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Sawatzky R, Larsdotter C, Carlssson E, Pettersson M, Kenne Sarenmalm E, Smith F, Nygren J, Russell L, Öhlén J. Predictors of preparedness for recovery following colorectal cancer surgery: a latent class trajectory analysis. Acta Oncol 2023; 62:1625-1634. [PMID: 37921342 DOI: 10.1080/0284186x.2023.2269303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
AIM With an interest in providing knowledge for person-centred care, our overall goal is to contribute a greater understanding of diversity among patients in terms of their preparedness before and up to six months after colorectal cancer surgery. Our aim was to describe and provide a tentative explanation for differences in preparedness trajectory profiles. MATERIAL AND METHODS The study was explorative and used prospective longitudinal data from a previously published intervention study evaluating person-centred information and communication. The project was conducted at three hospitals in Sweden. Patient-reported outcomes measures, including the Longitudinal Preparedness for Colorectal Cancer Surgery Questionnaire, were collected before surgery, at discharge, and four to six weeks, three months, and six months after surgery. Clinical data were retrospectively obtained from patients' medical records. We used latent class growth models (LCGMs) to identify latent classes that distinguish subgroups of patients who represent different preparedness trajectory profiles. To determine the most plausible number of latent classes, we considered statistical information about model fit and clinical practice relevance. We used multivariable regression models to identify variables that explain the latent classes. RESULTS The sample (N = 488) comprised people with a mean age of 68 years (SD = 11) of which 44% were women. Regarding diagnoses, 60% had colon cancer and 40% rectal cancer. The LCGMs identified six latent classes with different preparedness for surgery and recovery trajectories. The latent classes were predominantly explained by differences in age, sex, physical classification based on comorbidities, treatment hospital, global health status, distress, and sense of coherence (comprehensibility and meaningfulness). CONCLUSION Contrary to the received view that emphasizes standardized care practices, our results point to the need for adding person-centred and tailored approaches that consider individual differences in how patients are prepared before and during the recovery period related to colorectal cancer surgery.
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Affiliation(s)
- Richard Sawatzky
- School of Nursing, Trinity Western University, Langley, Canada
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, Canada
- Institute of Health and Care Sciences, and Centre for Person‑Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Eva Carlssson
- Institute of Health and Care Sciences, and Centre for Person‑Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monica Pettersson
- Institute of Health and Care Sciences, and Centre for Person‑Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Hybrid and Intervention, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Kenne Sarenmalm
- Institute of Health and Care Sciences, and Centre for Person‑Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Skaraborg Hospital, Skövde, Sweden
| | - Frida Smith
- Regional Cancer Centre West, Western Sweden Healthcare Region, Goteborg, Sweden
- Technology Management and Economics, Chalmers University of Technology, Gothenburg, Sweden
| | - Jonas Nygren
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lara Russell
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, Canada
| | - Joakim Öhlén
- Institute of Health and Care Sciences, and Centre for Person‑Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Palliative Centre, Sahlgrenska University Hospital Västra Götaland Region, Gothenburg, Sweden
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Chen XS, Changolkar S, Navathe AS, Linn KA, Reh G, Szwartz G, Steier D, Godby S, Balachandran M, Harrison JD, Rareshide CAL, Patel MS. Association between behavioral phenotypes and response to a physical activity intervention using gamification and social incentives: Secondary analysis of the STEP UP randomized clinical trial. PLoS One 2020; 15:e0239288. [PMID: 33052906 PMCID: PMC7556484 DOI: 10.1371/journal.pone.0239288] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/01/2020] [Indexed: 01/18/2023] Open
Abstract
Participants often vary in their response to behavioral interventions, but methods to identify groups of participants that are more likely to respond are lacking. In this secondary analysis of a randomized clinical trial, we used baseline characteristics to group participants into distinct behavioral phenotypes and evaluated differential responses to a physical activity intervention. Latent class analysis was used to segment participants based on baseline participant data including demographics, validated measures of psychosocial variables, and physical activity behavior. The trial included 602 adults from 40 U.S. states with body mass index ≥25 who were randomized to control or one of three gamification interventions (supportive, collaborative, or competitive) to increase physical activity. Daily step counts were monitored using a wearable device for a 24-week intervention with 12 weeks of follow-up. The model segmented participants into three classes named for key defining traits: Class 1, extroverted and motivated; Class 2, less active and less social; Class 3, less motivated and at-risk. Adjusted regression models were used to test for differences in intervention response relative to control within each behavioral phenotype. In Class 1, only participants in the competitive arm increased their mean daily steps during the intervention (adjusted difference, 945; 95% CI, 352-1537; P = .002), but it was not sustained during follow-up. In Class 2, participants in all three gamification arms significantly increased their mean daily steps compared to control during the intervention (supportive arm adjusted difference 1172; 95% CI, 363-1980; P = .005; collaborative arm adjusted difference 1119; 95% CI, 319-1919; P = .006; competitive arm adjusted difference 1179; 95% CI, 400-1957; P = .003) and all three had sustained impact during follow-up. In Class 3, none of the interventions had a significant effect on physical activity. Three behavioral phenotypes were identified, each with a different response to the interventions. This approach could be used to better target behavioral interventions to participants that are more likely to respond to them.
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Affiliation(s)
- Xisui Shirley Chen
- Department of Medicine, University of Pennyslvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Sujatha Changolkar
- Penn Medicine Nudge Unit, University of Pennyslvania, Philadelphia, Pennsylvania, United States of America
| | - Amol S. Navathe
- Department of Medicine, University of Pennyslvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
| | - Kristin A. Linn
- Department of Biostatistics, Epidemiology and Informatics, University of Pennyslvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Gregory Reh
- Deloitte Consulting, Philadelphia, Pennsylvania, United States of America
| | - Gregory Szwartz
- Deloitte Consulting, Philadelphia, Pennsylvania, United States of America
| | - David Steier
- Deloitte Consulting, Philadelphia, Pennsylvania, United States of America
| | - Sarah Godby
- Deloitte Consulting, Philadelphia, Pennsylvania, United States of America
| | - Mohan Balachandran
- Penn Medicine Nudge Unit, University of Pennyslvania, Philadelphia, Pennsylvania, United States of America
| | - Joseph D. Harrison
- Penn Medicine Nudge Unit, University of Pennyslvania, Philadelphia, Pennsylvania, United States of America
| | - Charles A. L. Rareshide
- Penn Medicine Nudge Unit, University of Pennyslvania, Philadelphia, Pennsylvania, United States of America
| | - Mitesh S. Patel
- Department of Medicine, University of Pennyslvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
- Penn Medicine Nudge Unit, University of Pennyslvania, Philadelphia, Pennsylvania, United States of America
- Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, United States of America
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Sy AU, Lim E, Ka'opua LS, Kataoka-Yahiro M, Kinoshita Y, Stewart SL. Colorectal cancer screening prevalence and predictors among Asian American subgroups using Medical Expenditure Panel Survey National Data. Cancer 2018; 124 Suppl 7:1543-1551. [PMID: 29578602 DOI: 10.1002/cncr.31098] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/10/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Asian American (AA) ethnic subgroups are diverse in socio-economic status, years in the United States, English proficiency, and cultures with different health seeking behaviors and health care access. Fifty-two percent of AAs age ≥50 years had colorectal cancer screening (CRCS) in 2013, compared with 61% of non-Hispanic whites. We hypothesized that CRCS prevalence among AA ethnicities is heterogeneous and that the reasons related to CRCS among AA subgroups are associated with demographic characteristics, acculturation, health care access, and health attitudes. METHODS Medical Expenditure Panel Survey data for 2009-2014 compared CRCS status among whites (n = 28,834), Asian Indians (n = 466), Chinese (n = 652), and Filipinos (n = 788). Multivariate logistic regression examined ethnic differences and correlates of CRCS accounting for complex sampling design. RESULTS Whites had the highest prevalence of screening (62.3%), followed by Filipinos (55.0%), Chinese (50.9%), and Asian Indians (48.6%). Older age, having health insurance, and having a usual care provider predicted CRCS across all ethnicities. Different demographic, health care access, and health attitude predictors within each ethnic group were related to CRCS. CONCLUSION This study contributes to the literature on influences of differential CRCS prevalence among AA subgroups. CRCS promotion should be tailored according to attitudes and structural barriers affecting screening behavior of specific ethnic subgroups to truly serve the health needs of the diverse AA population. Cancer 2018;124:1543-51. © 2018 American Cancer Society.
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Affiliation(s)
- Angela U Sy
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Eunjung Lim
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii
| | - Lana Sue Ka'opua
- Myron B. Thompson School of Social Work, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Merle Kataoka-Yahiro
- Department of Nursing, School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Yumiko Kinoshita
- Department of Health Sciences, Kyushu University, Fukuoka, Japan
| | - Susan L Stewart
- Division of Biostatistics, Department of Public Health Studies, University of California, Davis, California
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Huei-Yu Wang J, Ma GX, Liang W, Tan Y, Makambi KH, Dong R, Vernon SW, Tu SP, Mandelblatt JS. Physician Intervention and Chinese Americans' Colorectal Cancer Screening. Am J Health Behav 2018; 42:13-26. [PMID: 29320335 PMCID: PMC5765879 DOI: 10.5993/ajhb.42.1.2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We conducted a cluster-randomized trial evaluating an intervention that trained Chinese-American primary care physicians to increase their Chinese patients' colorectal cancer (CRC) screening. METHODS Twenty-five physicians (13 randomized to the intervention arm and 12 to the control arm) and 479 of their patients (aged 50-75 and nonadherent to CRC screening guidelines) were enrolled. The intervention, guided by Social Cognitive Theory, included a communication guide and 2 in-office training sessions to enhance physicians' efficacy in com- municating CRC screening with patients. Patients' CRC screening rates (trial outcome) and rating of physician communication before intervention and at 12-month follow-up were assessed. Intention-to-treat analysis for outcome evaluation was conducted. RESULTS Screening rates were slightly higher in the intervention vs. the control arm (24.4% vs. 17.7%, p = .24). In post hoc analyses, intervention arm patients who perceived better communication were more likely to be screened than those who did not (OR = 1.09, 95% CI: 1.03, 1.15). This relationship was not seen in the control arm. CONCLUSIONS This physician-focused intervention had small, non-significant effects in increasing Chinese patients' CRC screening rates. Physician communication appeared to explain intervention efficacy. More intensive interventions are needed to enhance Chinese patients' CRC screening.
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Affiliation(s)
- Judy Huei-Yu Wang
- Department of Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC, USA
| | - Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Wenchi Liang
- Center for Scientific Review, National Institutes of Health, Bethesda, MD, USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Kepher H Makambi
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University Medical Center, Washington DC, USA
| | - Roucheng Dong
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University Medical Center, Washington DC, USA
| | - Sally W Vernon
- Center for Health Promotion and Prevention Research, University of Texas-Houston School of Public Health, Houston, TX, USA
| | - Shin-Ping Tu
- Division of General Internal Medicine, Geriatrics and Bioethics, University of California Davis, Sacramento, CA, USA
| | - Jeanne S Mandelblatt
- Department of Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington DC, USA
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Kim SY, Shen Y, Hou Y, Tilton KE, Juang L, Wang Y. Annual Review of Asian American Psychology, 2014. ASIAN AMERICAN JOURNAL OF PSYCHOLOGY 2015; 6:291-332. [PMID: 26925199 PMCID: PMC4765738 DOI: 10.1037/aap0000031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This 2014 review of Asian American psychology is the sixth review in the series. It includes 316 articles that met the inclusion criteria established by the past five annual reviews. Featured articles were derived from three sources: 137 were generated via the search term "Asian American" in PyscINFO, 111 were generated via a search for specific Asian American ethnic groups, and 32 were generated via author searches of articles that met the inclusion criteria. The top primary topic was health and health-related behaviors, the most frequently employed study design was cross-sectional, and the most studied Asian American ethnic group was Chinese. This year's review includes information on the target population of the primary topic, the age range and developmental period of participants, and whether the study design was cross-sectional or longitudinal. It also identifies top authors and journals contributing to the 2014 annual review. These new features reveal that the most common target population of the primary topic was youths; studies most commonly included emerging adults ages 18-25; cross-sectional study design was employed more often than longitudinal design; the top contributor to the 2014 review was Stephen Chen, who authored the highest number of papers included; and the Asian American Journal of Psychology generated the highest number of publications for this review.
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Affiliation(s)
- Su Yeong Kim
- University of Texas at Austin, Department of Human Development and Family Sciences, 108 East Dean Keeton Street, Stop A2702, Austin, TX 78712, , (512) 471-5524
| | - Yishan Shen
- University of Texas at Austin, Department of Human Development and Family Sciences, 108 East Dean Keeton Street, Stop A2702, Austin, TX 78712, , (512) 983-7551
| | - Yang Hou
- University of Texas at Austin, Department of Human Development and Family Sciences, 108 East Dean Keeton Street, Stop A2702, Austin, TX 78712, , (512) 660-2236
| | - Kelsey E Tilton
- University of Texas at Austin, Department of Human Development and Family Sciences, 108 East Dean Keeton Street, Stop A2702, Austin, TX 78712, , (512) 956-459-4212
| | - Linda Juang
- University of Potsdam, College of Human Sciences, Education, Karl-Liebknecht-Str. 24-25, 14476 Potsdam, Germany, +49 (0)172 1882255,
| | - Yijie Wang
- University of Texas at Austin, Department of Human Development and Family Sciences, 108 East Dean Keeton Street, Stop A2702, Austin, TX 78712, , (512) 289-8136
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Tanaka M, Gehan E, Chen MY, Wang JHY. Hepatitis B screening practice among older Chinese in the Greater Washington, DC, area. South Med J 2014; 107:655-60. [PMID: 25279872 DOI: 10.14423/smj.0000000000000177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Older Chinese Americans are at greater risk of contracting hepatitis B virus (HBV) because they were born before the implementation of universal childhood vaccination policies. This study examined the prevalence of HBV screening, test results, and predictors of HBV screening among older Chinese. METHODS Two hundred fifty-two Chinese immigrants (older than 50 years) recruited from Chinese-speaking physicians' offices in the Washington, DC, area participated in a cancer screening questionnaire. Descriptive statistics and hierarchical logistic regressions were conducted. RESULTS Among the 164 participants (65%) who underwent HBV screening, 66% reported that they were susceptible to HBV infection. Stronger self-care beliefs, longer US residency, lower HBV knowledge, and lack of physician recommendations were independently and negatively associated with HBV screening. CONCLUSIONS Many older Chinese did not adhere to HBV screening guidelines because of cultural views and information deficiency. Culturally appropriate interventions aimed to enhance their knowledge and communication with physicians about HBV are needed for promoting screening.
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Affiliation(s)
- Miho Tanaka
- From Kelly Services Contract Program in support of the Division of Cancer Prevention and Population Sciences, National Cancer Institute, Rockville, Maryland, the Departments of Biostatistics, Bioinformatics, and Biomathematics, Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Edmund Gehan
- From Kelly Services Contract Program in support of the Division of Cancer Prevention and Population Sciences, National Cancer Institute, Rockville, Maryland, the Departments of Biostatistics, Bioinformatics, and Biomathematics, Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Mei-Yu Chen
- From Kelly Services Contract Program in support of the Division of Cancer Prevention and Population Sciences, National Cancer Institute, Rockville, Maryland, the Departments of Biostatistics, Bioinformatics, and Biomathematics, Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Judy Huei-Yu Wang
- From Kelly Services Contract Program in support of the Division of Cancer Prevention and Population Sciences, National Cancer Institute, Rockville, Maryland, the Departments of Biostatistics, Bioinformatics, and Biomathematics, Oncology, and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Wang JHY, Liang W, Ma GX, Gehan E, Wang HE, Ji CS, Tu SP, Vernon SW, Mandelblatt JS. Promoting Chinese-speaking primary care physicians' communication with immigrant patients about colorectal cancer screening: a cluster randomized trial design. J Health Care Poor Underserved 2014; 25:1079-100. [PMID: 25130226 PMCID: PMC6585434 DOI: 10.1353/hpu.2014.0114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Chinese Americans underutilize colorectal cancer screening. This study evaluated a physician-based intervention guided by social cognitive theory (SCT) to inform future research involving minority physicians and patients. Twenty-five Chinese-speaking primary care physicians were randomized into intervention or usual care arms. The intervention included two 45-minute in-office training sessions paired with a dual-language communication guide detailing strategies in addressing Chinese patients' screening barriers. Physicians' feedback on the intervention, their performance data during training, and pre-post intervention survey data were collected and analyzed. Most physicians (~85%) liked the intervention materials but ~84% spent less than 20 minutes reading the guide and only 46% found the length of time for in-office training acceptable. Despite this, the intervention increased physicians' perceived communication self-efficacy with patients (p<.01). This study demonstrated the feasibility of enrolling and intervening with minority physicians. Time constraints in primary care practice should be considered in the design and implementation of interventions.
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Wang JHY, Sheppard VB, Liang W, Ma GX, Maxwell AE. Recruiting Chinese Americans into cancer screening intervention trials: strategies and outcomes. Clin Trials 2014; 11:167-77. [PMID: 24567288 DOI: 10.1177/1740774513518849] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cancer is the leading cause of death among Asian Americans. While Asian Americans are the fastest growing minority population in the United States, they are underrepresented in cancer research and report poor adherence to cancer screening guidelines. PURPOSE This study utilized data from two large randomized intervention trials to evaluate strategies to recruit first-generation Chinese American immigrants from community settings and Chinese American physician practices. Findings will inform effective strategies for promoting Asian American participation in cancer control research. METHODS Chinese Americans who were non-adherent to annual mammography screening guidelines (Study 1 with 664 immigrant women > 40 years of age) and to colorectal cancer screening guidelines (Study 2 with 455 immigrants > 50 years of age) were enrolled from the greater Washington DC, New York City (NYC), and Philadelphia (PA) areas. Both studies trained bilingual staff to enroll Chinese-speaking participants with the aid of linguistically appropriate fliers and brochures to obtain consent. Study 1 adopted community approaches and worked with community organizations to enroll participants. Study 2 randomly selected potential participants through 24 Chinese American primary-care physician offices, and mailed letters from physicians to enroll patients, followed by telephone calls from research staff. The success of recruitment approaches was assessed by yield rates based on number of participants approached, ineligible, and consented. RESULTS Most participants (70%) of Study 1 were enrolled through in-person community approaches (e.g., Chinese schools, stores, health fairs, and personal networks). The final yield of specific venues differed widely (6% to 100%) due to various proportions of ineligible subjects (2%-64%) and refusals (0%-92%). The Study 2 recruitment approach (physician letter followed by telephone calls) had different outcomes in two geographic areas, partially due to differences in demographic characteristics in the DC and NYC/PA areas. The community approaches enrolled more recent immigrants and uninsured Chinese Americans than the physician and telephone call approach (p < .001). Enrollment cost is provided to inform future research studies. LIMITATIONS Our recruitment outcomes might not be generalizable to all Chinese Americans or other Asian American populations because they may vary by study protocols (e.g., length of trials), target populations (i.e., eligibility criteria), and available resources. CONCLUSIONS Use of multiple culturally relevant strategies (e.g., building trusting relationships through face-to-face enrollment, use of bilingual and bicultural staff, use of a physician letter, and employing linguistically appropriate materials) was crucial for successfully recruiting a large number of Chinese Americans in community and clinical settings. Our data demonstrate that substantial effort is required for recruitment; studies need to budget for this effort to ensure the inclusion of Asian Americans in health research.
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Affiliation(s)
- Judy Huei-yu Wang
- aDepartment of Oncology, Georgetown University Medical Center and Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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