparities in Asian communities is the lack of culturally and linguistically appropriate educational materials. To address this issue, ATECAR developed and translated, field tested, and distributed materials for Korean, Chinese, Vietnamese, Cambodian, and other Asian groups. Educational materials available in various Asian languages included cancer and tobacco educational curricula, booklets, flyers, posters, and handouts. To facilitate access to these materials, the Center for Asian Health also established an “Asian Language Health Resource Center” for the target communities.

Leveraging of Resources

Since 2000, ATECAR has leveraged its NCI funding for an additional $4.5 million from governmental agencies and private foundations through the submission of 21 proposals, 13 of which have been funded. These funds have broadened, enhanced, and contributed substantially to the mission and sustainability of the SPN network. Additionally, ATECAR assisted its network partners in generating numerous cancer health-related grants through a variety of state, city, and county health departments and the private sector. An example of this leveraging, resulting from ATECAR's training and capacity building program for community partners, was a grant made to a Southeast Asian community partner from the city of Philadelphia to conduct tobacco education and outreach.


Communities, irrespective of their socioeconomic status, possess enormous human and pecuniary resources and, given the appropriate tools, can define their respective health needs and act upon them responsibly. Even in the absence of scientific knowledge, communities can offer the researcher insights into human behavior that far exceed that which he or she can glean through independent inquiry. Over the past 5 years, ATECAR has imparted knowledge and skills and provided the essential tools for exploration. Asian communities have provided insights, effort, and participation in the research enterprise that have allowed ATECAR to exceed its goals.

Diversity has not been a negative factor in ATECAR's overall activities; rather, it has been a technical or a strategic factor in the context of CBPR. Transcending issues of diversity and focusing strictly on tobacco, cancer, and health disparities in Asian communities appeared to unite communities and create an environment where mutual concerns far outweighed other concerns. While ATECAR's CBPR experience corroborates the experiences of others in terms of advantages,39, 57, 58 establishing and maintaining viable partnerships with rapidly changing diverse populations has required vigilance and creativity.

Sustainable partnerships for community-based cancer control require continuing reinforcement, be it financial or technical. Research is not an everyday activity of communities, yet the basic concept of research exists in all communities—generally, people are exposed to research through media or other information avenues. ATECAR found that planning, design, support, and conduct of research with Asian communities can be challenging. Nonetheless, Asian communities are home to talent that can be nurtured for complex research tasks.

ATECAR's community-based cancer control efforts presented both challenges and barriers. To ensure the cultural sensitivity and competence of research or training instruments, ATECAR elicited the support of bilingual or polyglot staff and volunteers to carry out its research and other community-based activities. The community participatory nature of ATECAR's efforts reduced the potentially high cost of performing these activities.

Finally, given the fact that the SPN was a 5-year program, reduction in cancer health disparities cannot be assessed solely by cancer incidence and mortality rates, rather, by a spectrum of measures that assess the effectiveness of the total ATECAR effort. We conducted comprehensive evaluations at individual, community and cancer care system levels. Examples of these measures include knowledge, attitude, and behavior changes regarding cancer risks and cancer screening, adherence to cancer screening and follow-up on diagnostic and treatment services, as well as increased knowledge about tobacco risks and positive changes in smoking behaviors. All these measures indicate progress toward achieving the goal of narrowing or eliminating cancer health disparity in our target population.


The U.S. healthcare delivery system is facing critical challenges in providing adequate health services to a growing number of uninsured and underserved citizens. These challenges have had a profound impact on the health of minority populations, widening the gap of cancer health disparities in these populations. Uninsured and medically underserved Asian Americans are particularly vulnerable because of inherent cultural and linguistic barriers that isolate them from and prevent them from accessing mainstream health systems.

ATECAR, a community-based network, has addressed cancer health disparities in the uninsured, medically underserved, and low-income Asian American populations in the eastern region of the U.S. through innovative, comprehensive, and culturally and linguistically appropriate strategies. The network has empowered Asian communities through infrastructure and coalition capacity building, creation of sustainable partnerships, and provision of technical assistance, as well as by fostering a cadre of community leaders and junior researchers. ATECAR community-identified needs guided the network's research, training, cancer awareness education, and outreach programs.

Our experience with the successful application of the ATECAR-SPN model, first, in the Delaware Valley region of Pennsylvania and New Jersey and, second, in the NYC area, would indicate that the model can be generalizable to other Asian American communities in the U.S. We are particularly confident that our tobacco cessation programs for adolescents and adults are generalizable across Asian ethnic communities in the U.S. Our experience to date with HBV, breast cancer, and cervical cancer programs leads us to believe that these programs, too, have a high probability of generalizability across U.S. Asian communities.

Narrowing and eliminating cancer health disparities in a dynamically changing Asian American population requires long-term commitment of pecuniary and human resources, and culturally and linguistically appropriate approaches that combine multidisciplinary research, training, education, and viable community outreach efforts. We believe that the ATECAR-SPN model is a significant step toward achieving the goals of the NCI/NIH and the mission of ATECAR, Center for Asian Health.


We are grateful to members of the Asian Community Cancer Coalition, ATECAR, Center for Asian Health staff, and partners for their contributions to the network infrastructure and capacity building, research, training, and community outreach in Asian cancer health disparity issues. We also thank Dr. Kenneth Chu and Mr. Frank Jackson at NCI's Special Populations Network for their guidance and encouragement over the past 5 years; and to Drs. Harold Freeman and Nadarajen Vydelingum, who have provided vision and leadership in reducing cancer disparities among racial/ethnic minorities