COVID-19 CULTURAL EDUCATION 1 Addressing COVID-19 Vaccine Hesitancy Among Korean Americans Via Digital Storytelling: Lessons Borrowed from Vaccine Uptake Research Paula Yoon Edson College of Nursing and Health Innovation, Arizona State University Author Note Paula Yoon is a registered nurse at Mayo Clinic Hospital in the nursing department. She has no conflicts of interest to disclose. Correspondence concerning this article should be addressed to Paula Yoon, Edson College of Nursing and Health Innovation, Arizona State University, Downtown Campus, 550 N. 3rd Street, Phoenix, AZ 85004. Email: pyoon4@asu.edu COVID-19 CULTURAL EDUCATION 2 Abstract Background: The COVID-19 pandemic has been causing high rates of hospitalization and death among the marginalized Asian American Pacific Islander (AAPI) community. Disaggregated data revealed low COVID-19 vaccine uptake among Korean Americans/Immigrants (KA/I) due to vaccine-related fears unaddressed by cultural and linguistic barriers. Prior evidence demonstrates that digital storytelling (DST) is an effective medium to improve recommended vaccine intent and uptake among AAPIs. Objective: This DNP project aimed to assess the effect of DST intervention on improving KA/I’s COVID-19-related vaccine hesitancy, intent, and uptake. Methods: A quasi-experimental design was conducted, with participants (n=4) selfidentifying as KA/I adults with English or Korean fluency residing in the U.S. Participants were recruited online via convenience sampling from CARE (Collaborative Approach for AAPI Research and Education). Individuals who had already received COVID-19 vaccines were excluded. The intervention included two first-person audiovisual stories documenting the personal experience of receiving the COVID-19 vaccine. Outcomes were measured via a prepost-1-month-follow-up survey utilizing a modified Vaccine Hesitancy Scale (α = 0.72) and Narrative Quality Assessment Tool (α = 0.78-0.81). Results: DST intervention had a marginally significant effect on lowering post-COVID-19 vaccine hesitancy scores (p = 0.068). Participants (n=2) who rated the DST videos with a higher score indicated vaccine uptake at one-month follow-up. Conclusion: This cost-effective, sustainable, and scalable DST evidence-based project has the potential to promote COVID-19 vaccination among KA/I and other AAPI groups with appropriate modification. Keywords: COVID-19, Korean Americans, digital storytelling, vaccine hesitancy, vaccine uptake COVID-19 CULTURAL EDUCATION 3 Acknowledgment The completion of my Doctoral Nursing Practice (DNP) degree would not have been possible without the support from faculty, colleagues, family, and friends. First, I would like to express my sincere gratitude to Dr. Angela Chen for her invaluable mentorship, guidance, encouragement, and vision for this project. Her passion for innovatively addressing health disparities among AAPIs has profoundly inspired my motivation to continue bridging health inequities as a future nurse practitioner. Next, I would like to acknowledge Charse, Heejoo, Olivia, and Ricky for taking the time out of their busy schedules to provide Korean translation for critical elements of this project. To my mom, extended family, and dear friends, Michelle, Esther, Sooji, Joowon, Ashlee, Koimo, Lydia, and Julie, thank you for your emotional support and prayers throughout this arduous journey. To my dad and James - I wish you were physically here to witness the completion of my DNP degree. I know you would be proud. Finally, to Dr. Jesse Ha - my husband, best friend, biggest cheerleader, and counselor; thank you for believing in me and helping me surpass what I thought to be my limits. Thank you for bearing my stress and hearing my rants, especially during the midst of a pandemic. Your optimism, hugs, delicious meals, nightly walks, and weightlifting together kept me sane, healthy, and well-nourished. Because of you, I can walk with you down the graduation aisle together as doctors. We did it! COVID-19 CULTURAL EDUCATION 4 Addressing COVID-19 Vaccine Hesitancy Among Korean Americans Via Digital Storytelling: Lessons Borrowed from Vaccine Uptake Research Coronavirus Disease 2019 (COVID-19) is a highly infectious viral respiratory illness (World Health Organization [WHO], n.d.) that continues to significantly increase morbidity and mortality rates across the world (WHO, 2020). While there are limited therapeutic treatments for COVID-19 (National Institutes of Health, 2021), successful disease mitigation includes the use of face masks, social distancing, and vaccination uptake among all communities (Schoch-Spana et al., 2020). However, racial/ethnic healthcare disparities such as language and cultural barriers may limit vaccine uptake among minorities (Vergara et al., 2021). To combat vaccine hesitancy, this project explores how culturally and linguistically tailored education may bridge the gap in COVID-19 vaccination uptake among Asian American Pacific Islanders (AAPI), specifically Korean Americans/Immigrants (KA/I). Problem Statement Individuals infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) can exhibit mild to life-threatening symptoms (Centers for Disease Control and Prevention [CDC], 2022f). As of April 2022, there were approximately 505 million COVID-19 cases and 6.21 million deaths globally (WHO, 2022). Within the United States, there were more than 80.6 million COVID-19 cases and close to 987,000 deaths in the U.S. (CDC, 2022a). These rampant COVID-19 outbreaks have significantly strained critical care staffing and hospital bed capacities, forcing some healthcare providers (HCP) to triage care and withdraw patients from life support (Robert et al., 2020). Disaggregated data shows that AAPIs have been disproportionately affected by COVID19 (Wang et al., 2020). Some contributing factors include multiple health co-morbidities, poor COVID-19 CULTURAL EDUCATION 5 access to healthcare, and financial/health insurance limitations (Wang et al., 2020). According to Mein et al. (2020), racial/ethnic minorities are significantly more vulnerable to complications associated with COVID-19. Purpose and Rationale Widespread COVID-19 vaccine uptake is needed to return to normalcy (Schoch-Spana et al., 2020). The Advisory Committee on Immunization Practices (ACIP) has pushed efforts to distribute the COVID-19 vaccine ethically and equitably (McClung et al., 2020). Also, ACIP has strongly recommended accessible vaccine resources for at-risk populations (McClung et al., 2020). However, there have been limited culturally and linguistically tailored health resources on the COVID-19 vaccine for those groups, including AAPIs (Wong et al., 2022). The American Community Survey shows that approximately a quarter of AAPIs (about 4.6 million) speak English “less than well” (US Census Bureau, 2019a; 2019b). Other studies demonstrate that low English proficiency remains a significant barrier to promoting recommended vaccinations among the AAPI population (Lee et al., 2016; Wong et al., 2022). To date, limited published research shows effective ways to reduce COVID-19 vaccine hesitancy among the at-risk group. Alternatively, prior research demonstrating successful vaccine uptake strategies may apply to vaccine-hesitant populations during a global pandemic. Therefore, this project aims to assess how culturally and linguistically tailored education may promote health equity and improve COVID-19 vaccine hesitancy, intent, and uptake among AAPIs, specifically KA/Is. Background/Significance Most population data analyses categorize AAPIs as one homogenous group. However, the “Asian” population consists of diverse and distinct ethnicities, cultures, languages, and COVID-19 CULTURAL EDUCATION 6 countries of origin (Hoeffel et al., 2012; Srivastav et al., 2018). According to the National Alliance on Mental Illness (n.d.), AAPIs represent approximately 50 different ethnicities and 100 different languages. Due to these distinct differences, each ethnic group may have varying socioeconomic and health needs than other AAPI subgroups. Unvaccinated Asian American Pacific Islanders In contrast to the aggregated data in published national surveys, some studies show that different subgroups of Asian American populations have varying vaccine uptakes (Daniels et al., 2010). Moreover, Asian Americans are falsely perceived as meeting the national target goals due to misreported vaccination data (Daniels et al., 2010). Further, some Asian subgroups, Native Hawaiians and South Asians, are automatically categorized as “other race,” which further misrepresents data (Srivastav et al., 2018). For instance, Srivastav et al.’s (2018) study showed that although Asian Americans had an overall high rate of influenza vaccine uptake, disaggregated statistics showed that Korean and Chinese Americans had five to six percent less uptake compared to non-Hispanic whites. Park et al.’s (2021) study revealed key reasons some AAPIs are not currently COVID-19 vaccinated. Among the 1,649 participants, 36.4% had multiple concerns, including vaccine safety (i.e., efficacy, distrust in government, speed of vaccine production) and side effects (Park et al., 2021). Further, the findings revealed that KA/Is were one of the AAPI subgroups with the most significant COVID-19 vaccine concerns. Among 337 KA/I participants surveyed, 38.8% felt the vaccine was unsafe, and 63.2% were concerned about the side effects (Park et al., 2021). Moreover, H. Y. Lee et al. (2018) and Srivastav et al. (2018) reported language and cultural barriers as leading causes of low vaccine uptake among some AAPI subgroups. Culturally and Linguistically Tailored Education COVID-19 CULTURAL EDUCATION 7 The Biden Administration has funded more than six billion dollars (US Department of Health & Human Services [HHS], 2021a) to the CDC and Health Resources and Services Administration (HRSA) to promote equitable community-based COVID-19 testing, treatment, and vaccination among marginalized populations (HHS, 2021b). A culturally and linguistically tailored intervention can increase COVID-19 vaccination intent to reach those populations. Various studies have shown the positive benefits of utilizing culturally tailored education such as digital storytelling to improve human papillomavirus (HPV) vaccinations (Chen et al., 2019, 2022; Kim et al., 2020). A culturally tailored text messaging system is also a cost-effective approach that has shown to improve uptake of health recommendations such as HPV vaccine initiation (H. Lee et al., 2018; H. Y. Lee et al., 2015; Y. M. Lee et al., 2019), breast cancer screening (Lee et al., 2017), and smoking cessation (Whittaker et al., 2019). Some of these interventions (Chen et al., 2019; H. Y. Lee et al., 2019) were conducted in the participants’ native language as most participants had poor English proficiency. Standard Messaging Governmental and health organizations have attempted to provide translations of COVID-19 facts and resources in Asian languages (Association of Asian Pacific Community Health Organizations [AAPCHO], 2021; CDC, 2022d). However, most online written health resources are graded as “difficult to read,” which disadvantages those with limited health literacies (Mishra & Dexter, 2020). Problematically, most KA/Is are first-generation immigrants, and literature suggests that most KA/I participants have low health literacy rates (Chae et al., 2021). Further, prior studies demonstrate that culturally tailored education increased vaccine uptake more successfully than standard written health information (Kim et al., 2020; Lee et al., 2016, 2017). COVID-19 CULTURAL EDUCATION 8 COVID-19 Vaccine Initiation Currently, there are three CDC (2022c) recommended and authorized vaccines in the U.S., namely- Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen. The PfizerBioNTech and Moderna vaccines require two doses approximately three or four weeks apart (CDC, 2022e). Clinical trials have shown that when individuals complete the series of COVID19 vaccinations, there is 94-95% efficacy against symptomatic disease (Olliaro, 2021). About 50 to 80% of the population needs to be vaccinated to reach herd immunity (Erzurum, 2021; Randolph & Barreiro, 2020). Because there is limited intervention-based research to promote COVID-19 vaccine initiation among the AAPI community, lessons will be borrowed from other vaccine initiatives that have been successful in improving vaccine intent and uptake (Chen et al., 2019, 2022; Kim et al., 2020; H. Y. Lee et al., 2019). Internal Data Some Korean communities within the Tri-state area of the U.S. have struggled to sign up for the COVID-19 vaccine and have their questions answered (Alvarado, 2021). A bilingual receptionist who works for the COVID-19 hotline states that he receives hundreds of calls per day from Korean Americans because those residents have limited English proficiency and do not know where to obtain COVID-19 vaccine information and resources (Alvarado, 2021). Further, Wang (2021) also reports that Southeast Asians in Minnesota are less likely to receive COVID19 vaccines because of language barriers. A survey from Asian and Pacific Islander community partners shows that 90% of the organizations need translated and culturally tailored COVID-19 resources (Asian and Pacific Islander Health Forum [APIAHF], 2020). This inquiry has led to the clinically relevant PICOT question, “In unvaccinated Asian Americans (P), how does COVID-19 CULTURAL EDUCATION 9 culturally-tailored education (I), compared to standard messaging (C), affect COVID-19 vaccine initiation (O)?” Search Strategy To address the PICO question, a thorough search of the literature was conducted through the databases – PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus. Due to the novel nature of COVID-19, there were limited search yields based on keywords associated with the PICO question. Grey literature search was also conducted with zero results. After multiple attempts, the keywords were modified to examine which cultural interventions can increase the uptake of all or any nationally recommended vaccinations among Asian Americans. Such immunizations included HPV, hepatitis, and influenza vaccines. MeSH terms and Boolean connectors were applied to all searches. Filters included searches in the last five years, English and primary language, and full-text availability. Keyword Selection The initial keywords: Asian American, cultural education, education, intervention, and COVID-19 vaccine, yielded two results on PubMed, zero results on CINAHL, and two results on Scopus. The population was expanded to include Asian, Korean American, Chinese American, and Vietnamese American. The intervention was expanded to include promotion, and messaging. Because COVID-19, coronavirus, sars-cov-2, narrowed the search results significantly, those phrases were not included. The outcome included general terms such as vaccination, and immunization. Search Yield PubMed resulted in 229 results, CINAHL resulted in 86 results, and SCOPUS resulted in 114 results. All titles and abstracts were carefully reviewed, then selected if the search focused COVID-19 CULTURAL EDUCATION 10 on an intervention to increase vaccine uptake among Asian Americans. Ten articles were selected for rapid critical appraisals (RCA; Melnyk & Fineout-Overholt, 2019). These included one systematic review, two pilot quantitative studies, three surveys with quantitative analyses, and four qualitative studies (Appendix A, Table A1 and A2). Critical Appraisal & Synthesis Ten studies (Chen et al., 2019; Frew et al., 2014; Hopfer et al., 2017; M. Kim et al., 2017, 2020; H. Y. Lee et al., 2019; Y. M. Lee et al., 2019; Shon & Wells, 2020; Srivastav et al., 2018; Vu et al., 2020) were selected and graded for their quality and level of evidence (LOE) through Melnyk and Fineout-Overholt’s (2019) RCA tool. While systematic reviews and quantitative randomized-controlled trials (RCTs) would yield a more robust quality and LOE, no published studies focused on exploring culturally tailored interventions to improve COVID-19 vaccine uptake among the AAPI community. Alternatively, the search strategy was broadly changed to include studies exploring all vaccine improvement initiatives/strategies among Korean, Chinese, and Vietnamese Americans. Qualitative analyses (see Appendix A, Table A1) provided rich, indepth statements from AAPIs on their vaccine attitudes, beliefs, knowledge, intention, and initiation. Some of the quantitative studies (see Appendix A, Table A2) provided insight into AAPI’s vaccine perception and included culturally tailored intervention studies that could be applied to promote COVID-19 vaccine uptake. The ten studies were synthesized into a table (see Appendix A, Table A3) to understand which cultural factors affect the intent to vaccinate and, ultimately, vaccine uptake. On average, the participants in the study were 32.8 years old. They identified their ethnicities as either Korean, Vietnamese, or Chinese. Many participants immigrated to the U.S., and most were not fluent in English. All studies were conducted in the U.S., mainly in the COVID-19 CULTURAL EDUCATION 11 community setting. Among the ten articles selected through the RCA tool, only two studies were intervention-based (Chen et al., 2019; Kim et al., 2020). Both studies utilized narrative storytelling to provide culturally relevant information regarding the HPV vaccine. The pre-andpost-test assessed HPV vaccine knowledge, attitude, beliefs, and intent differences. Kim et al. (2020) intervention was conducted via mobile, web-based technology and included a “Learn More” segment in which a Korean American physician recommends the HPV vaccine. Overall, both studies significantly improved HPV vaccine knowledge, attitude, belief, and intent. Theory Application The Model of Culture-centric Narratives in Health Promotion is fitting for this DNP project (Larkey & Hetch, 2010; see Appendix B, Figure 1B). This theoretical framework defines how attitude, beliefs, and behaviors can be modified through the interplay of personal/sociocultural characteristics and narrative traits. Narrative is a form of realistic storytelling that communicates a message through characters and events in which the listener/viewer can culturally self-identify (Larkey & Hetch, 2010). Larkey and Hetch (2010) define culture as a community of members who not only communicate with one another but also have a collective set of beliefs, values, and laws. This theory postulates that narratives influence the viewer/listener to establish a sense of self and identity based on how they connect and interpret the story. Then, their personal connection to the narrative is shared with others in their community. For a narrative story to be personally engaging, the characters should be “realistic,” “likeable,” “homophily (like self),” and “generates empathy” (p. 122). The story should be able to capture the attention of the audience through its storyline. For a story to be socio-culturally engaging, it should include “culturally familiar/similar characters,” “cultural events,” and “culturally relevant language” (p. 122). COVID-19 CULTURAL EDUCATION 12 There are key mediators in storytelling that predict whether the viewer/listener’s response to the characters will result in attitude, belief, and behavioral change (Larkey & Hetch, 2010). The three mediators are defined as transportation, identification, and social proliferation. Transportation is defined as the story’s ability to fully capture its audience’s attention and emotional reaction. Identification is defined as the ability of the viewer/listener to identify and relate him or herself to the character personally. Social proliferation is defined as the act of sharing and re-telling the story with other members via word of mouth or through social media platforms. Through this act of sharing, community members can discuss and support one another in carrying out the intended behavior. Digital storytelling (DST) is defined as a form of narrative storytelling using technology to incorporate the storyline narrated by the participant with images and music. Chen et al.’s (2019, 2022) studies show that DST intervention increased Vietnamese mothers’ intent to vaccinate their adolescent children against HPV. Secondly, AAPI immigrants may be less susceptible to behavioral change if the vaccination programs are only geared towards the general English-speaking population. To resolve this matter, educational information that is culturally, linguistically, and personally relevant to AAPIs may increase their intent to receive the COVID19 vaccine. Implementation Framework This DNP project was planned, developed, implemented, and evaluated through Stetler’s Model of Evidence-Based Practice (2009; see Appendix B, Figure B2). The Stetler’s Model (2009) provides a detailed how-to guide on developing evidence-based processes and practice change to address a problem proposed by a project site (Schaffer et al., 2013). Given the imminent need to resolve the barriers associated with COVID-19 vaccine uptake, an COVID-19 CULTURAL EDUCATION 13 implementation framework that considers timeliness was needed. Concerningly, the time that it takes for research to be translated into clinical practice can take up to 17 years (Morris et al., 2011). The Stetler’s Model (2009) outlines six key steps: (1) Preparation, (2) Validation, (3) Comparative evaluation/decision making, (4) Translation/application, and (5) Evaluation. During the preparation phase, the problem of a lack of culturally tailored education for the COVID-19 vaccine among the AAPI community was identified by the author and project site and deemed as a high priority issue. Internal data and supplemental evidence showed that organizations were having a challenging time meeting the needs of the AAPI community. In the validation and evaluation/decision making phase, a thorough literature search was conducted, critiqued, critically appraised, and synthesized to assess if there was substantial evidence for utilizing digital storytelling as a form of culturally tailored education. Given the urgency and need for a culturally tailored intervention, the project moved on to the next phases of translation/application and evaluation, which will be discussed in the next sections. Methods and Design Ethical Considerations To ensure the rights of the participants were protected, an Institutional Review Board (IRB) was obtained from Arizona State University. The submitted documents to IRB detail that no personal identifiers (e.g., name, social security number, phone, and address) were collected to protect the confidentiality of the participants. Valid email addresses were used to send the prepost-1-month-follow-up survey, interventions, and incentive payments. Notably, the email addresses were separated from the survey data, and all data were de-identified. The DNP project was conducted on Arizona State University’s (ASU) Research Electronic Data Capture site COVID-19 CULTURAL EDUCATION 14 (REDCap; Harris et al., 2009). The REDCap site is a secure HIPAA-compliant database that maintains strong web security through routine monitoring by a centralized technical support team, an encrypted server, multilevel password protection, antivirus barriers, and an enterpriselevel firewall. Prior to the intervention, the participants had to sign a consent that included information about the study, including associated risks, benefits, the confidentiality of all responses, what they should anticipate, and their right to refuse to consent and leave the study at any time. Population and Setting This project aimed to recruit 20 participants from the University of California San Francisco’s (UCSF; n.d.) Collaborative Approach for Asian Americans and Pacific Islanders Research and Education (CARE) Registry. To aid in AAPI health data disaggregation, the CARE Registry allows researchers to access a vast source of U.S. residing AAPI adults with fluency in English, Mandarin, Cantonese, Korean, Samoan, Vietnamese, or Hindi willing to take healthrelated online surveys (UCSF, n.d.). For this DNP project, the inclusion criteria for the participants included: (1) self-identification as a Korean/Korean American/Korean immigrant, (2) fluency in English or Korean, (3) currently residing in the U.S., and (4) 18 years of age or older. Exclusion criteria included those who have already received any COVID-19 vaccine dose and those who did not meet the inclusion criteria. All study activities, including screening, consenting, intervention (videos) implementation, and assessments, were conducted online via ASU’s REDCap site. Project Description and Timeline Time 0 Pre-Intervention COVID-19 CULTURAL EDUCATION 15 Three phases organized this project. Before the intervention, an email invitation was sent to the CARE registry participants, which briefly outlined the project’s objective, eligibility requirements, investigators’ contact information, and quantity/type of incentive. A unique REDCap weblink was provided in the email for those interested in participating in this project. Based on what the participants listed as their preferred language (under their CARE registry profile), they were sent either an English or Korean survey (see Appendix D, Figure D1, Figure D2). The first section of the survey included three brief screening questions (see Appendix D, Figure D3). Eligible participants were led to an online consent form. Those willing to participate had to click “agree,” and they were directed to an online pre-survey. The pre-survey included questions on sociodemographics, COVID-19 vaccine attitudes/beliefs (Rodriguez et al., 2021), and COVID-19-vaccine intent and reason (Chen et al., 2021). Survey instrument details will be discussed in the next section. The Time 0 Pre-Intervention phase took approximately 10 to 15 minutes to complete. Time 0 Intervention During the intervention phase, the participants were able to play two first-person audiovisual stories that documented personal experiences about the COVID-19. These videos were selected from YouTube (Choi, 2021; Rheem, 2021), and email permission was obtained from the two video creators to use these stories for this project. Story 1 is narrated in Korean by Dr. Rheem, a KA male internal medicine physician, and English subtitles are provided. Story 2 is narrated in English by Dr. Choi, a KA female dentist, and Korean subtitles are provided. Permission was also obtained to shorten the length of the videos so that the most salient parts were included. The final edited videos are approximately 10 minutes long in combined length, and the links are as follows: (1) https://youtu.be/rsfrL_PZpNg and (2) COVID-19 CULTURAL EDUCATION 16 https://youtu.be/B1MkZpMMERY. All videos included subtitles with validated translations in English and Korean. Time 1 Post-Intervention After the participants watched the videos, they were prompted to complete a post-test which took approximately 10 to 15 minutes. The post-test included the same questions on COVID-19 vaccine attitude/beliefs (Rodriguez et al., 2021), COVID-19 vaccine intent (Chen et al., 2021), as well as questions that assessed the quality of the video interventions (W. S. Kim et al., 2017). Once the participants completed the pre-test and post-test, they received a $10 Amazon gift card via email. Time 2 One-Month Post-Intervention A follow-up email that included a REDCap weblink was sent one-month postintervention to participants who completed the project’s time 0 through time 1 phases. The follow-up survey asked questions regarding COVID-19 vaccine intent or uptake. This phase took approximately one to two minutes to complete, and upon completion, participants received another $5 Amazon gift card sent to their provided email. Instrumentation The pre-test survey began with sociodemographic questions intended to assess the participants’ age, gender, immigration/acculturation status, preferred language, financial situation, and health insurance (see Appendix D, Figure D4). Next, a 17-item COVID-19 Vaccine Hesitancy Scale (VHS) was adapted from Rodriguez et al.’s (2021) study with email permission granted for this project’s use (see Appendix D, Figure D5). This scale assessed factors associated with COVID-19 vaccine hesitancy, including perceived vaccine risks and vaccine confidence levels for those diagnosed with Human Immunodeficiency Virus (HIV; COVID-19 CULTURAL EDUCATION 17 Rodriguez et al., 2021). The first 10 VHS questions were based on a 5-point Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree). A higher score represents greater COVID-19 vaccine hesitancy. Inverted scores were applied to VHS questions 8-10. The VHS questions 1117 were yes and no questions to further assess general COVID-19 vaccine attitudes. These questionnaire items have been tested for construct validity through exploratory factor analysis and achieved an acceptable level of reliability (α=0.72; Rodriguez et al., 2021). However, this survey has not been tested on Korean men and women without HIV. The pre-test concluded with a 2-item COVID-19 vaccine intent question adapted from Chen et al. (2021). The answer choices included were “yes,” “maybe,” and “no.” Based on the answer choice, the participants were asked to provide the reason for their answer selection with “select all that apply” options (see Appendix D, Figure D6). The post-survey included the same questions as the pre-survey except for questions on sociodemographics. The post-survey consisted of 15 questions from W. S. Kim et al.’s (2017) Narrative Quality Assessment Tool (based on the Model of Culture-centric Narratives in Health Promotion; see Appendix D, Figure D7). Email permission was obtained to use this instrument. The first 12 narrative assessment tool questions were based on a 5-point Likert scale, ranging from a score of 1 (disagree a lot) to 5 (agree a lot). The higher score represents positive attitudes, identification, captivation, and recommendation of the video stories. The narrative questions 13 and 14 included “yes” and “no” responses to assess whether the participants would recommend the videos to their family and friends. The last question asked which story the participants preferred with the following choices- “Story 1,” “Story 2,” or “Both.” When tested on Vietnamese mothers, this instrument showed high-reliability levels (α = 0.78-0.81; Chen et al., 2022). COVID-19 CULTURAL EDUCATION 18 The 1-month follow-up survey included a 6-item question adapted from Chen et al. (2021), which assessed the participants’ intent to receive the COVID-19 vaccine (see Appendix D, Figure D8). For those participants who received the vaccine, the questions asked them to specify vaccine type, dose, and side effects. Participants who did not receive the vaccine were directed to a question that asked for their vaccine intent and for them to specify their reason as “select all that apply” options. All of the survey questions were translated to Korean and then back-translated. For documentation, the translators completed a university translation certification (ASU, n.d.). Data Collection and Data Analysis Once data collection was complete, the International Business Machine’s Statistical Package for the Social Sciences (Version 28; IBM Corp, 2021) program was used to conduct univariate, bivariate statistics, and non-parametric testing. Univariate statistics described the sample, mean, and distributions of study variables. Next, bivariate statistics examined patterns of change in DST narrative scores and vaccine uptake. Last, the Wilcoxon Signed Ranks Test assessed the effect of DST on pre-and-post-VHS mean scores. Budget and Funding The projected cost for this project was approximately $300. The calculated cost was for compensating recruited participants who had completed the pre-test, post-test, and 1-month follow-up survey. Outside funding was sought through ASU’s Graduate and Professional Student Association (n.d.). However, the grant was denied, and the budget was sourced from the coinvestigator’s private fund. The incentive amount was considered appropriate for the participants’ time and efforts. Project Results/Outcomes COVID-19 CULTURAL EDUCATION 19 Of the 299 CARE registry KA/Is who were invited to the project via convenience sampling, there were 25 initial responses. Of the 25 respondents, 19 were excluded because they had already received a COVID-19 vaccine. While six participants completed the pre-post-survey and intervention, two were further excluded due to no variability in post-survey answers, likely indicating that the responses were invalid. Descriptive Data A total of four KA/I participants (n = 4) met the inclusion criteria and completed the time 0 through time 1 phases of the project with valid response patterns. Their ages ranged from 39 to 65 years (M = 47.8, SD = 11.70). Two participants were females (50%), and all participants were born in Korea (100%). Fifty percent of the participants indicated English as the preferred language, whereas the other half indicated Korean as the preferred language. Among the participants who were fluent in English (50%), they immigrated to the US 19 to 25 years ago, whereas the participants who preferred to speak Korean (50%) immigrated to the US 13 years prior to this study. All participants (100%) indicated they had a graduate degree. Data Results COVID-19 Vaccine Hesitancy Scale Based on Rodriguez et al.’s (2021) COVID-19 VHS, the mean scores prior to DST intervention was 2.80 (SD = 0.59, Min = 2.20, Max = 3.60). The mean scores post-DST intervention was 2.25 (SD = 0.58, Min = 1.60, Max = 3.00). The Wilcoxon Signed Ranks test was calculated to assess for changes in VHS scores pre-and-post-DST intervention. DST intervention had a marginally significant effect on lowering pre-post-COVID-19 vaccine hesitancy scores (pretest Mdn = 2.70; posttest Mdn = 2.15; z = -1.83; p = 0.068). COVID-19 Vaccine Intent and Uptake COVID-19 CULTURAL EDUCATION 20 After the DST intervention, half the participants (n = 2, 50%) responded “maybe” for vaccine intent, one participant (25%) responded “no,” and the other (25%) responded “yes” for vaccine intent. Among the participants who responded “maybe,” their vaccine concerns included “I do not trust vaccines” and “egg allergy.” For the participant who responded “no” to vaccine intent, his vaccine concerns included “I do not trust vaccines,” “Vaccines can cause health problems such as Autism,” “I do not need it because I do not see any risk of getting infected,” “I am morally opposed to vaccines,” and “Companies develop vaccines to make money.” For the participant who responded “yes” to vaccine intent, he indicated, “It will protect me from COVID-19.” Two participants (50%) completed the 1-month follow-up survey. One participant indicated that she received the Pfizer vaccine with no side effects. The other participant reported that she received the Moderna vaccine and reported headache as a side effect. Digital Storytelling Narrative Assessment Participants (n = 2) who rated the narratives with a higher score were the ones who reported COVID-19 vaccine uptake. Between the two participants who reported COVID-19 vaccine uptake, they had a mean score of 4.25 (SD = 1.06) for narrative identification, a mean score of 3.00 (SD = 0.47) for narrative transportation, and a mean score of 5.00 (SD = 0.00) for the narrative recommendation. One participant preferred story 2, while the other participant preferred both stories. In comparison, the participants who did not report COVID-19 vaccine uptake had a mean score of 3.08 (SD = 0.12) for narrative identification, a mean score of 2.67 (SD = 0.47) for narrative transportation, and a mean score of 2.50 (SD = 3.53) for the narrative recommendation. In the post-survey, one of the participants stated that he intended to get the vaccine; however, he did not respond to the 1-month follow-up survey. The participant who indicated he did not intend COVID-19 CULTURAL EDUCATION 21 to get the COVID-19 vaccine pre-and-post-intervention reported “no” to recommending the stories to others; he preferred neither story. Project Sustainability This DNP project supports financial sustainability. The DST videos are cost-effective interventions that can be disseminated to any person and organization and repeatedly watched via mobile or computer device with an internet connection. This eco-friendly project does not require additional materials such as paper and ink. The videos already include translated subtitles and shareable web links. For these videos to gain awareness and views among the KA/I community, the results can be shared with key AAPI organizations, including APIAHF (2020) and Association of Asian Pacific Community Health Organizations (AAPCHO; 2021). The videos should also be shared with KA/I community leaders, including churches, which serve as a popular hub for health information (Kim et al., 2015). Next, the findings may be disseminated via peer-reviewed journals (e.g., Nurse Practitioner) and conferences to clinicians, educators, and researchers who work with KA/I patients. Discussion This project's findings show that DST may be an effective culturally and linguistically tailored intervention to improve COVID-19 vaccine hesitancy among the KA/I community. Participants who rated the DST with a higher score were the ones who received the COVID-19 vaccine. Among the participants who received the vaccine, they indicated that they would recommend the DST videos to others. Additionally, both participants indicated that the vaccine would protect them from COVID-19 as a reason for vaccine uptake. This finding reveals a change in attitude towards the COVID-19 vaccine as they initially indicated a lack of trust in the vaccine or concern of side effects. Further, the findings from this project are consistent with COVID-19 CULTURAL EDUCATION 22 previous studies (Chen et al., 2019, 2022) that showed changes in vaccine attitude/beliefs postDST intervention. While no definitive claims can be made due to the small sample size, a marginally significant reduction in vaccine hesitancy score post-DST intervention (p = 0.068) suggests the potential of using DST intervention to promote COVID-19 vaccine uptake in the target population (see Appendix D, Figure D9). Future rigorous research with a powered sample is needed to understand the effect of this intervention Project Impact/Clinical Significance The novel findings of this DNP project address the national threat of vaccine hesitancy during the midst of an ongoing COVID-19 pandemic. A literature review revealed limited intervention-based research promoting culturally and linguistically tailored education on the COVID-19 vaccine for the AAPI community. By applying lessons from prior research that improved the intent of other recommended vaccines among AAPIs (Chen et al., 2019, 2022; H. Y. Lee et al., 2019; Kim et al., 2020), this innovative DNP project demonstrates that DST may be a feasible solution for improving COVID-19 vaccine hesitancy among the KA/I community. In clinical practice, HCPs can easily share these DST videos as a web link to unvaccinated KA/I patients, as long as a device is accessible with a Wi-Fi connection. According to Bender et al. (2014), Koreans were more likely to own a mobile device and computer than Caucasian, Filipino, and Latino American subgroups. HCPs can ask KA/I patients to watch these videos before or after their medical appointments. Further, the benefit of these DST videos featuring two HCPs may influence KA/I vaccine decisions. According to Chen et al. (2017) and Rambout et al. (2014), vaccine recommendations by HCPs significantly influence vaccine uptake decisions. COVID-19 CULTURAL EDUCATION 23 In non-clinical settings, these DST videos can serve as an informational resource for AAPI organizations, community centers, and vaccine centers to share with the KA/I community. The benefit of this intervention is that the DST videos contain a shareable web link and can be watched unlimited times. Accordingly, KA/Is may feel empowered to disseminate these videos with their family and friends. Further, this project addresses AAPI health inequities and provides disaggregated data on COVID-19 vaccine hesitancy among KA/Is. Limitations There were several limitations in this DNP project. First, no definitive conclusions can be drawn from the findings because of the small sample size. This project only recruited participants from one source, which may limit the generalizability of the findings. Among the participants who had initially completed the time 0 and time 1 phases of the project, only half responded to the 1-month follow-up survey. The 1-month follow-up survey was essential for the data collection to understand whether DST affected COVID-19 vaccine uptake. While ASU (2008) allows reasonable financial incentives for research participants, some participants may have randomly answered the surveys to receive the incentive. Consequently, two participants were excluded because there was no variability in post-survey answers and the post-survey answers contradicted their responses in the pre-survey. There were also limitations noted within the data collection instruments. First, Rodriguez et al.’s (2021) COVID-19 VHS was intended for the English-speaking population with HIV. While the participant demographics from this DNP project differ, there were no other COVID-19 specific VHS instruments with adequate reliability, internal consistency, and construct validity (Rodriguez et al., 2021). Second, construct validity and reliability for the Narrative Quality Assessment Tool have been tested in different populations (i.e., Latinos in W. S. Kim et al., COVID-19 CULTURAL EDUCATION 24 2017) and Vietnamese American/immigrant mothers in Chen et al. (2022). However, those studies did not include KA/I participants. Future Research/Recommendation Future studies can consider adding a larger sample size to elucidate the findings of this project. More participants can be recruited through other online platforms such as Amazon Mechanical Turk (n.d.), frequently visited Korean community websites like Hey!Korean (n.d.), and popular Korean chat rooms such as Kakao messenger (Google Play, n.d.). Also, partnering with organizational leaders is beneficial as those leaders can advocate for the project and garner support from their community members. Secondly, future research can assess whether DST can improve COVID-19 vaccine booster hesitancy among KA/Is. According to recent data, only 60.4% of Asian Americans received the vaccine booster (CDC, 2022c). Currently, CDC (2022b) recommends three doses of the Pfizer-BioNTech or Moderna vaccines to restore immunity against COVID-19 infection. A new video that addresses COVID-19 vaccine boosters by a KA/I character can be selected and modified. Alternatively, KA healthcare providers can be invited to record a video on their COVID-19 booster experience and why they would recommend the vaccine to others. Next, modifications can be made to this existing project to improve COVID-19 vaccine uptake among other vaccine-hesitant AAPI subgroups. According to Park et al.’s (2021) study, Filipinos were another subgroup with high COVID-19 vaccine hesitancy. Perhaps, a DST video that features a Filipino character can be filmed, or a pre-existing video can be selected to address COVID-19 vaccine hesitancy among the Filipino subgroup. Conclusions COVID-19 CULTURAL EDUCATION 25 Many socio-cultural barriers limit AAPIs from receiving recommended vaccinations. More than ever, COVID-19 vaccines are needed to reach vulnerable communities such as KA/Is. KA/Is are at higher risk for complications, and they tend to have higher COVID-19 vaccine hesitancy unaddressed by cultural and language barriers. DST intervention is cost-effective, sustainable, and scalable and has the potential to address vaccine hesitancy in vulnerable populations, including KA/Is. After all, the benefits of receiving the COVID-19 vaccine far outweigh the risks. COVID-19 CULTURAL EDUCATION 26 References Alvarado, M. (2021). Fighting racial gap, NJ towns promote COVID vaccine to Black, Asian, Latino communities. https://www.northjersey.com/story/news/newjersey/2021/02/04/covid-vaccine-nj-towns-push-black-asian-latinocommunities/4314890001/ Amazon Mechanical Turk. (n.d.). Get started with Amazon Mechanical Turk. https://www.mturk.com/get-started Arizona State University. (n.d.). Translation certification – ASU research integrity and assurance. https://researchintegrity.asu.edu/sites/default/files/2018-04/Form-translationcertificate.docx Arizona State University. (2008). FIN 421-05: Human subject payments. https://www.asu.edu/aad/manuals/fin/fin421-05.html Asian and Pacific Islander Health Forum. (2020). What Asian American, Native Hawaiian, and Pacific Islander community organizations need in the face of the COVID-19 pandemic. https://www.apiahf.org/wp-content/uploads/2020/07/2020.07.16_CBONeeds Assessment_Factsheet_v4.pdf Association of Asian Pacific Community Health Organizations. (2021). COVID-19 resource hub. https://aapcho.org/covid19/ Bender, M. S., Choi, J. W., Arai, S., Paul, S. M., Gonzalez, P., & Fukuoka, Y. (2014). Digital technology ownership, usage, and factors predicting downloading health apps among Caucasian, Filipino, Korean, and Latino Americans: The digital link to health survey. JMIR mHealth and uHealth, 2(4), e43–e43. https://doi.org/10.2196/mhealth.3710 Centers for Disease Control and Prevention. (2022a). COVID data tracker. Retrieved April 21, 2022, from https://covid.cdc.gov/covid-data-tracker/#datatracker-home COVID-19 CULTURAL EDUCATION 27 Centers for Disease Control and Prevention. (2022b). COVID-19 vaccine boosters. Retrieved April 24, 2022, from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/boostershot.html Centers for Disease Control and Prevention. (2022c). Demographic characteristics of people receiving COVID-19 vaccinations in the United States. Retrieved April 24, 2022, from https://covid.cdc.gov/covid-data-tracker/#vaccination-demographic Centers for Disease Control and Prevention. (2022d). Frequently asked questions about vaccination against COVID-19. Retrieved April 21, 2022. https://korean.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html Centers for Disease Control and Prevention. (2022e). Stay up to date with your COVID-19 vaccines. Retrieved April 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines.html Centers for Disease Control and Prevention. (2022f). Symptoms of coronavirus. Retrieved April 21, 2022. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html Chae, S. Lee, Y.-J., & Han, H.-R. (2021). Sources of health information, technology access, and use among non–English-speaking immigrant women: Descriptive correlational study. Journal of Medical Internet Research, 23(10), e29155–e29155. https://doi.org/10.2196/29155 Chen, A. C.-C., Han, S. Y., Li, W., Leong, K. L., & Ou, L. (2021). COVID-19 and Asian American college students: Discrimination, fear, and mental health. Journal of Emergency Management, 19(9), 121-131. https://doi.org/10.5055/jem.0598 Chen, A. C.-C., Kim, W. S., & Larkey, L. (2019). Developing and pilot testing a digital COVID-19 CULTURAL EDUCATION 28 storytelling intervention to promote HPV vaccination among Vietnamese American adolescents. GSTF Journal of Nursing and Health Care 4(1). https://core.ac.uk/download/pdf/327108728.pdf Chen, A. C.-C., Kim, W. S., Todd, M., & Larkey, L. (2022). A digital storytelling intervention for Vietnamese American mothers to promote their children’s HPV vaccination. Cancer Prevention Research. https://doi.org/10.1158/1940-6207.CAPR-21-0618 Chen, A. C.-C., Todd, M., Amresh, A., Menon, U., & Szalacha, L. (2017). A pilot study of computerized, tailored intervention to promote HPV vaccination in Mexican-heritage adolescents. GSTF Journal of Nursing and Health Care, 5(1). https://asu.pure.elsevier.com/ws/portalfiles/portal/75346356/2017_pilot_tailored_interve ntion_for_Latino_parents_to_promote_teen_HPV_vaccination_ChenACC.pdf Choi, S. (2021, September 10). Dr. Sarang Choi’s COVID-19 vaccine vlog. [Video]. YouTube. https://www.youtube.com/watch?app=desktop&v=B1MkZpMMERY&feature=youtu.be Daniels, N. A., Gildengorin, G., Nguyen, T. T., Liao, Luong, T. N., & McPhee, S. J. (2010). Influenza and pneumococcal vaccination rates among Vietnamese, Asian, and NonHispanic White Americans. Journal of Immigrant and Minority Health, 12(3), 370–376. https://doi.org/10.1007/s10903-008-9195-6 Erzurum, S. (2021). How much of the population will need to be vaccinated until the pandemic is over? https://health.clevelandclinic.org/how-much-of-the-population-will-need-to-bevaccinated-until-the-pandemic-is-over/ Frew, P. M., Alhanti, B., Vo-Green, L., Zhang, S., Liu, C., Nguyen, T., Schamel, J., SaintVictor, D. S., & Nguyen, M. L. (2014). Multilevel factors influencing hepatitis B screening and vaccination among Vietnamese Americans in Atlanta, Georgia. The Yale COVID-19 CULTURAL EDUCATION 29 Journal of Biology & Medicine, 87(4), 455–471. https://www-ncbi-nlm-nihgov.ezproxy1.lib.asu.edu/pmc/articles/PMC4257033/ Graduate Professional Student Association. (n.d.). Graduate research support program. https://gpsa.asu.edu/funding/research/graduate-research-support-program/ Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010 Hey!Korean. (n.d.). Community. https://talk.heykorean.com/web/us/discussions Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. (2012). The Asian population: 2010 census briefs. U.S. Department of Commerce Economics and Statistics Administration. https://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf Hopfer, S., Garcia, S., Duong, H., Russo, J., & Tanjasiri, S. (2017). A narrative engagement framework to understand HPV vaccination among Latina and Vietnamese women in a planned parenthood setting. Health Education & Behavior, 44(5), 738–747. https://doi.org/10.1177/1090198117728761 Google Play. (n.d.). KakaoTalk: Messenger. https://play.google.com/store/apps/details?id=com.kakao.talk&hl=en_US&gl=US IBM Corp. (2021). IBM SPSS Statistics for Windows (Version 28.0) [Computer software]. https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-280 Kim, M., Lee, H., Kiang, P., Aronowitz, T., Kennedy Sheldon, L., Shi, L., & Allison, J. J. (2020). A storytelling intervention in a mobile, web-based platform: A pilot randomized controlled trial to evaluate the preliminary effectiveness to promote human COVID-19 CULTURAL EDUCATION 30 papillomavirus vaccination in Korean American college women. Health Education & Behavior, 47(2), 258–263. https://doi.org/10.1177/1090198119894589 Kim, M., Lee, H., Kiang, P., & Kim, D. (2017). Human papillomavirus: A qualitative study of Korean American female college students’ attitudes toward vaccination. Clinical Journal of Oncology Nursing, 21(5), E239–E247. https://doi.org/10.1188/17.CJON.E239-E247 Kim, W., Kreps, G. L., & Shin, C.-N. (2015). The role of social support and social networks in health information-seeking behavior among Korean Americans: A qualitative study. International Journal for Equity in Health, 14(1), 1–10. https://doi.org/10.1186/s12939015-0169-8 Kim, W. S., Shin, C. N., Larkey, L., & Roe, D. (2017). Development and validation of a measure to evaluate critical components of storytelling interventions: The narrative quality assessment tool. Journal of Nursing Measurement, 25(1), 171-183. https://doi.org/10.1891/1061-3749.25.1.171 Larkey, L., & Hecht, M. (2010). A model of effects of narrative as culture-centric health promotion. Journal of Health Communication, 15(2), 114–135. https://doi.org/10.1080/10810730903528017 Lee, H., Ghebre, R., Le, C., Jang, Y. Y., Sharratt, M., & Yee, D. (2017). Mobile phone multilevel and multimedia messaging intervention for breast cancer screening: Pilot randomized controlled trial. JMIR mHealth and uHealth, 5(11), e154–e154. https://doi.org/10.2196/mhealth.7091 Lee, H., Kim, M., Cooley, M. E., Kiang, P. N., Kim, D., Tang, S., Shi, L., Thiem, L., Kan, P., Peou, S., Touch, C., Chea, P., & Allison, J. (2018). Using narrative intervention for HPV vaccine behavior change among Khmer mothers and daughters: A pilot RCT to examine COVID-19 CULTURAL EDUCATION 31 feasibility, acceptability, and preliminary effectiveness. Applied Nursing Research, 40, 51–60. https://doi.org/10.1016/j.apnr.2017.12.008 Lee, H. Y., Choi, J. K., & Lee, M. H. (2015). Health literacy in an underserved immigrant population: New implications toward achieving health equity. Asian American Journal of Psychology, 6(1), 97–105. https://doi.org/10.1037/a0037425 Lee, H. Y., Choi, Y. J., Yoon, Y. J., & Oh, J. (2018). HPV literacy: The role of English proficiency in Korean American immigrant women. Clinical Journal of Oncology Nursing, 22(3), E64–E70. https://doi.org/10.1188/18.CJON.E64-E70 Lee, H. Y., Koopmeiners, J. S., McHugh, J., Raveis, V. H., & Ahluwalia, J. S. (2016). MHealth pilot study: Text messaging intervention to promote HPV vaccination. American Journal of Health Behavior, 40(1), 67–76. https://doi.org/10.5993/AJHB.40.1.8 Lee, H. Y., Lee, M. H., Sharratt, M., Lee, S., & Blaes, A. (2019). Development of a mobile health intervention to promote papanicolaou tests and human papillomavirus vaccination in an underserved immigrant population: A culturally targeted and individually tailored text messaging approach. JMIR mHealth and uHealth, 7(6), e13256–e13256. https://doi.org/10.2196/13256 Lee, Y. M., Mondragon, E., Jeong, Y. M., Lee, H. H., Aquino, E., & Shim, K. (2019). Exploring the need of HPV education programs in Korean American communities. Journal of Community Health Nursing, 36(1), 19-30. https://doi.org/10.1080/07370016.2018.1555312 Melnyk, B. M., & Fineout-Overholt, E. (2019). Making the case for evidence-based practice and cultivating a spirit of inquiry. In B. M. Melynk & E. Fineout-Overholt (Eds.), Evidencebased practice in nursing & healthcare (4 ed., pp. 35-62). Wolters Kluwer. th COVID-19 CULTURAL EDUCATION 32 McClung, N., Chamberland, M., Kinlaw, K., Bowen Matthew, D., Wallace, M., Bell, B. P., Lee, G. M., Talbot, H. K., Romero, J. R., Oliver, S. E., & Dooling, K. The advisory committee on immunization practices’ ethical principles for allocating initial supplies of COVID-19 vaccine – United States, 2020. Morbidity and Mortality Weekly Report, 69(47), 17821786. http://dx.doi.org/10.15585/mmwr.mm6947e3external icon Mein, S. A. (2020). COVID-19 and health disparities: The reality of “the great equalizer.” Journal of General Internal Medicine, 35(8), 2439–2440. https://doi.org/10.1007/s11606020-05880-5 Mishra, V. & Dexter, J. P. (2020). Comparison of readability of official public health information about COVID-19 on websites of international agencies and the governments of 15 countries. JAMA Network Open, 3(8), e2018033–e2018033. https://doi.org/10.1001/jamanetworkopen.2020.18033 Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: Understanding time lags in translational research. Journal of the Royal Society of Medicine 104(12), 510-520. https://doi.org/10.1258/jrsm.2011.110180 National Alliance on Mental Illness (n.d.). Asian American and Pacific Islander. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/Asian-Americanand-Pacific-Islander#:~:text=AAPI%20communities%20consist%20of%20 approximately,Asian%20and%20Pacific%20Islander%20ancestries. National Institutes of Health. (2021). Therapeutic management of adults with COVID-19. https://www.covid19treatmentguidelines.nih.gov/therapeutic-management/ Olliaro. (2021). What does 95% COVID-19 vaccine efficacy really mean? The Lancet Infectious Diseases, 21(6), 769–769. https://doi.org/10.1016/S1473-3099(21)00075-X COVID-19 CULTURAL EDUCATION 33 Park, V. T., Dougan, M., Meyer, O., Nam, B., Tzuang, M., Park, L., Vuong, Q., & Tsoh, J. (2021). Differences in COVID-19 vaccine concerns among Asian Americans and Pacific Islanders: The COMPASS survey. Journal of Racial and Ethnic Health Disparities, 1-13. https://doi.org/10.1007/s40615-021-01037-0 Rambout, L., Tashkandi, M., Hopkins, L., & Tricco, A. C. (2014). Self-reported barriers and facilitators to preventive human papillomavirus vaccination among adolescent girls and young women: A systematic review. Preventive Medicine, 59(1), 22-32. https://doi.org/10.1016/j.ypmed.2013.10.009 Randolph, H. E., & Barreiro, L. B. (2020). Herd immunity: Understanding COVID-19. Immunity, 52(5), 737-741. https://doi.org/10.1016/j.immuni.2020.04.012 Rheem, J. (2021, January 1). Moderna vaccine review: Who shouldn’t receive the vaccine? [Video]. YouTube. https://www.youtube.com/watch?v=m5KrCHJ4aTM&list=PLx_eycEQCKUjvXvBJGM WTRGCKBOJMv9fm&index=3 Robert, R., Kentish-Barnes, N., Boyer, A., Laurent, A., Azoulay, E., & Reignier, J. (2020). Ethical dilemmas due to the Covid-19 pandemic. Annals of Intensive Care, 10(1), 84–84. https://doi.org/10.1186/s13613-020-00702-7 Rodriguez, Alcaide, M. L., Salazar, A. S., Montgomerie, E. K., Maddalon, M. J., & Jones, D. L. (2021). Psychometric properties of a vaccine hesitancy scale adapted for COVID-19 vaccination among people with HIV. AIDS and Behavior, 1–6. https://doi.org/10.1007/s10461-021-03350-5 Schaffer, M. A., Sandau, K. E., & Diedrick, L. (2013). Evidence-based practice models for COVID-19 CULTURAL EDUCATION 34 organizational change: overview and practical applications. Journal of Advanced Nursing, 69(5), 1197–1209. https://doi.org/10.1111/j.1365-2648.2012.06122.x Schoch-Spana, M., Brunson, E. K., Long, R., Ruth, A., Ravi, S. J., Trotochaud, M., Borio, L., Brewer, J., Buccina, J., Connell, N., Hall, L. L., Kass, N., Kirkland, A., Koonin, L., Larson, H., Lu, B. F., Omer, S. B., Orenstein, W. A., Poland, G.,…White, A. (2020). The public’s role in COVID-19 vaccination: Human-centered recommendations to enhance pandemic vaccine awareness, access, and acceptance in the United States. Vaccine. https://doi.org/10.1016/j.vaccine.2020.10.059 Shon, E., & Wells, A. (2020). Effects of patient-centered communication on influenza vaccination and self-reported general health status among Asian Americans: A comparison model for young/middle-aged and older adults. Journal of Aging and Health, 32(10), 1409–1418. https://doi.org/10.1177/0898264320930888 Srivastav, A., O’Halloran, A., Lu, P. J., & Williams, W. W. (2018). Influenza vaccination coverage among English-speaking Asian Americans. American Journal of Preventive Medicine, 55(5), e123–e137. https://doi.org/10.1016/j.amepre.2018.06.018 Stetler, C. B. (2009). Stetler model. In J. Rycroft-Malone & T. Bucknall (Eds.), Models and frameworks for implementing evidence-based practice: Linking evidence to action (pp. 51-81). Wiley-Blackwell. United States Census Bureau. (2019a). Asian alone or in any combination by selected groups: American Community Survey. https://data.census.gov/cedsci/table?q=B02018&tid=ACSDT1Y2018.B02018&hidePrevi ew=true United States Census Bureau. (2019b). Household language by household limited English COVID-19 CULTURAL EDUCATION 35 speaking status: American Community Survey. https://data.census.gov/cedsci/table?q=english&tid=ACSDT5YSPT2015.B16002 University of California San Francisco. (n.d.). Researchers. https://careregistry.ucsf.edu/researchers U.S. Department of Health & Human Services. (2021a). Biden administration invests more than $6 billion from the American rescue plan into community health centers nationwide. https://www.hrsa.gov/about/news/press-releases/health-center-program-american-rescueplan U.S. Department of Health & Human Services. (2021b). Ensuring equity in COVID-19 vaccine distribution: Engaging federally qualified health centers. https://www.hrsa.gov/coronavirus/health-center-program Vergara R. J. D., Sarmiento, P. J. D., & Lagman, J. D. N. (2021). Building public trust: A response to COVID-19 vaccine hesitancy predicament. Journal of Public Health, fdaa282. https://doi.org/10.1093/pubmed/fdaa282 Vu, M., Berg, C. J., Escoffery, C., Jang, H. M., Nguyen, T. T., Travis, L., & Bednarczyk, R. A. (2020). A systematic review of practice-, provider-, and patient-level determinants impacting Asian-Americans’ human papillomavirus vaccine intention and uptake. Vaccine, 38(41), 6388–6401. https://doi.org/10.1016/j.vaccine.2020.07.059 Wang, C. (2021). Community groups help elderly, low-income Asian Americans get vaccine access. https://www.nbcnews.com/news/asian-america/community-groups-help-elderlylow-income-asian-americans-get-vaccine-a-rcna496 Wang, D., Gee, G. C., Bahiru, E., Yang, E. H., & Hsu, J. J. (2020). Asian-Americans and Pacific COVID-19 CULTURAL EDUCATION 36 Islanders in COVID-19: Emerging disparities amid discrimination. Journal of General Internal Medicine, JGIM, 35(12), 3685–3688. https://doi.org/10.1007/s11606-02006264-5 Whittaker, R., McRobbie, H., Bullen, C., Rodgers, A., Gu, Y., & Dobson, R. (2019) Mobile phone text messaging and app-based interventions for smoking cessation. The Cochrane Database of Systematic Reviews, CD006611. https://doi.org/10.1002/14651858.CD006611.pub4 Wolters Kluwer. (n.d.). Nurse Practitioner. https://journals.lww.com/tnpj/pages/default.aspx Wong, J. A., Yi, S. S., Kwon, S. C., Islam, N. S., Trinh-Shevrin, C., & Đoàn, L. N. (2022). COVID-19 and Asian Americans: Reinforcing the role of community-based organizations in providing culturally and linguistically centered care. Health Equity, 6(1), 278–290. https://doi.org/10.1089/heq.2021.0124 World Health Organization. (n.d.). Coronavirus. https://www.who.int/health-topics/coronavirus#tab=tab_1 World Health Organization. (2020). WHO director-general’s opening remarks at the media briefing on COVID-19 - 11 March 2020. https://www.who.int/directorgeneral/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefingon-covid-19---11-march-2020 World Health Organization. (2022). WHO Coronavirus Disease (COVID-19) dashboard. Retrieved April 21, 2022, from https://covid19.who.int COVID-19 CULTURAL EDUCATION 21 Appendix A Evaluation and Synthesis Tables Table A1 Evaluation of Qualitative Studies Citation Conceptual Framework Design/ Method/ Sampling Y. M. Lee et al. (2019). Development of a mobile health intervention to promote Pap tests and HPV in an underserved immigrant pop.: A culturally targeted and individually tailored text messaging approach. Fogg Behavioral Model Design: FG. Funding: National Cancer Institute Purpose: Examine how mScreening, a culturally tailored MTM intervention, was created to increase pap tests and HPV vaccine uptake among female KA immigrants. Sample/ Setting Major Variables Studied and Definitions N: 20 1. Barriers and facilitators of Setting: HPV Unspecified. screening and vaccination. 2. Effective ways Sample to increase Demographic: awareness of Mn age: 26. HPV Gender: f. screening and Nativity: vaccination. Korea. 3. Patterns of Residence in mobile phone US: Avg of 3.9 use and text years. messaging as a Occupation: tool for Either intervention undergraduate 4. Strategize or graduate ways to students in deliver text Minnesota. messages that are engaging. Exclusion: None listed. Measurement/ Instrumentation Data Analysis FG were asked questions by first author; follow-up questions asked by 2 other research staff. Braun and Clarke’s thematic qualitative MOA. T1- Tailoring the message content to provide basic knowledge about cervical cancer. Quotes were first translated from Korean to English by bilingual research team member, then back translated by another bilingual member to T2- Formatting message to be interactive and visually appealing. Conducted in Korean. Digitally recorded. Findings/ Themes T3– Formatting message delivery to be brief and engage participants. T4– Motivate participation through use of incentive. Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization LOE: IV Strengths: No other study examines this phenomenon. Provides insight on how to tailor MTM to be culturally relevant based on participants’ insight, to promote HPV screening and vaccination. Weaknesses: Poor generalizability to other locations, non-college students, and < or >21–26 y.o.; Inapplicable to nonEG readers. Conclusions: Can guide future research on how to tailor MTM that is culturally appropriate for HPV screening/ vaccination among AA. Key: CCNHP – Culture-centric Narratives in Health Promotion, CN – Chinese, CSS – Cross-sectional survey, CT – culturally tailored, DST-digital storytelling, DV - Dependent variable, f – female, FBM – Fogg Behavioral Model, FG – focus groups, HBV – hepatitis B vaccine, HCP-healthcare provider, HPVV – Human Papillomavirus vaccine, HSUM – Health services utilization model, IV – Independent variable, IZV – Influenza, KA – Korean American, KN – Korean, Mn – mean, mo, - month, N-number of studies (if SR) or participants in study; NEM – Network Episode Model, NET – Narrative Engagement Theory, NSQA – Narrative story quality assessment, P: Phase, Pap – PCC – patient-centered communication, PPPM – practice, provider, patient model, PPTpre- post-test, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, SDF – Sociodemographic form, SEM – Social Ecological Model, SR – systematic review, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, y.o. – years old, TPB – Theory of Planned Behavior, TS – telephone survey, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Citation Conceptual Framework Design/ Method/ Sampling Bias: None recognized Country: US. H. Y. Lee et al. (2019). Exploring the need of HPV education programs in Korean American Communities. Funding: Not listed. Bias: Not listed. Country: US. Health Belief Model. Design: 4 sexsegregated FG (2 m, 2 f) Method: Convenience sampling via flyers and brochures. Purpose: Examine cultural influences/ barriers r/t HPV vaccine uptake and assess best HPV educational format. 38 Sample/ Setting Major Variables Studied and Definitions 5. Strategize ways to Attrition: 0. maximize participation and engagement. N: 20 1. HPV-related knowledge and Setting: KN information church in 2. Negative Chicago perception suburb. toward HPV vaccine. Sample 3. HCP impact Demographic: 4. Affordability Mn age: 46.75. Gender: m-10 / of vaccine 5. Cultural f- 10. influence of Residence in vaccine U.S.: Avg of acceptance. 21.95 years. Education: College (71.4%) / High school (4.8%). Exclusion: non-KN, inability to read, speak, understand Measurement/ Instrumentation Data Analysis Findings/ Themes Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization Feasibility: Limited application as this is only intended for f KA immigrants between 21-26 y.o. T1- Limited knowledge (i.e. HPV is only beneficial for girls, not boys). LOE: IV T2- Distrust r/t novelty of vaccine and unknown side effects. Weaknesses: Poor generalizability to other KA parents living outside of Chicago suburbs. Small sample size. T3-HCP recommendation affects parents’ decision. Conclusions: This study can help guide HCP and researchers on how to develop HPV-focused education tailored for KA parents. T4- KN cultural barrier of discussing sex with child. Feasibility: Limited application as this is only intended for KA parents with adolescents age 1118. ensure consistent meaning. 1-hour semistructured interview with each FG. Deductive coding and content analysis via KN language. Audio recordings transcribed in KN Transcript by study team. read and coded by 2 KN speaking coders. Research group collectively finalized major themes and subthemes via team discussion. Strengths: Provides insight on what factors affect KA parents’ HPV vaccine decision-making. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Citation Conceptual Framework Design/ Method/ Sampling 39 Sample/ Setting KN, parent of child <11 y.o. or >18 y.o. Major Variables Studied and Definitions Measurement/ Instrumentation Attrition: 0. M. Kim et al. (2017) HPV: A QL study of KA female college students’ attitudes toward vaccination. Funding: Institute of Asian American Studies at the University of Massachusetts in Boston. Network Episode Model (revised) and Theory of Planned Behavior. Design: 5 FG. Method: Qualitative descriptive study; purposive sampling method. Purpose: Examine KA female college students’ attitude, knowledge, and socio- N: 20 Setting: Massachusetts college. Sample Demographic: Mn age: 21.7. Gender: f. Nativity: Korea- 14 / U.S.-6. Acculturation: KA- 12, KN6, American2. KA behavior influenced by: 1. socio-cultural factors (i.e. nativity, language, social situation) 2. Social network (relationships and interactions). 3. Individual (knowledge and attitudes). Semi structured interview guideline. Audio recorded. Data Analysis Findings/ Themes Translated to EG by bilingual speaker. T5- Parents want to withhold if not covered by HI. Translation verified by bilingual coders (2) and nursing faculty (2). Audio recordings transcribed and translated to EG by authors and professional transcriber. Content analyzed via open coding. Data evaluated 3 times by 3 Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization T6-In-person seminars and short (10 min) family videos suggested by participants. T1- Awareness r/t HPV, HPV vaccine, and cervical cancer T2Misunderstanding s r/t HPV, HPV vaccine, and cervical cancer. T3-Attitudes r/t HPV vaccine T4- Social factors r/t HPV vaccine LOE: IV Strengths: Provides awareness of cultural barriers and HPV misconceptions among KA female college students. Weaknesses: Limited to KA female college students residing in Massachusetts (not generalizable). Conclusions: Can guide HCP and researchers on how to develop HPV-focused education tailored for KA female college students. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Citation Conceptual Framework Bias: None recognized. Country: US. Hopfer et al. (2017). A narrative engagement framework to understand HPV vaccination among Latina and VN women in planned parenthood setting. Funding: Allan Hubbell Narrative Engagement Theory. 40 Design/ Method/ Sampling Sample/ Setting cultural influences r/t HPV vaccine intent and uptake. Exclusion: none-listed. Design: Exploratory study. N: 50 n= 24 (Latina) n=24 (VN) n=2 (PPH staff) Method: Narrative inquiry interview technique; purposive sampling method. Purpose: Examine how cultural values and Attrition: 0. Setting: PPH in Orange and San Bernardino Counties in Southern California. Sample Demographic: Major Variables Studied and Definitions Behavior/ intention shaped by: 1. Attitude toward behavior 2. Subjective norms 3. Control over predictive behavior. Measurement/ Instrumentation 1. Motherdaughter narratives 2. HCP recommendatio n 3. HPV (un)awareness narratives 4. Independence narratives among VN women. 5. School-based HPV knowledge. Semi-structured interviews. Data Analysis Findings/ Themes authors for themes and subthemes. T5- Cultural role of health communication/ healthcare system. 3 participants reviewed data interpretatio n to ensure accuracy of themes/ translations. NVivo version 11 software. Interviews transcribed verbatim; 3 coders coded all transcripts via grounded theory approach. T1- Barriers to vaccinating (perceived susceptibility to HPV, family communication gap/ stigma on sexual health). T2- Promoting HPV vaccination among men (low awareness, “machismo”). Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization Feasibility: Limited application as this is only intended for KA female college students. LOE: IV Strengths: Identified HPV vaccine decision stories from VN and Latina women. Weaknesses: Lacks follow-up with participants. Potential lack of data saturation in decision narratives. Conclusions: Can guide HCP and researchers on how to discuss HPV vaccine uptake among Latina and VN women and men. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Citation Research & Education Fund via NIH. Bias: None recognized. Country: US. Conceptual Framework 41 Design/ Method/ Sampling Sample/ Setting attitudes impact HPV vaccine uptake among Latina and VN women who attend PPH facilities. VN (n=24): Mn age: 22. Gender: f. HPV 1+ dose: 67% / 3-dose: 63% Sexually active: 96%. HI: 75%. Hx. Pap smear: 54% Major Variables Studied and Definitions Measurement/ Instrumentation Data Analysis Findings/ Themes T3 – PPH HCP perspective (extensive application process for uninsured to apply for HPV vaccine discount). Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization Feasibility: Limited application as this is study only explored Latina and VN participants. Latina (n=24): Mn age: 22. Gender: f. HPV 1+ dose: 66% / 3-dose: 48% Sexually active: 90%. HI: 77%. Hx. Pap smear: 52% HCP (n=2): -Nurse Practitioners, 4 and 12yrs with PPH. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Citation Conceptual Framework Design/ Method/ Sampling 42 Sample/ Setting Exclusion: none-listed. Major Variables Studied and Definitions Measurement/ Instrumentation Data Analysis Findings/ Themes Level/Quality of Evidence; Decision for practice/ application to practice/ Generalization Attrition: 0. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION 43 Table A2 Evaluation of Quantitative Studies Citation Chen et al. (2019). Developing and pilot testing a DST intervention to promote HPV vaccination among Vietnamese American adolescents. Funding: American Nurses Foundation and Western Institute of Nursing Bias None recognized Country U.S Theoretical/ Conceptual Framework Culturecentric Narratives in Health Promotion Design/ Method/ Purpose Design: Two phases; Phase 1: Creation of digital stories by VN mothers with HPV vaccinated adolescents. Phase 2: Quasiexperimental pre- and post-test on HPV knowledge, perception, and intent to vaccinate children among VN mothers. Sample/Setting Major Variables & Definitions Measurement/ Instrumentation Data Analysis Results/ Findings N: Phase 1: 2; Phase 2: 10. IV: DST on HPV vaccine. Setting: Phase 1: Workshop setting unspecified. Phase 2: Community settings/ salons. DV1: Change HPV vaccine knowledge, attitude, belief. Pre-test survey and sociodemographic form (23 questions). REDCap, SPSS, univariate analyses, nonparametric statistics, effect size calculated with significant variables. Wilcoxon Signed Ranks test DV1: Significant change in 2 items (1) HPV vaccine needed without physical symptom: pretest Mdn=2.89; posttest Mdn=1.70; Z=2.23, p=0.025) and (2) only girls need to be vaccinated (pretest Mdn=2.00; post Mdn=1.60; Z=2.00, p=0.046). Large effect size 1.0 and 0.8. Sample Demographic: Phase 1: VN mothers age 52 and 59. Both born in VN, have HPV vaccinated adolescents, have family members diagnosed with cancer, and learned HPV DV2: HPV vaccine intention. HPV knowledge, attitude belief: 6likert scale. HPV vaccine intent: 2-item (yes/no). Narrative DST quality: 12 5point likert scale (α=0.93-0.95) Level of Evidence; Application to practice/ Generalization LOE: III Strengths: Culturally engaging HPV DST education that can influence VN mothers’ intention to vaccinate children. Weakness: Small sample size of 10. Not a RCT. Study did not follow-up on whether 1st vaccine was completed. Feasibility: Can easily be administered in out-pt. offices and communities. DV2: 100% HPV vaccine Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Purpose: To promote uptake of HPV vaccine among VN adolescent children. 44 vaccine from HCP. One bilingual in English and VN; other primarily VN. intention postintervention. Phase 2: Mn age: 28. Gender: f. Nativity: VN. Exclusion: Children previously HPV vaccinated. Attrition: 0. Vu et al. (2020). A SR of practice-, provider-, and pt.-level determinants impacting AA’ HPV intention and uptake. Funding: NCI, US Fogarty Practice, provider, and pt. model. Design: SR, QL and QN studies. Purpose: To assess how practice-, provider-, and pt.-level factors affect AA HPV vaccine N: 26 DS: Pubmed, CINAHL, PsychINFO, ProQuest, EMBASE. Inclusion Criteria: Written in EG; US based; peerreviewed of original data; IV1: Practice (vaccine supply, policy, use of standing orders, language services, HI policy). IV2: Provider (clinical experience, training, selfefficacy, HPV vaccine recommendation). PRISMA checklist Sig. factors in QL: main Ts and categories >20% Sig. factors in QN: multivariate associates w/ p <0.05. IV1: N=3 (12%). Importance of language service and HI policy as barrier. IV2: N=12 (46%). Importance of HPV vaccine recommendation from providers. LOE: IIa. Strengths: First SR that examines AA subgroup disparities on HPV vaccine uptake. Weakness: Lack of generalizability to other AA subgroups other than KN, CN, CB pop. Limited number of studies with varying statistical analyses. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION International Center, US National Institute on Environmental Health Science, CDC Cancer Prevention and Control Research Network. Bias None recognized Country US intention and uptake. 45 published 1/1994 to 5/2019; Asian pop. focus; outcomes r/t HPV vaccine intention/ uptake. Exclusion Criteria: Prior to 1994; nonEnglish; focused on nonAsian pop.; non-HPV vaccine. IV3: Pt. (sociodemographic traits, attitudes, knowledge, access to care, social influences). DV1: Vaccine intention (willingness, acceptability DV2: Vaccine uptake (initiation or completion). QATSDD: Quality appraisal Each study scored by lead author; accuracy ensured by another author reviewing score. IV3: N=26 (100%). Barriers: lack of HPV vaccine knowledge, lack of perceived susceptibility, not knowing where to get vaccine, whether HI will cover. DV1: Higher intention among those who perceive social approval from family and friends, knowing someone with cancer. Intention: 23.4% to 72%. Conclusion: Need for culturally-appropriate HPV education (i.e. family-based, cultural beliefs, accessrelated). Data analysis should consider differences among AA subgroups. Feasibility: Culturally tailored education focusing on HPV vaccine information, familial/ social influence and/or access to obtain vaccine can improve HPV intention/ uptake. Applicability is limited to CB, CN, and KN population. DV2: Initiation: 14% to 67%. Completion 9% to 63%. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Kim et al. (2020). A storytelling intervention in a mobile, web-based platform: A pilot RCT to evaluate the preliminary effectiveness to promote HPV. Funding: ACS; supported by NCI of NIH at the University of Massachusetts Medical School Worcester Bias None recognized Country U.S Situationspecific theoretical framework 46 Design: Pilot RCT (pre- & post survey, 2mn followup survey). N= 104 n = 54 (IG) n = 50 (CG) IV1: Mobile, webbased CT storytelling video. Qualtrics, an online survey tool. Setting: Webbased. Purpose: Assess effectiveness of a mobile, web-based CT storytelling video intervention to promote HPV vaccine among KA college women. IV2: HPV written information by ACS and CDC. Demographics: No significant differences between IG and CG. Mn age of IG: 21.5 (CG), 22.0 (CG). Gender: all f for both IG and CG. South Korea nativity: 81% (IG), 77.6% (CG). U.S. nativity: 18.9% (IG), 22.4% (CG). DV1: HPV vaccine initiation/ scheduling appointment. Knowledge: HPV 16-item (α=0.91), HPV vaccine 8item (α=0.82), cervical cancer 8item (α=0.81). HPV vaccine Attitude: Cognitive perception 9-item (α=0.78). Affect/ feelings 10-item (α=0.75), motivation/ intention. Inclusion: F US northeast college students; KN or KA; 18-26 yo. Exclusion: m; history of prior DV2: HPV vaccine intention DV3: Changes in HPV knowledge and attitudes. SPSS, Fisher’s exact test, paired t test, independent t test. DV1: Postintervention: IG 15.5%; CG= 7.1%; p<.317 (IG twice as likely to receive/ schedule HPVV). 2-mo Postintervention: 10 participants (22.2%) received at least one dose/ scheduled for vaccine. LOE: IIb Strengths: In line with other research that shows benefits of narrative video with reminder system. Weakness: Does not assess long-term effects; only monitored for 2 months postintervention. Intervention is not translated in Korean. Feasibility: Highly accessible to those who own mobile phones. However, intervention should be offered in Korean language to target non-English speakers. DV2: Postintervention: IG 144%; CG=67%. DV3: Both groups significantly improved C.G. =p<0.001 Mean score changes t (102) =2.11; Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION 47 HPV vaccination; unable to read/speak English. p<.05. Both groups had more positive cognitive and affective attitudes toward HPV vaccine from pre- to post (p<0.001). Attrition: 0 Frew et al. (2014). Multilevel factors influencing hepatitis B screening and vaccination among Vietnamese Americans in Atlanta, Georgia. Funding: Atlanta Clinical and Not listed, inferred to be Social Ecological Model. Design: Survey Purpose: Examine barriers and ways to improve HBV vaccine uptake among VN. N: 316 Setting: Atlanta, GAHealth fairs, CBO/ events, offices, churches, temples, festivals. Sample Demographic: Mn age: 41. m (43%) / f (54%). Nativity: IV1: Social and community support. IV2: Misconceptions r/t HBV vaccine. IV3: HI / ability to afford medical care. IV4: Transportation access. DV1: HPV screen Cross-sectional survey samples. 157-item questionnaire (VN or English) measuring HBV attitudes, screening, and vaccination. No group mean differences in HPV cognition and attitudes, t(100) =−1.93, p=.06. IBM SPSS IV1: Social & community for support of HBV Windows, exploratory vaccine r/t: 1. Screening factor (OR=1.69, 95% analyses, bivariate and CI [1.21,2.38]). multivariable 2. Vaccination (OR=1.89, logistic [1.27,2.81]). regressions, 3. Intent to multiple vaccinate (ORimputations 1.77, [1.13, 2.78]). LOE: IV Strengths: Provides insight on knowledge deficit, misconceptions, sociodemographic traits that are barriers to low HBV vaccine uptake. Weaknesses: Potential recall bias from self-reports. “Don’t know” answers may also lead to bias in analyses. Conclusions: Lack of HBV vaccine education and Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Translational Science Institute 48 VN (91%) / US (5.1%). Language: VN (82%) / EG (11%). HI: Yes (55%) / No (23%). Income: <$20,000 (39%). HBV screen: Yes (49%) / No (38%). HBV vaccine: None (46%) /1 (34%) / 3 (13%). Bias: None recognized Country: US. DV2: HPV vaccine intent. IV2: Misconceptions led to decreased: 1. Screening (OR=0.67, [0.46, 0.99]). 2. Vaccination (OR=0.55, [0.35, 0.86]). DV3: HPV vaccination. Funding: Not listed. Not listed, inferred to be Social Ecological Model. Design: Telephone survey, randomdigit-dialed. MSCD. Method: 2013-2015 BRFSS by state health Attrition: 0 N: 28,577 Setting: N/A. Sample Demographic: Asian specific ethnicities: Other (27%), Asian Indian (21.7%), CN Feasibility: Helps HCP and researchers focus on improving vaccine uptake among VN. IV3: Ability to afford medical tx.: (OR=1.23, [1.01, 1.50]). IV4: Greater transportation access: (OR =1.42, [1.07, 1.87]). Exclusion: Not listed. Srivastav et al. (2018). Influenza vaccination coverage among Englishspeaking AA. programs to improve uptake among at-risk VN pop. IV1: Sociodemographic factors IV2: Access-tocare factors DV1: State-level estimates of vaccination. Participants were asked if in the past 12 months they had either a flu shot, or flu vaccine sprayed in nose. SUDAAN, multivariate logistic regression, ttests, IV1: Vaccine uptake among all Asians 42.4%. Filipinos and Japanese higher than whites. Lower among CN and KN compared to whites. Similar among Asian LOE: IV Strengths: Reveals differences in vaccine uptake depending on Asian subgroup. Weaknesses: Potential recall bias (self-reports). BRFSS done in EG only. Lack of generalizability to AA of other subgroups who are older, less Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION departments with CDC to gather health information. Bias: None recognized. Country: US. Shon & Wells. (2020). Effects of PCC on influenza vaccination and selfreported general health status among Asian Americans: A comparison model for young/middle- Purpose: Assess influenza vaccination among EGspeaking AA. Health services utilization model. Design: Telephone survey; random digital dialing. Method: 2014-2016 CHIS merged. Purpose: To assess 49 (20.2%), Filipino (14%), Japanese (6.7%), KN (5.5%), VN (4.9%). Exclusion: <18 y.o., respondents who did not know or did not respond regarding vaccine status. Attrition: Not listed. N: 2,838 Setting: California residents. Sample Demographic: CN (59.2%), KN (18.1%), VN (22.7%). Younger: 18-64 y.o. (57.4%) / Older 65+ y.o. (42.6%). Indian, VN, and other compared to whites. educated, and with less income. Missing data on nativity, US citizenship, length of acculturation. IV2- Higher uptake among those with HCP, HI, <1 year time since last checkup, except for Koreans. Conclusions: Influenza vaccine coverage varied significantly among AA subgroups. Need for data analyses to disaggregate AA into subgroups and ethnicities. Feasibility: Helps HCP and researchers focus on improving vaccine uptake among KN and CN. IV1: PCC (HCP clear explanation on what to do or listening skills) IV2: Younger (1864 y.o.) vs Older (65+ y.o.). DV1: Uptake of influenza vaccine. DV2: Selfreported GH status Self-report on GH, PCC, and influenza vaccine status. SPSS and IV1/ IV2: AMOS 23.0; 1. PCC (both types) sig. univariate improved frequencies, younger descriptive influenza statistics, vaccine uptake histograms, and selfbivariate reported GH. scatterplots; 2. PCC did not independent sample t-test improve vaccine uptake among and chiolder adults. square test, PCC sign path improved older analyses, LOE: IV Strengths: Reveals importance of PCC to improve influenza vaccine uptake. Weaknesses: Lack of generalizability to other Asian subgroups. Only 2 types of PCC were measured. Only 2 age groups assessed. Conclusions: PCC provide clear information and careful Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION aged and older adults. Funding: None. Bias: None recognized. Country: US. impact of PCC on influenza vaccine uptake and GH of CN, VN, and KN Americans. 50 Exclusion: <18 y.o., nonCalifornia resident, nonC.N., K.N., V.N. GFI, CFI, RMSEA, and SRMR. adults’ GH status. listening to motivate young adults to get vaccinated. Feasibility: Helps HCP and researchers focus on creating PCC manual to improve vaccine uptake. Attrition: Not listed. Key: AA – Asian Americans, ACS – American Cancer Society, BRFSS – Behavioral Risk Factor Surveillance System, CBO – community-based organization, CDC- Centers for Disease Control and Prevention, CFI – comparative fit index, CG – control group, CHIS – California Health Interview Survey, CN – Chinese, CT – culturally tailored, DST-digital storytelling, DV – Dependent Variable, EG- English, f – female, FBM – Fogg Behavioral Model, FG – focus groups, f/u – follow-up, GFI – goodness of fit index, GH – general health, HBV – hepatitis B vaccine, HBM – Health Belief Model, HCP-healthcare provider, HI – health insurance, HPVV – Human Papillomavirus vaccine, IG – intervention group, IV – Independent Variable, IZV – Influenza, KN – Korean, m – male, MA – meta-analysis, Mdn – median, Mn – mean, mo, - month, MOA- method of analysis, MTM – mobile text messaging, MSCD – Multi-stage cluster design, N-number of studies (if SR) or participants in study; n – number of participants in SR or subset, NCI - National Cancer Institute, NIH-National Institute of Health, P: Phase, Pap – Papananicolau, PCC – patient-centered communication, PI-post-intervention, pop. – population, PPH – planned parenthood, PPT- pre- post-test, pt. – patient, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QATSDD – Quality Assessment Tool for Studies with Diverse Designs, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, REDCap- Research Electronic Data Capture, RMSEA – root mean square error of approximation, r/t – related to, SDF – Sociodemographic form, SEM – Social Ecological Model, sig. – significant, SPSS – Statistical Package for the Social Sciences, SR – systematic review, SRMR – standardized root mean residual, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, T – theme, y.o. – years old, TS – telephone survey, tx. – treatment, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION 34 Table A3 Synthesis Table Studies Chen et al. Year LOE Design N Theory Measurement Tools Data/ Intervention length Setting Country Age (Mn y.o.) f (%) Residence in U.S. (Mn years) 2019 III P1: DST video; P2: QE PPE P1: 2; P2: 10 CCNHP Frew et al. Hopfer et al. M. Kim et Kim et al. H. Y. Lee al. et al. Study Characteristics 2017 2020 2019 IV IIb IV FG Pilot RCT, FG PPT, 2-mo. f/u 20 104 20 NEM, TPB SSTF FBM 2014 IV CSS 2017 IV Exploratory 316 SEM, inferred QS on HBV attitude, screening, vaccine 24 (VN) NET SSI SSI QS on HBV attitude, knowledge, vaccine (Qualtrics) n/a 1 mo. 1 mo. 2 mo. Community US. Community US. Community US. P1: 55.5; P2: 28 100% P1: 14.5; P2: 17.9 41 22 (VN) 54% unknown 100% n/a SDF, PPT (HPV knowledge, attitude, belief, VI), NSQA P1: 2 days; P2: 1 day Community Community US. US. Participant Traits 21.7 21.8 100% n/a 100% n/a Y. M. Lee et al. Shon & Wells Srivastav et al. Vu et al. 2019 IV FG 2020 IV TS 2018 IV TS, MCSD 2020 IIa SR (QL & QN) 20 FBM 2,838 HSUM 26 PPPM SSI SSI QS on GH, PCC, IZV status 28,577 SEM, inferred QS on IZV uptake 7 days n/a 2 yrs. 2 yrs. n/a Community US. Community US. Telephone US. Telephone US. Community US. 26 46.75 n/a n/a n/a 100% 3.9 50% 21.95 56.9 n/a 50.3% (AA) n/a n/a n/a PRISMA Key: CCNHP – Culture-centric Narratives in Health Promotion, CN – Chinese, CSS – Cross-sectional survey, CT – culturally tailored, DST-digital storytelling, DV - Dependent variable, f – female, FBM – Fogg Behavioral Model, FG – focus groups, HBV – hepatitis B vaccine, HCP-healthcare provider, HPVV – Human Papillomavirus vaccine, HSUM – Health services utilization model, IV – Independent variable, IZV – Influenza, KA – Korean American, KN – Korean, Mn – mean, mo, - month, N-number of studies (if SR) or participants in study; NEM – Network Episode Model, NET – Narrative Engagement Theory, NSQA – Narrative story quality assessment, P: Phase, Pap – PCC – patient-centered communication, PPPM – practice, provider, patient model, PPTpre- post-test, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, SDF – Sociodemographic form, SEM – Social Ecological Model, SR – systematic review, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, y.o. – years old, TPB – Theory of Planned Behavior, TS – telephone survey, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Nativity outside U.S. (%) English fluency (%) Korean Vietnamese Chinese Practice Language services Provider HCP recommendation Patient Community support / approval CT text-message DST video Incentive Health Insurance Transportation Knowing one w/ illness Bilingual flyer Changes in attitude/ beliefs Improved knowledge Improved VI P1: 100%; P2: 100% P1: 50%; P2: 30% • 52 94.7% 0% (VN) 70% 77.9% 100% unknown 100% (VN) n/a 100% n/a • • • • • 80% n/a n/a n/a n/a 100% n/a • • • • • • • • • • IV / Interventions • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • DV / Themes Identified • • • • • • • • • • • • • Key: CCNHP – Culture-centric Narratives in Health Promotion, CN – Chinese, CSS – Cross-sectional survey, CT – culturally tailored, DST-digital storytelling, DV - Dependent variable, f – female, FBM – Fogg Behavioral Model, FG – focus groups, HBV – hepatitis B vaccine, HCP-healthcare provider, HPVV – Human Papillomavirus vaccine, HSUM – Health services utilization model, IV – Independent variable, IZV – Influenza, KA – Korean American, KN – Korean, Mn – mean, mo, - month, N-number of studies (if SR) or participants in study; NEM – Network Episode Model, NET – Narrative Engagement Theory, NSQA – Narrative story quality assessment, P: Phase, Pap – PCC – patient-centered communication, PPPM – practice, provider, patient model, PPTpre- post-test, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, SDF – Sociodemographic form, SEM – Social Ecological Model, SR – systematic review, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, y.o. – years old, TPB – Theory of Planned Behavior, TS – telephone survey, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION Improved vaccine initiation n/a 53 • • IV DST video Social support HCP recommendation Disease Culture HPV VN HBV VN HPV VN Multi-language Health literacy Community • • • • • • Cultural Tailoring HCP DST video, CT textrecommendation Bilingual messaging flyer HPV HPV HPV KN KN KN • • • • • • HPV education HCP recommendation HCP recommendation HPV KN Influenza CN, KN, VN CN, KN, VN • • • n/a HPV CN, KN, VN • • • Key: CCNHP – Culture-centric Narratives in Health Promotion, CN – Chinese, CSS – Cross-sectional survey, CT – culturally tailored, DST-digital storytelling, DV - Dependent variable, f – female, FBM – Fogg Behavioral Model, FG – focus groups, HBV – hepatitis B vaccine, HCP-healthcare provider, HPVV – Human Papillomavirus vaccine, HSUM – Health services utilization model, IV – Independent variable, IZV – Influenza, KA – Korean American, KN – Korean, Mn – mean, mo, - month, N-number of studies (if SR) or participants in study; NEM – Network Episode Model, NET – Narrative Engagement Theory, NSQA – Narrative story quality assessment, P: Phase, Pap – PCC – patient-centered communication, PPPM – practice, provider, patient model, PPTpre- post-test, PRISMA – Preferred Reporting Items for SR and Meta-Analyses, QE- Quasi-experimental, QL – qualitative, QN – quantitative, QS – questionnaire, RCT- randomized controlled trial, SDF – Sociodemographic form, SEM – Social Ecological Model, SR – systematic review, SSI – Semi-structured interviews, SSTF – Situation-specific theoretical framework, y.o. – years old, TPB – Theory of Planned Behavior, TS – telephone survey, VI – vaccine intent, VN-Vietnamese/ Vietnam COVID-19 CULTURAL EDUCATION 54 Appendix B Models and Frameworks Figure B1 Culture-Centric Narratives in Health Promotion Theory Larkey & Hetch (2010). COVID-19 CULTURAL EDUCATION Figure B2 Stetler’s Model of Evidence-Based Practice Stetler (2009). 55 COVID-19 CULTURAL EDUCATION 56 Appendix C Budget and Timeline Figure C1 Budget COVID-19 CULTURAL EDUCATION Figure C2 Timeline 57 COVID-19 CULTURAL EDUCATION 58 Appendix D Data Methods Figure D1 Email Project Invitation (English) COVID-19 CULTURAL EDUCATION Figure D2 Email Project Invitation (Korean) 59 COVID-19 CULTURAL EDUCATION Figure D3 Pre-survey: 3-Item Brief Screening Questions 60 COVID-19 CULTURAL EDUCATION Figure D4 Pre-survey: Sociodemographic Questions 61 COVID-19 CULTURAL EDUCATION Figure D5 Pre-post-survey: Rodriguez et al.’s (2021) 17-Item Vaccine Hesitancy Scale 62 COVID-19 CULTURAL EDUCATION 63 COVID-19 CULTURAL EDUCATION Figure D6 Pre-post-survey: Chen et al.’s (2021) 2-Item Vaccine Intent 64 COVID-19 CULTURAL EDUCATION Figure D7 Post-survey: W. S. Kim et al.’s (2017) 15-Item Narrative Quality Assessment Tool 65 COVID-19 CULTURAL EDUCATION Figure D8 1-Month-Post-Survey: Chen et al.’s (2021) 6-Item Vaccine Intent/Uptake 66 COVID-19 CULTURAL EDUCATION 67 COVID-19 CULTURAL EDUCATION Figure D9 Bar Graph: VHS Scores Pre-Post-DST Intervention 68