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Cancer Risk Factors of Vietnamese Americans in Rural South Alabama

Posted on: Friday, 7 October 2005, 03:00 CDT

By Xu, Yu; Ross, M Candice; Ryan, Rebecca; Wang, Bin

Purpose: To identify aggregate-specific cancer risk factors of Vietnamese Americans in south Alabama and present a comparison with available national data and Healthy People 2010 targets.

Design: Cross-sectional survey.

Methods: A convenience sample of 284 Vietnamese community residents 18 years and over completed an investigator-designed questionnaire. Data were analyzed using descriptive correlational analysis.

Findings: Aggregate-specific cancer risk factors included high prevalence of hepatitis, high smoking and drinking rates in men, extended sun exposure without protection, knowledge deficit of cancer and cancer screenings, and low cancer screening rates. Educational level was significantly related to many cancer risk factors.

Conclusions: Significant cancer risk factors exist in the target population in comparison to available national data and Healthy People 2010 targets. More focused cancer prevention and early detection efforts should be initiated for this underserved population. Future research is needed to (a) determine the effect of acculturation on cancer risk factors and (b) develop culturally appropriate interventions to improve the effectiveness of cancer prevention and early detection interventions in this subgroup of Asian Americans.

JOURNAL OF NURSING SCHOLARSHIP, 2005; 37:3, 237-244. 2005 SIGMA THETA TAU INTERNATIONAL.

[Key words: cancer risk factors, Vietnamese Americans, Alabama]

Vietnamese Americans (Vietnamese hereafter) are the fourth largest Asian American (AA) ethnic group, totaling 1,122,528 or 11% of the U.S. Asian population (Barnes & Bennett, 2002). The growth rate of Vietnamese was 82.7% over the 1990-2000 period, the second fastest among all AA subgroups (Asian American Federation, 2001). Despite an influx of Vietnamese immigrants to south Alabama in the last 2 decades, little is known about their health status. As part of a larger research project on cancer prevention and early detection behaviors of Southeast Asian Americans in southern Alabama, this study was done to examine aggregate-specific cancer risk factors among Vietnamese.

Underreported and obscured by the general public perception of AAs as one of the most prosperous racial or ethnic groups with few health issues, a bimodal distribution of socioeconomic status has been observed among AAs (Chen, 2000; Louise, 2001). For instance, 47.2% of Asian Americans and Pacific Islanders (AAPI) completed a 4- year college education and beyond, compared to 29.4% of the non- Hispanic, White population; however, the proportion completing less than 9th grade almost doubled that of nonHispanic Whites (7.4% vs. 4.0%; U.S. Bureau of the Census, 2002). In addition, 10.2% of AAPIs lived below the federal poverty line, compared to 7.8% of non- Hispanic Whites (U.S. Bureau of the Census, 2002).

Vietnamese as a group are at the lower end on the continuum of socioeconomic status among AAs, exposing them to increased health risks. One area of increasing concern is cancer. Cervical cancer was the number one cancer in Vietnamese women and its incidence was five times higher than in White women: 43 vs. 8.7 per 100,000 (Miller et al, 1996). Vietnamese men have the highest liver cancer rate among all racial and ethnic groups (Miller et al., 1996); Southeast Asian men have one of the highest smoking rates among all racial and ethnic groups in the US (U.S. Department of Health and Human Services, 1998); and lung cancer rates in Southeast Asians are 18% higher than are those in Caucasians (Coultas et al., 1994).

Background

A systematic search of Medline and CINAHL indicated an increasing research interest in cancer prevention and early detection in Vietnamese after the 1990s. The available studies can be grouped into two broad categories: descriptive (mostly prevalence) studies and intervention studies. Before 1995, researchers were preoccupied with the "what" and "why" questions; most studies were descriptive and exploratory in nature. The seminal study by Jenkins, McPhee, Bird, and Bonilla (1990) was representative of studies in this category. McPhee et al. (1995) conducted one of the first intervention studies to evaluate the effectiveness of a medialed information and education smoking cessation campaign. This and other subsequent intervention studies (Bird et al., 1998; Jenkins et al., 1999; Jenkins, McPhee, et al., 1997; Nguyen, Vo, McPhee, & Jenkins, 2001; Sadler, Dong, Ko, Luu, & Nguyen, 2001) were focused on the "how" question. The consensus of those studies was: (a) Vietnamese men had a higher smoking rate than did their U.S. counterparts (Jenkins, McPhee et al., 1997; McPhee et al., 1995), ranging from 34.7% to 64.7% (Lew & Tanjasiri, 2003); : (b) Vietnamese had a knowledge deficit regarding cancer and cancer screenings (Jenkins et al., 1990; Sadler et al., V 2001; Schulmeister & Lifsey, 1999; Taylor, Jackson, Pineda, Fischer, & Yasui, 2000); and (c) Vietnamese women had significantly lower breast and cervical cancer screening rates than did U.S. women (Bird et al., 1998; Jenkins et al., 1990; Jenkins et al., 1999; Jenkins, McPhee, Ha, Nam, & Chen, 1995; McPhee, Bird et al., 1997; McPhee, Stewart et al., 1997; Pham & McPhee, 1992; Tu, Taplin, Barlow, & Boyko, 1999).

However, these studies were geographically imbalanced; the majority were conducted in California on Vietnamese in urban areas, although similar studies were carried out in Massachusetts (Yi, 1994), Pennsylvania (Phipps, Cohen, Sorn, & Braitman, 1999), southeastern Louisiana (Schulmeister & Lifsey, 1999), and Washington (Taylor, Jackson, Pineda, Fischer, & Yasui, 2000). In addition, most studies were limited in scope, either restricted to one sex, or confined to one or two areas of cancer prevention and early detection. For instance, none of the studies included protective or risk factors such as screening behaviors related to prostate cancer and radiation exposure via sunlight. No studies have been reported to compare relative cancer risk factors of Vietnamese with available national data on Asian Americans as an aggregate and to evaluate them against the targets in Healthy People 2010. To the authors' knowledge, this is the first comprehensive cancer risk assessment on Vietnamese Americans in rural southern Alabama.

Methods

This study was part of a larger research project on cancer risk factors of Southeast Asian Americans in rural southern Alabama (Xu, Ross, Ryan, & Wang, 2005). In addition to Vietnamese, the larger study included Cambodians, Filipinos, Laotians, Thai, Malaysians, and Singaporeans. Its purpose was to assess the progress toward the achievement of the specific goals set in the Alabama Comprehensive Cancer Control Plan: 2000-2005 (Alabama Department of Public Health Cancer Prevention Branch, 2001).

Inclusion criteria for the study participants were: (a) self- identified Vietnamese ethnicity, (b) residence in the Greater Mobile area, and (c) age 18 or over. A convenience sampling method was used through two datacollection approaches: onsite face-to-face interview and "snow-balling." A Vietnamese-owned neighborhood grocery store in Bayou La Batre, Alabama, served as the primary data-collection site, supplemented by data-collection opportunities at church functions and community events. The second approach was "snowballing" whereby previously interviewed respondents referred family members, friends, and co-workers to the study. For the onsite survey, 63% of those approached participated, and the participation rate through snowballing was 84%.

The lifestyles of Vietnamese in Bay La Batre were markedly different from their urban peers. The living environment for most participants could be typically categorized as semiisolated. Bay La Batre is located in a rural area at the southern tip of Mobile County along Mobile Bay. These Vietnamese people had infrequent contact with the outside world because the majority of the participants lived in a marine village and made a living by fishing, shrimping, crabbing, or oystering. Most participants spent more than half of their lives in Vietnam and their degree of acculturation was lower than that of their counterparts living in urban areas.

A paper-and-pencil questionnaire was designed by the investigators, based on the Alabama Comprehensive Cancer Control Plan: 2001-2005 (Alabama Department of Public Health Cancer Prevention Branch, 2001), the scientific literature published by the International Agency for Research on Cancer (IARC; 2003), and Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System. The instrument consisted of 64 items in three parts: demographic data (6 items), general health information (8 items), and cancer risk factors (50 items).

To ensure content validity and cultural relevance, two experienced cross-cultural nurse researchers, who served as external consultants for the study, critiqued the instrument. In addition, a national panel of eight experts on Asian American health, particularly Southeast Asian American health, from medicine, public health, and nursing reviewed the instrument. Based on the feedback from both groups, the survey instrument was revised. Subsequently, the instrument was translated into Vietnamese and back-translated into English by two independent groups of bilingual and bicultural healthprofessionals to ensure lexical accuracy. Given the low educational attainment of Vietnamese as a group, efforts were made to keep the survey language simple. The Flesch-Kincaid Grade Level (FKGL) of the instrument was 5.6. FKGL is a numerical readability index of the U.S. grade-school level required to read and understand a given sample of English text. After the authors' institutional review board approved the study, the survey instrument was pilot- tested on members of the target population, with subsequent minor technical revisions.

To standardize data-collection procedures, a training session was conducted with a selected group of Southeast Asian bilingual and bicultural health professionals. These trained health professionals were gender-matched with the participants, whenever possible, to ensure cultural sensitivity during data collection. After consent was obtained, qualified participants completed the survey either independently or with assistance of the bilingual and bicultural health professionals. Participants had the choice of completing the survey in either English or Vietnamese. As a standard procedure, verbal offers to read the survey were provided to all participants. Most Vietnamese, especially older adults, preferred this format of survey administration because it was perceived as a gesture of courtesy and respect.

To encourage community residents to participate in the study, as well as to demonstrate the research team's commitment to the community, free screenings of blood glucose and vital signs were offered to both study participants and other community residents. Upon completion of data collection, a coding scheme was designed by the research team. A graduate assistant (GA) entered the collected data into SPSS (version 12.0) for Windows. A training session regarding the coding scheme was conducted with the GA, including supervised practice. To ensure quality of data entry, periodic audits of randomly selected surveys were performed. Coding problems during data entry were resolved through consensus among members of the research team. Upon completion of data entry, descriptive statistics and Pearson correlational analyses were performed. Unanswered questions were treated as missing data listwise. The reported data were based on valid replies only.

Results

Characteristics of Sample

In all, 284 Vietnamese community residents participated in the survey. The age of participants ranged from 18 to 83. The majority (84.5%) lived in South Vietnam during 1962-1975 when Agent Orange (a documented carcinogen) was used in the Indochina Conflict. Table 1 shows the characteristics of the sample. Overall, 42.8% reported no difficulties in seeking health care. Perceived difficulties for access to health services were associated with educational level (r=- .155, p<.05), insurance status (r=-.174, p<.01), and age(r=.196, p<.01).

Table 1. Demographic and Socioeconomic Characteristics of Survey Respondents (N = 284)

Profile of Cancer Risk Factors

Personal and family cancer risk factors. Among those surveyed, 6.5% had hepatitis B and 1.1% had hepatitis C at some time in their lives. In addition, 2.5% reported a cancer diagnosis for their mother, 3.9% for their father, 1.4% for their siblings, and 6.4% for second-degree relatives. A reported cancer diagnosis in the family was significantly related to living with at least one family member who was a smoker (r=.135, p<.05), activity level (r=-.141, p<.05), and consumption of betel nuts (r=.187, p?<.01). Finally, 24.8% and 6.4% of surveyed women had ever used birth control pills and hormone replacement therapy, respectively.

Tobacco use. The prevalence of smoking in the sample was 20.8%. The rate of current smokers was much higher in men (39.3%) than in women (2.1%). Of all current smokers, 38.1% smoked one pack or more per day, with a mean of 13 cigarettes. Similarly, the average reported daily amount of consumption by male smokers was significantly higher than that of their female counterparts (13.5 vs. 7.8 cigarettes). The average age of smoking initiation was 17.7, with 73.8% starting from age 13-20. The use of smokeless tobacco was minimal (1.2%). When asked about attempts to quit in the last 12 months, 68.8% of current smokers responded "No." Of all respondents, 41.5% reported living with at least one family member who was a smoker. Current smoker status was positively associated with consumption of alcohol ,: (r=A36, p<.01) and red meat (r=A57, p<.0l). Daily smoking amount was significantly related to higher alcohol consumption (r=.395, p<.01), higher consumption of red meat (r=.516, p<.01), higher activity level (r=.398, p<.01), and lower educational level (r=-.256, p<.01).

Alcohol consumption. Drinking prevalence in the sample was 31%. Weekly usage ranged from none to 42 drinks, with 12% consuming 10 or more (one drink defined as a bottle or can of beer or a shot of liquor). Drinking rate in men was much higher than in women (54.2% vs. 8.3%). Average weekly drinking amount also varied significantly between men and women (8.6 for men and 3.4 for women) and was significantly correlated with daily smoking quan- .. tity (r-.395, p<.01), length of daily sun exposure (r=.372, p<.Ql), red meat consumption (r=.355, p<.0l), and educational level (r=-.197, p<.01).

Radiation exposure. Half of the respondents had a daily sun exposure of 1-3 hours, with 13.1% for 4-7 hours and 12.2% for 8 hours or more. The prolonged exposure was primarily because of their occupations such as fishing that required working in the sun. When asked about protection against direct radiation exposure, 77.3% reported taking no measures at all, and 11.2% and 9.1% reported a sunburn in the previous year and in childhood, respectively. Protective measures were less likely to be used by current smokers (r=-.334, p<.01) and with larger quantity of daily tobacco use (r=- .322, p<.01), but were more likely to be used by people who had sunburns in the previous year (r=.191, p<.01). As expected, more education was associated with more use of protective measures (r=.128, p<.05) and with less sun exposure (r=-.252, p<.01).

Diet. Salted fish, part of the traditional Vietnamese diet, contains N-nitrosodimethylamine, a documented carcinogen (IARC, 1993). Among all respondents, 65.2% confirmed its consumption, with 10.2% eating it daily, 34.4% weekly, and 44.7% monthly. More than three quarters , (76%) reported eating barbequed foods, with 2.8% having them daily, 29.2% weekly, and 58% monthly. About one quarter (23.3%) reported having eight or more servings of red meat per week. Red meat consumption was significantly associated with being a current smoker (r=.457, p<.01), daily smoking quantity (r=516, p<.01), and activity level (r=.283,p<.01).

Physical activity. About one third (30.5%) identified themselves as "active" (1-2 hours of daily physical activity), with 15.6% being "very active" (2-4 hours) and 17.5% "extremely active" (>4 hours). However, 13% rated themselves as "inactive" (<.5 hour). Participants with more physical activity had significantly more tobacco use (r=.398, p<.01) and longer sun exposure (r=.490,p<.01), but less education (r=0 -.188, p<.01).

Cancer knowledge and screening behaviors. Of all respondents, 27.9% did not know if they had ever been diagnosed with hepatitis. Only 31% were aware that a test (i.e., occult blood test or colonoscopy) could detect colorectal cancer; even fewer (21.5%) of the at-risk group (>50 in age) had ever received the test. Reported reasons for failing to get the test were, in order of frequency, "multiple factors" (i.e., combined effect of cost; lack of insurance; difficulty with language, finding a doctor, or transportation; fear or anxiety of procedure; and lack of time; 37.5%), cost (16.7%), lack of time (6.9%), and language difficulty (5.6%). However, 26.4% of the sample did not report any difficulties.

Of all male respondents, 56.3% were unaware that a test could be conducted to detect prostate cancer. In the atrisk group (>40 in age), only 23.1% had this knowledge and even fewer (9.8%) had ever received the test. Among cited barriers to getting the test, 30.6% referred to "multiple factors," 14.3% mentioned cost, and 8.2% mentioned language difficulty. However, 44.9% cited no difficulties at all. Receipt of the screening was inversely related to age (r=0 - .245,/7<.01).

According to the American Cancer Society (2003), women in their 20s should be informed of the benefits and limitations of self- breast exam (SBE), and women in their 20s and 30s should have clinical breast exam (CBE) as part of their regular health checkups, preferably at least every 3 years. Of all female respondents, 31.5% did not know that they could perform SBE to detect cancer and 33.3% had never done it. In addition, 22.3% did not know that their physicians could perform CBE to detect cancer and 35.2% had never received one. Finally, 34% were unaware that mammography could be done to screen for breast cancer and 46.4% had never had it.

The American Cancer Society (Saslow et al., 2002) recommends that cervical cancer screening (Pap smear) should begin about 3 years after onset of vaginal intercourse or no later than 21 years of age. Of all female respondents, 30% did not know that Pap smear could detect cervical cancer and 38.4% had never received the test, although 46.7% identified no difficulties in getting the test. Nearly two-thirds of the surveyed women never heard of the Alabama Breast (65.5% ) and Cervical Cancer (59.9%) Early Detection Program that provided free screenings for qualified, low-income women.

Educational level was significantly related to cancer knowledge and screening behaviors. For instance, higher educational level was significantly related to more knowledge of SBE (r=.234, p<.01), doing SBE (r=.265, p<.01), having CBE (r=.190, p<.05), and prostate cancer screening (r=.184, p<.01), but to less receipt of mammogram (r=-\.224, p<.01). All screening behaviors were significantly associated with knowledge of related screening tests. For instance, colorectal cancer screening rate was significantly related to knowledge of fecal occult blood test or colonoscopy (r=.568, p<.01). As expected, knowledge of various cancer screenings and early detection procedures were positively correlated.

Table 2. Comparisons of Selected Cancer Risk Factors

Discussion

Comparison with Other Studies and National Data

Hepatitis. The most striking cancer risk factor in this sample was the extremely high hepatitis rate (Table 2). The prevalence of hepatitis B was comparable to that reported in Jenkins et al. (1990), but was much higher than that of the general U.S. population and the Healthy People 2010 target (see Table 2). Statistically, 70% of Vietnamese immigrants have serologic evidence of past hepatitis B virus (HBV) infection (Taylor et al., 2000). Given its endemicity in Vietnamese, the Healthy People 2010 national target for reducing hepatitis B appears unrealistic for this subpopulation.

Because about 80% of liver cancer is etiologically associated with HBV infection (Taylor et al., 2000), an important action is to increase HBV immunization rates among noninfected Vietnamese through universal vaccines to reduce vertical transmission (mother to child) and horizontal transmission. In addition, pregnant women infected with HBV and their infants should be treated with latest clinical protocols. Nurses can counsel patients about risks of sharing personal care items (e.g., razors, toothbrushes) with possible blood contamination and having a tattoo or body part pierced. Additional counseling should be focused on reducing risky sexual behaviors and injection-drug use among known HBV carriers.

Tobacco use. Smoking prevalence for Vietnamese men in the current study was lower (39.3%) than that in Jenkins et al.'s (1990; 56%) and comparable to the rates for Vietnamese men reported in other studies (34.7% to 64.7% as cited in Lew & Tanjasiri, 2003). However, it was significantly higher than that of U.S. men in the general population (25.7%; CDC, 2002), and more than three times higher than the Healthy People 2010 target (12%). Intensified public and media campaigns against smoking in recent years might have explained the differences in smoking prevalence between the present study and that of Jenkins et al. (1990). Contrary to Jenkins et al.'s finding, this study indicated that lower educational level was significantly related to smoking.

Without doubt, the smoking epidemic has presented one of the greatest challenges in cancer prevention in Vietnamese men. However, the long-term public health burden associated with smoking cannot be overestimated, especially when nearly three quarters (73.8%) of the current smokers initiated smoking during their teens and nearly half (41.5%) of the sample lived with a family member who smoked. A "culture of smoking" is believed to be the primary culprit for the high smoking rate. To many Vietnamese men, smoking is a way of life that offers a means to initiate rapport, strengthen bonding, and maintain social relationships. Moreover, cigarettes are exchanged as valued gifts among families and friends as an accepted social norm (Jenkins, Pham, et al., 1997; Wiecha et al., 1998). Therefore, in addition to efforts to bring changes in social, economic, and political arenas (e.g., banning smoking in public places, raising cigarette taxes, and curtailing tobacco industry's aggressive targeted marketing to Asian Americans), sustained grass-roots campaigns to change the "culture of smoking" might eventually lead to changes in social attitudes toward smoking over time, from tolerance and acceptance to disapproval and rejection.

Cancer knowledge and screenings. This study showed knowledge deficits regarding cancer and cancer screenings in this Asian American subgroup that were also documented in other studies (Jenkins et al., 1990; Sadler et al., 2001; Schulmeister & Lifsey, 1999; Taylor et al., 2000). In addition, cancer screening rates of the sample were significantly lower than those of the U.S. general population and Asian Americans as a group (Table 2). Except for mammogram, all other screening rates in the current study were lower than those in Jenkins et al. (1990) and far below the national rates and the Healthy People 2010 targets.

Jenkins et al.'s study was conducted in the San Francisco Bay area. The availability of and ready access to various health services in the bay area, including Vietnamese physicians, interpreter services, and health materials in the Vietnamese language, as well as an urban environment might have accounted for some of the differences between the screening rates. Less acculturation of the current sample might be another potential variable to explain the discrepancy. Contrary to Jenkins et al.'s (1990) finding, this study indicated that screening behaviors were significantly associated with educational level and knowledge of cancer.

To increase cancer screening rates, nurses should educate Vietnamese people on the epidemiology and etiology of cancer and current cancer prevention guidelines. Such health education is particularly important for a population unfamiliar with the philosophy and practice of preventive health. Additionally, nurses should address a culture-based "fear of cancer" (i.e., cancer equals terminal illness, which is, in turn, equivalent to a death verdict). Further, culturally rooted misconceptions about cancer such as Pap test being reserved for only married women should be dispelled in a sensitive manner. Gender match between client and health provider should be ensured whenever possible to be sensitive to the modesty of Vietnamese women. Finally, logistic barriers such as lack of transportation, childcare, and interpreter service should be within current legal and policy guidelines. In collaboration with other healthcare professionals, nurses can play a major part in addressing these issues as clinician, counselor, educator, advocate, and participant in policymaking. The effectiveness of the interventions is expected to improve if a partnership is forged to nurture a sense of ownership among all those involved.

Implications for Future Research

Future research is needed concerning the following questions: What are the most effective ways to increase the rates for smoking cessation and cancer screenings, as well as for hepatitis B immunization in uninfected Vietnamese? To what extent does acculturation affect cancer risk factors? Does culture determine smoking and cancer screening behaviors? If yes, to what extent? How can cancer control measures proven effective for the U.S. general population be adapted for this Asian American subgroup? Further, an intriguing study would be a comparison of Vietnamese immigrants in the US and their peers back in their homeland to determine the effect of acculturation on cancer risk behaviors.

This study indicated that culture may be more significant in cancer prevention and early detection behaviors than traditionally realized. Specifically, we hypothesize that culture is the primary determinant of whether Vietnamese participate in cancer screenings. Available evidence indicated that the relationship between cancer screening knowledge and cancer screening behaviors was nonlinear (Pham 8c McPhee, 1992), and removal of financial barriers alone did not enhance screening rates (Tu, Taplin, Barlow, & Boyko, 1999). Further, a family-centered smoking cessation approach is hypothesized to be most effective for Vietnamese male smokers. Its uniqueness lies in leveraging the inner strengths of the collectivistic Vietnamese culture to garner involvement of family members, friends, and physicians to create a socially conducive environment for smoking cessation. This approach would capitalize on a deep sense of responsibility by most Vietnamese men to keep their loved ones healthy. However, both hypotheses require empirical testing so that culturally tailored nursing interventions can be designed accordingly.

Limitations

Caution is warranted in making generalizations of this study to Vietnamese Americans living in other parts of the US because of limitations regarding its sampling method. In addition, no verification of self-reports was obtained through biochemical testing or medical records. Because of acquiescence bias and culture- based fear of cancer, cancer risk factors in this study are likely to be underreported. Finally, the effect of acculturation on behaviors associated with cancer risks could have been estimated if the study had included a proxy measure such as length of time of living in the US or English language proficiency.

Conclusions

Cancer is the second leading cause of mortality for Americans. Further, cancer causes a range of morbidities leading to decreased productivity, loss of job, and reduced quality of life. Cancer was identified as one of three leading indicators of health disparities for Asian Americans in Healthy People 2010. It was recommended as a research priority to the National Institutes of Health by AAPI health organization leaders in 1995 (Louise, 2001).

We identified aggregate-specific cancer risk factors of Vietnamese Americans in rural southern Alabama, and noted deficits in cancer prevention and early detection in this underserved Asian American subgroup. The urgency to address these risks is apparent because smoking is the single most preventable cause of death (U.S. Department of Health and Human Services, 1998), and cervical cancer is highly preventable and curable when detected at an early stage (CDC, 2004).

Knowledge of the health status of Asian Americans in general, and of Asian American subgroups in particular, remains limited because of lack of data, inadequate sample sizes in available studies, or data aggregation from different cultural groups. Consequently, researchers and p\olicymakers know little about Asian American health risks and their magnitudes, especially those specific to various Asian American subgroups. These data deficiencies have affected establishing, tracking, and evaluating health status indicators in Healthy People 2010 (Louise, 2001). Consequently, "The paucity of systematic collection of disaggregated AAPI data leads to a lack of information on the health status, treatment, and service delivery to various AAPI subgroups" (Louise, 2001, p. 176). With Asian American people representing over 30 ethnic groups and speaking more than 60 languages, intergroup heterogeneities require that more group-based studies be conducted to fill in the data gaps in order to design effective, specific, and culturally tailored interventions to improve the health status of various groups and Asian Americans as an aggregate.

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Yu Xu, RN, PhD, CTN, Mu, Associate Professor, University of Connecticut, Storrs, CT; M. Candice Ross, RN, PhD, Zeta Gamma, Professor and Associate Dean for Research & Development; Rebecca Ryan, EdD, Associate Professor and Director of Special Projects & Evaluations; Bin Wang, PhD, Assistant Professor; all at the University of South Alabama, Mobile, AL. Funding for this study is provided by grants from Sigma Theta Tau International and the University of South Alabama Research Council. The authors thank a national panel of eight experts who reviewed the instrument designed for this study. Correspondence to Dr. Xu, University of Connecticut School of Nursing, 231 Glenbrook Road, Storrs, CT 06269-2026. E- mail: yu.xu@uconn.edu.

Accepted for publication February 16, 2005.

Copyright Sigma Theta Tau International, Inc., Honor Society of Nursing Third Quarter 2005

Source: Journal of Nursing Scholarship

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