1. health and fitness
2. disease
3. cancer

COLORECTAL CANCER SCREENING BEHAVIORS AMONG KOREAN
AMERICANS
by
Moonju Lee Ko
________________________
Copyright © Moonju Lee Ko 2013
A Dissertation Submitted to the Faculty of the
COLLEGE OF NURSING
In Partial Fulfillment of the Requirements
For the Degree of
DOCTOR OF PHILOSOPHY
In the Graduate College
THE UNIVERSITY OF ARIZONA
2013
2
THE UNIVERSITY OF ARIZONA
GRADUATE COLLEGE
As members of the Dissertation Committee, we certify that we have read the dissertation
prepared by Moonju Lee Ko entitled “Colorectal Cancer Screening Behaviors among Korean
Americans” and recommend that it be accepted as fulfilling the dissertation requirement for the
Degree of Doctor of Philosophy.
___________________________________________________________________________
Date: November 14, 2013
Terry A. Badger, PhD, RN, PMHCNS-BC, FAAN
Professor
___________________________________________________________________________
Date: November 14, 2013
Marylyn M. McEwen, PhD, PHCNS-BC, FAAN
Associate Professor
__________________________________________________
Elaine G. Jones, PhD, RN
Associate Professor
Date: November 14, 2013
___________________________________________________________________________
Date: November 14, 2013
Miyong Kim, PhD, RN, FAAN
Professor
Final approval and acceptance of this dissertation is contingent upon the candidate’s submission
of the final copies of the dissertation to the Graduate College.
I hereby certify that I have read this dissertation prepared under my direction and recommend
that it be accepted as fulfilling the dissertation requirement.
____________________________________________________ Date: November 14, 2013
Dissertation Director: Terry A. Badger, PhD, RN, PMHCNS-BC, FAAN
Professor
3
STATEMENT BY AUTHOR
This dissertation has been submitted in partial fulfillment of requirements for an
advanced degree at The University of Arizona and is deposited in the University Library to be
made available to borrowers under rules of the Library.
Brief quotations from this dissertation are allowable without special permission, provided
that accurate acknowledgment of source is made. Requests for permission for extended quotation
from or reproduction of this manuscript in whole or in part may be granted by the copyright
holder
SIGNED: __Moonju Lee Ko__________________
4
ACKNOWLEDGEMENTS
I would like to acknowledge and extend my sincere appreciation to the many individuals
who have supported me throughout the doctoral program and the dissertation. First, heartfelt
thanks to my advisor and dissertation chair, Dr. Terry Badger, for her wonderful academic
guidance and mentorship, as well as her continued support, patience, and encouragement to
successfully complete my doctoral program and dissertation. Dr. Terry Badger has always been
with me whenever I had unexpected family issues during the program with love and great
support. Her support through the entire process has been a key factor in my success. Also, I
would like to thank my dissertation committee members, Dr. Marylyn McEwen who has always
provided invaluable input and brilliant insight for the immigrant health and health disparities,
and Dr. Elain Jones who shares her expertise in the instrument development and translation
which were an important part of my dissertation. A special thanks go to Dr. Miyong Kim,
Professor at the University of Texas Austin. Dr. Kim is a great mentor and a model for the
wonderful leadership in the community health research when I had worked with her in Maryland.
Dr. Kim provided the initial impetus to pursue my interest in health disparities of Korean
Americans. My sincere appreciation is also given to Dr. Eunice Lee, Associate Professor at the
University of California at Los Angeles, for sharing knowledge and expertise in cancer screening
studies of Korean Americans, and Dr. Myunghan Choi, Assistant Professor at the Arizona State
University, for generosity and giving her valuable time to teach statistics for analyzing data.
Furthermore, I would like to thank the Global Korean Nursing Foundation for the generous
financial assistance with this project.
My heartfelt gratitude is also extended to my family, who have made sacrifices to my
achievement. My dear mother, Jeong-Hee Hwang, has offered great support and encouraged me
throughout my life. She helped me during a critical time even she was sick. My lovely daughters,
Esther and Michelle, have sacrificed so much to support me. As incredible children, they
provided unconditional love and emotional support during this entire journey. I would like to
thank Pastors Sun-Ok Jung and Suk-ho Sohn for their endless prayer and support, especially
Pastor Jung for being the second mother for my children and being there for me through rough
times. My best friend, Sunmi Yoo from Korea has encouraged me to pursue and achieve my
goals and has always been by my side for 30 years of friendship.
I would like to thank all Korean Americans who participated in my dissertation study, and
also appreciate many Korean American pastors in Los Angeles for their generosity to invite me
for data collection with a great encouragement for my dissertation. My appreciation is also given
to many Korean community organizations; the Joong-Ang Cultural Center, the Modern Chronic
Disease Care Institute, and the Canaan Community Center, for their great help for data
collection.
5
DEDICATION
This dissertation is dedicated to the Korean American Communities in the United States.
6
TABLE OF CONTENTS
LIST OF FIGURES .........................................................................................................................9
LIST OF TABLES .........................................................................................................................10
ABSTRACT ...................................................................................................................................12
CHAPTER I: STATEMENT OF THE PROBLEM .................................................................14
Introduction ..................................................................................................................................14
Background ..................................................................................................................................17
Theoretical Framework ...............................................................................................................20
Key Constructs of the Health Belief Model ...................................................................21
Relationships among Constructs ....................................................................................28
Purpose of Study ..........................................................................................................................31
Research Questions ......................................................................................................................31
Significance of Study....................................................................................................................32
Summary .......................................................................................................................................32
CHAPTER II: REVIEW OF RESEARCH ...............................................................................34
Perceived Susceptibility ...............................................................................................................34
Cultural Beliefs.................................................................................................................34
Perception of Cancer Screening .....................................................................................37
Perceived Benefits ........................................................................................................................39
Knowledge ........................................................................................................................39
Perceived Barriers .......................................................................................................................43
Cancer Fatalism ...............................................................................................................43
Lack of Health Care Access ............................................................................................47
Low Health Literacy ........................................................................................................50
Cues to Action ..............................................................................................................................57
Physician’s Recommendation .........................................................................................57
Modifying Factors ........................................................................................................................61
Acculturation ....................................................................................................................61
Gender Differences ..........................................................................................................64
Length of U.S. Residence .................................................................................................66
Summary .......................................................................................................................................68
CHAPTER III: METHODOLOGY ...........................................................................................70
Research Design ...........................................................................................................................70
Sample ...........................................................................................................................................70
Power Analysis .................................................................................................................71
Settings ..........................................................................................................................................71
Protection of Human Subjects ....................................................................................................72
7
TABLE OF CONTENTS – Continued
Measurements ..............................................................................................................................73
Demographic Information...............................................................................................73
Cultural Beliefs.................................................................................................................74
Perception of Cancer Screening .....................................................................................74
CRC Screening Behaviors ...............................................................................................75
Cancer Fatalism ...............................................................................................................75
Knowledge ........................................................................................................................76
Healthcare Access ............................................................................................................76
Health Literacy.................................................................................................................77
Physician’s Recommendation .........................................................................................77
Health Belief Model Scale ...............................................................................................78
Acculturation ....................................................................................................................79
Instrument Translation ...............................................................................................................80
Data Collection Procedures .........................................................................................................82
Data Analysis ................................................................................................................................82
Summary .......................................................................................................................................84
CHAPTER IV: RESULTS ..........................................................................................................85
Characteristics of Sample............................................................................................................85
Description of Study Variables ...................................................................................................91
CRC Screening Behaviors ...............................................................................................91
Dependent Variables ........................................................................................................94
Cultural beliefs. ....................................................................................................94
Perception of cancer screening. ..........................................................................95
Knowledge of CRC. .............................................................................................96
Cancer fatalism. ...................................................................................................97
Health literacy. .....................................................................................................97
Health care access. ...............................................................................................97
Physician’s recommendation. .............................................................................99
HBM scale. ..........................................................................................................100
Acculturation. .....................................................................................................101
Correlations between CRC Behaviors and Independent Variables ......................................101
Findings Related to Research Questions..................................................................................103
Research Question One .................................................................................................103
Research Question Two .................................................................................................104
Research Question Three ..............................................................................................104
Research Question Four ................................................................................................106
Research Question Five .................................................................................................107
Korean Americans who have lived in the U.S. ≤ 10 years. .............................108
Korean Americans who have lived in the U.S. ≥ 10 years. .............................109
Summary .....................................................................................................................................110
8
TABLE OF CONTENTS – Continued
CHAPTER V: DISCUSSION ...................................................................................................112
Discussion of Sample Characteristics.......................................................................................112
Discussion of CRC Screening Behaviors..................................................................................116
Implications of the Findings for Research Questions .............................................................117
Research Question One .................................................................................................117
Research Question Two .................................................................................................119
Research Question Three ..............................................................................................121
Research Question Four ................................................................................................123
Research Question Five .................................................................................................123
Implications of the Study ..........................................................................................................125
Implications for Theory .................................................................................................125
Implications for Practice ...............................................................................................126
Implications for Further Research ...............................................................................127
Strengths of the Study ...............................................................................................................129
Instruments .....................................................................................................................129
Recruitment ....................................................................................................................130
Two-Group Analysis ......................................................................................................131
Limitations of the Study ............................................................................................................131
Data Collection Method .................................................................................................131
Instruments .....................................................................................................................132
Conclusion ..................................................................................................................................132
APPENDIX A:
HUMAN SUBJECTS REVIEW AND APPROVAL ....................................134
APPENDIX B:
REVISED HUMAN SUBJECTS APPROVAL ............................................136
APPENDIX C:
DISCLOSURE (ENGLISH) ..........................................................................138
APPENDIX D:
DISCLOSURE (KOREAN) ..........................................................................140
APPENDIX E:
REVISED DISCLOSURE (ENGLISH) ........................................................143
APPENDIX F:
REVISED DISCLOSURE (KOREAN) .........................................................145
APPENDIX G:
INSTRUMENT (ENGLISH) .........................................................................148
APPENDIX H:
INSTRUMENT (KOREAN) .........................................................................168
REFERENCES ............................................................................................................................186
9
LIST OF FIGURES
FIGURE 1.
Health Belief Model Constructs and Linkages ......................................................28
FIGURE 2.
HBM to Predict Cancer Screening Behaviors in Korean Americans ....................29
10
LIST OF TABLES
TABLE 1.
HBM Constructs and Concepts Influencing Cancer Screening in Korean
Americans .............................................................................................................. 21
TABLE 2.
Characteristics of Demographics of Sample ......................................................... 86
TABLE 3.
Demographic Differences by Gender .................................................................... 88
TABLE 4.
Demographic Differences by Length of U.S. Residence ...................................... 90
TABLE 5.
CRC Screening Behaviors among Korean Americans .......................................... 92
TABLE 6.
CRC Screening Behaviors by Length of U.S. Residence ...................................... 94
TABLE 7.
Relationship between Cultural Beliefs and Perceptions of Cancer Screening and
Length of U.S. Residence ...................................................................................... 96
TABLE 8.
Relationship between Healthcare Access and Length of U.S. Residence ............. 99
TABLE 9.
Relationship between Physician’s Recommendation and Length of U.S.
Residence............................................................................................................. 100
TABLE 10. HBM Scale for CRC and Screening among Korean Americans ......................... 101
TABLE 11. Correlations Matrix between CRC Screening Behaviors and Independent
Variables .............................................................................................................. 103
TABLE 12. Logistic Regression Analysis: Predictor of Ever Having Had a FOBT .............. 105
TABLE 13. Logistic Regression Analysis: Predictor of Ever Having Had a Colonoscopy ... 105
TABLE 14. Logistic Regression Analysis: Predictor of Ever Having Had a Sigmoidoscopy 106
TABLE 15. Differences of CRC Screening Behaviors and Variables by Gender .................. 106
TABLE 16. Differences of CRC Screening Behaviors by Length of U.S. Residence ............ 107
TABLE 17. Predictors and Barriers between the Two Groups Divided by Length of U.S.
Residence............................................................................................................. 108
TABLE 18. Logistic Regression: Predictor of Ever Having Had a FOBT of LOS ≤ 10 Years109
TABLE 19. Logistic Regression: Predictor of Ever Having Had a Colonoscopy of LOS ≤ 10
Years .................................................................................................................... 109
11
LIST OF TABLES – Continued
TABLE 20. Logistic Regression: Predictor of Ever Having Had a Sigmoidoscopy of LOS ≤ 10
Years .................................................................................................................... 109
TABLE 21. Logistic Regression: Predictor of Ever Having Had a FOBT of LOS ≥ 10 Years110
TABLE 22. Logistic Regression: Predictor of Ever Having Had a Colonoscopy of LOS ≥ 10
Years .................................................................................................................... 110
TABLE 23. Logistic Regression: Predictor of Ever Having Had a Sigmoidoscopy of LOS ≥ 10
Years .................................................................................................................... 110
12
ABSTRACT
Colorectal cancer (CRC) is the third most common cancer in the United States (U.S.) and
is the second leading cause of cancer deaths. Although the incidence of CRC has been decreasing
with CRC screenings, disparities of CRC and screening prevalence exist for racial and ethnic
groups. The CRC incidence rates have dramatically increased in Korean Americans, however,
there is little known about their CRC screening behaviors and the factors that may predict
screening behaviors have not been fully investigated. The purposes of this study were to describe
CRC screening behaviors and identify the predictors and barriers influencing CRC screening
behaviors among Korean Americans. A sample of 254 Korean Americans participated in this
study. Correlation, Multiple logistic regression, and Chi-square were used to analyze data. In this
study, Korean American had lower rates of CRC screenings compared to the general U.S.
population. Only 20% of the sample had ever had a fecal occult blood Test (FOBT), 49% had
ever had a colonoscopy, and 19% responded they had ever had a sigmoidoscopy in their lifetime.
Korean Americans had low rates of perception of cancer screening (annual physical exam and
periodic cancer screening), moderate CRC knowledge, low cancer fatalism, limited CRC literacy,
lack of health care access, and a low rate of receiving the physician’s recommendation of CRC
screenings. The greatest predictors influencing CRC screening were perception of cancer
screening for a FOBT, and the physician’s recommendation for a colonoscopy and a
sigmoidoscopy. There were no significant differences by gender in CRC screening behaviors.
However, significant differences were found between the two groups divided by length of U.S.
residence. Compared to those who have lived in the U.S. >10 years, new immigrants had lower
rates of all three CRC screening, lower perception of cancer screening, higher uninsured, less
receiving physician’s recommendation, and higher perceived barriers to CRC screening.
13
The findings of this study suggest that improved efforts are needed to increase CRC
screenings among Korean Americans. Further research is needed to increase a physician’s
recommendation for CRC screenings and awareness for the importance of annual checkups and
periodic cancer screening among Korean Americans.
14
CHAPTER I: STATEMENT OF THE PROBLEM
Introduction
Cancer is a major public health problem among all racial and ethnic groups in the United
States (U.S.). Colorectal cancer (CRC) is the third most common cancer in the U.S. among both
men and women and is the second leading cause of cancer deaths (ACS, 2010; Maxwell, Crespi,
Antonio & Lu, 2010). Over the last two decades, CRC incidence and mortality rates have
declined in the U.S. even though they have rapidly increased in economically transitioning
countries worldwide (Center, Jemal & Ward, 2009; Umar & Greenwald, 2009). This is likely due
to increased CRC screenings in the U.S. compared to those in transitioning countries.
CRC screening is able to reduce the incidence of CRC by the detection and removal of
precancerous colorectal polyps, as well as diagnosing cancers at an early stage when they are
most treatable to increase survival and reduce mortality rates (National Cancer Institute, 2010;
Sarfaty & Wender, 2007). Many CRC cells develop from adenomatous polyps which turn
cancerous over a 10-year period of time, and the removal of these precancerous polyps by CRC
screening prevents CRC development. Early detection of CRC is essential and the cure rate is
over 90%. In contrast, a diagnosis in the later stages with metastasis provides a 5-year survival
rate of about 10%. Although CRC mortality rates have declined and adherence to CRC screening
have been increasing in the U.S., only 39% of all CRC cases are diagnosed at the early stages
due to poor adherence to CRC screening guidelines (Ueland, Hornung & Greenwald, 2006).
Two different types of CRC screening tests have been recommended: the fecal occult
blood test (FOBT) and endoscopic examinations: sigmoidoscopy and colonoscopy (NCI, 2010;
Smith, Cokkinides, Brooks, Saslow & Brawley, 2010). CRC screening may be one of the most
effective ways to prevent CRC development and decrease the burden of this disease: human
15
suffering, disability, premature mortality, and economic costs (Center, Jemal & Ward, 2009;
NCI, 2010; Smith, Cokkinides, Brooks, Saslow & Brawley, 2010). According to the U.S.
Preventive Services Task Force, routine CRC screening of all men and women aged 50 and older
could reduce CRC mortality (Maxwell & Crespi, 2009) by 60 to 70% (Ransohoff, 2009).
Despite the effectiveness of CRC screening, disparities of CRC and screening prevalence
exist for racial and ethnic groups nationwide (James, Greiner, Ellerbeck, Feng & Ahluwalia,
2006; Klabunde, Brown, Barbash, White, Thompson, Plescia & King, 2012). Cancer disparities
are defined as differences in the incidence, prevalence, mortality, and related adverse health
outcomes existing among special populations in the U.S. (Powe, 2007). According to the
Institute of Medicine Report, ethnic minorities in the U.S. have poorer health outcomes
compared to non-Hispanic Whites from preventable and treatable conditions such as cancer in
national data. The racial and ethnic disparities occur not only in health, but also in health care.
One of the contributing factors to the racial and ethnic disparities in health is that minorities are
in conditions that influence social determinants of health (Betancourt & Maina, 2004). The social
determinants of health are defined as the conditions in which people are born, grow, and work.
The social determinants of health include social structures and economic systems including the
physical and social environments, health services, and structural and societal factors put in place
to deal with illness. These conditions are shaped by economic, social policies, and politics
throughout local communities, nations, and the world. The social determinants of health are
mostly responsible for health disparities (Center for Disease Control and Prevention, 2011;
World Health Organization, 2011).
Freeman and Chu (2005) addressed that disease and its consequences occur within the
context of human social settings in their social determinants of health disparities model, and
16
identified three major barriers: poverty, culture, and social justice as major causes of health
disparities in social determinants of health. Poverty, culture, and social justice-related barriers
exist in cancer screening. Barriers related to poverty include low socioeconomic status (SES),
lack of access to care, lack of primary care physicians and physician recommendation for cancer
screening, and lack of resources and knowledge of cancer and screening. Barriers related to
culture are beliefs and attitudes discouraging individuals from seeking care and fear of cancer
screening. Barriers related to social justice are racial prejudice and discrimination which results
in unequal treatment (Freeman & Chu, 2005; Gerend & Pai, 2008). The social determinants of
health disparities affect minorities who receive lower quality of cancer care and unequal health
treatment, and these contribute to poorer health outcomes and health disparities (Betancourt &
Maina, 2004).
Although research has shown that significant racial and ethnic disparities exist in the
general cancer screening (Flynn, Betancourt & Ormseth, 2011; Gerend & Pai, 2008; Klabunde et
al., 2012), only a few studies have examined trends in CRC screening by ethnic groups (Maxwell
& Crespi, 2009; Philips et al., 2007), Korean Americans in particular. Korean Americans are one
of the most recent ethnic groups to arrive in the U.S. and they are also one of the most rapidly
growing ethnic groups (Daniels, 2007). As Korean Americans are predominately first-generation
immigrants (92.5%) (Han, Kim, Kim & Kim, 2011), they are under-represented in cancer
screening efforts and less well studied than other ethnic minority groups (Jo, Maxwell, Rick, Cha
& Bastani, 2009).
At the national level, cancer rates for Asian Americans are reported either as an aggregate
group or not at all, except in the states of California and Hawaii. Therefore, it is difficult to
determine the exact incidence or prevalence rates for Korean Americans because cancer statistics
17
for Korean Americans are integrated into those of all Asian Americans and often combined with
statistics for Pacific Islanders (Kagawa-Singer, Dadia, Yu & Surbone, 2010). Thus, cancer
disparities may actually be larger than what is visible in Korean Americans. Although cancer is
the second leading cause of death among Korean Americans, there is little known about Korean
Americans’ cancer screening practices and the factors that may predict screening practices in this
group have not been fully investigated (Chen, 2005).
Background
According to the California Cancer Registry (CCR), CRC incidence rates in California
have significantly decreased by 29.9% for men and 24.9% for women from 1988 to 2007.
Despite the overall state trend of declining rates, CRC incidence rates dramatically increased in
Korean American men and women (CCR, 2010). The American Cancer Society (ACS) had
reported that CRC was the most commonly diagnosed cancer among Korean American men and
the second most commonly diagnosed cancer among Korean American women from 2003 to
2007 (ACS, 2010).
Although regular screening is the most effective means for reducing the burden of the
disease (NCI, 2010; Smith, Cokkinides, Brooks, Saslow & Brawley, 2010), studies have reported
extremely low cancer screening utilization among Korean Americans (ACS, 2010; CCR, 2010;
California Health Interview Survey, 2005; Lee, Kim & Han, 2009). In various community
samples, only 10 to 38% of Korean Americans have reported that they have ever had CRC
screening (Jo, Maxwell, Wong & Bastani, 2008; Juon, Han, Shin, Kim & Kim, 2003). In a study
conducted by Ma and associates, the never-screened rate of CRC was 74.5% and only 17% were
screened in compliance with the ACS recommendation among Korean Americans (Ma, Shive,
Wang, & Tan, 2009). According to the 2005 California Health Interview Survey (CHIS), 77% of
18
Korean Americans at the age of 40 and older have never received any CRC screening as
compared to other Asian Americans (55%), Caucasians (39%) and the general population (46%)
who are living in California (CHIS, 2005; Jo, Maxwell, Rick, Cha & Bastani, 2009).
The CHIS reported that Korean Americans were the only ethnic group showing a
statistically significant decline in CRC screening prevalence from 2001 to 2005, with the
screening levels of 49%, 43% and 33%. CRC screening levels showed a 16% drop between 2001
and 2005. Korean Americans had the lowest prevalence of CRC screening in all years covered
by the CHIS (CCR, 2010; Maxwell, Crespi, Antonio & Lu, 2010). This trend may be associated
with the fact that Korean Americans are recent immigrants, that many are small business owners
or employees with no health insurance and that Korean Americans have a lower median
household income than other Asian groups. However, even after controlling for access to care
and English proficiency, a significant decline in CRC screening among Korean Americans
between 2001 and 2005 persisted and remained unexplained (Maxwell, Crespi, Antonio & Lu,
2010; U.S. Census Bureau, 2007).
Despite rapidly increasing CRC incidence among Korean American men as represented
in current cancer statistics (ACS, 2010; CCR, 2010; Lee, Demissie, Lu & Rhoads, 2007), cancer
practices of Korean American men have rarely been studied. Most of the cancer screening
studies for Korean Americans are for breast and cervical cancer. There is a dearth of studies that
have included Korean American men; therefore, we know even less about Korean American men
than Korean American women. Gender differences have rarely been studied in cancer screening
behaviors among Korean Americans (Im, Lee & Park, 2002), and the relationship between
gender and cancer screening behaviors is still unclear. Therefore, it remains in question how
gender difference affects CRC screening behaviors among Korean American men and women.
19
According to the U.S. Census, the Korean American population dramatically grew from
354,000 in 1980 to 1,423,784 in 2010 (U.S. Bureau of Census, 2011). Approximately 90% of
Korean Americans are foreign-born (Han, Kim, Kim & Kim, 2011) and 44.3% of foreign-born
Korean Americans entered the U.S. since 1990 (U.S. Bureau of Census, 2007).
Most cancer screening studies for Korean Americans have reported that average year of
U.S. residence of study subjects was about 20 years (Lee, Kim & Han, 2009; Ma, Shive, Wang
& Tan, 2009; Maxwell, Crespi, Antonio & Lu, 2010). Although new immigrants have
dramatically increased, there is no study of comparing new Korean immigrants with those who
have lived longer in the U.S. Recent Korean immigrants may have different predictors and
barriers in CRC screening behaviors from those who have lived longer in the U.S. For example,
access to health care and the level of acculturation may differently affect to cancer screening
behaviors in the two groups divided by length of U.S. residence. Therefore, it will be meaningful
to investigate the differences between the two groups. If study results have significant
differences between the two groups, the findings may provide the rationale of different strategies
to increase CRC screening rates in these two groups.
In summary, CRC among Korean Americans has received little attention. However,
recently CRC has been a commonly diagnosed cancer among Korean Americans and their CRC
incidence and prevalence have dramatically increased. Although CRC is a significant health
problem among Korean Americans, studies and data have reported their extremely low cancer
screening prevalence compared to other ethnic groups and U.S. general population (Lee, TrippReimer, Miller, Sadler & Lee, 2007). Disparities of CRC screening in Korean Americans lead
them to a relatively high risk of CRC morbidity and mortality due to delayed diagnosis. As new
20
immigrants, Korean Americans have many barriers and limited resources in health care and it
leads them to CRC disparities.
Korean Americans are an underserved group, with respect to health services, research,
and policy. They are less studied as a group than other minority populations and under
represented in cancer screening efforts (Jo, Maxwell, Rick, Cha & Bastani, 2009). Therefore,
there is an urgent need to investigate the CRC screening behaviors and identify the barriers and
predictors influencing cancer screening behaviors among Korean Americans, especially Korean
American men because of lesser knowledge of their CRC screening behaviors than women with
rapidly increasing CRC incidence. This study will further investigate gender differences in
cancer screening behaviors and how the barriers and predictors act differently for men and
women.
Theoretical Framework
The Health Belief Model (HBM) was used for this study as a guiding framework for the
literature review, instrument development, and study implementation (Table 1). The HBM was
developed to explain why people commonly failed to participate in disease detection and
prevention programs (Strecher & Rosenstock, 1997), and why people accept preventive health
services and do or do not adhere to other kinds of health care regimens (Rimer, 2008). The HBM
has been one of the most commonly used theoretical frameworks in health promotion studies,
and it has explained what factors influence one’s health beliefs and behaviors (NCI, 2009). The
HBM has been one of the most widely applied theoretical models for the study of cancer
screening and health behavior change since early 1950s (Champion & Skinner, 2008; Green &
Kelly, 2004; Rimer, 2008).
21
The HBM contains several constructs that predict why people will take action to prevent,
to screen for, or to control illness conditions. The major constructs are perceived susceptibility,
perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy.
Modifying factors, such as age, gender, ethnicity, personality, or socioeconomic status, may
influence major constructs of the HBM (Champion & Skinner, 2008; NCI, 2009). The seven key
constructs of the HBM play pivotal roles in determining individuals’ attitudes and beliefs about
their health behaviors. The theoretical definitions of constructs in the HBM are described and the
relationship among the constructs is discussed as follows. From the literature review, ten
concepts are found in cancer screening behaviors among Korean Americans and these concepts
derived from key constructs of the HBM are found in Table 1.
TABLE 1. HBM Constructs and Concepts Influencing Cancer Screening in Korean Americans
Constructs of the HBM
Perceived Susceptibility
Perceived Benefit
Perceived Barrier
Cue to Action
Modifying Factors
Concepts
Cultural Belief
Perception of Cancer Screening
Knowledge
Cancer Fatalism
Limited Health Care Access
Low Health Literacy
Physician’s Recommendation
Acculturation
Gender
Length of U.S. Residence
Key Constructs of the Health Belief Model
Perceived susceptibility refers to an individual’s feeling of danger to contract the disease
or one’s belief about the chances of experiencing a risk and/or developing a condition or disease
(Champion & Skinner, 2008; NCI, 2009). Cultural beliefs for causes of cancer and perceptions
of cancer screening may influence perceived susceptibility in Korean Americans.
22
Korean Americans believe that family history, improper diet, and stress are the major
causes of cancer. They believe they have no risk of cancer if they have no family history of
cancer and have not experienced stressful events recently (Lee, Tripp-Reimer, Miller, Sadler &
Lee, 2007). Korean Americans have the perception that cancer screening is unnecessary because
they would have no risks if the person does not have any symptoms of the disease (Jo, Maxwell,
Rick, Cha & Bastani, 2009; Maxwell, Crespi, Antonio & Lu, 2010; Ma, Shive, Wang & Tan,
2009).
Cancer is believed as a life-threatening condition; however, an individual’s perception of
susceptibility may vary (Remennick, 2003). While considering perceived susceptibility, the
concept of unrealistic optimism is relevant. Unrealistic optimism is defined as the
underestimated likelihood of experiencing negative events or being at high risk for health
problems. People tend to underestimate their vulnerability and risk of health problems (Barnoy,
Bar-Tal & Treister, 2003). Unrealistic optimism occurs when people perceive their own health
risks more positively than other people’s risks in similar circumstances (Clarke, Lovegrove,
Williams & Machperson, 2000). Past experience and controllability of negative events may
influence the perceptions of unrealistic optimism.
The belief that cancer screening is unnecessary was higher for Korean Americans who had
unrealistic optimism for cancer than those who had no unrealistic optimism because they had no
past exposure to cancer screening. Receiving routine checkups without symptoms was an
important factor for participating in cancer screening in many studies with Korean Americans
(Lee, Fogg & Sadler, 2006; Lee, Fogg & Menon, 2008; Maxwell, Bastani & Warda, 2000). Their
cultural beliefs about the cause of cancer and perceptions of cancer screening influence
perceived susceptibility of CRC, and these will be measured in this study.
23
Perceived severity, a second key construct, refers to one’s belief regarding the seriousness
of a condition and its consequences. This includes both medical and possible social
consequences. Examples of medical consequences are death, disability, or pain; and an example
of social consequences is the changes of the conditions of work, family life, and social relations.
Both perceived susceptibility and severity could be viewed as the threat of a disease that is
supposed to motivate individuals to take preventive action (Champion & Skinner, 2008; NCI,
2009).
Perceived benefits refer to one’s beliefs that the advised actions reduce the risk or
seriousness of impact. Although individuals have perceived susceptibility and severity for a
certain belief and behavior, it is not guaranteed they will accept any advised health action unless
they have perceived benefits. Perceived benefits were the most powerful predictor of behavior
changes across all studies (Champion & Skinner, 2008; NCI, 2009).
Knowledge of cancer disease and screening can be considered as a perceived benefit in
this study. Studies have reported that knowledge of cancer disease, cancer screening tests and/or
guidelines was strongly associated with having regular cancer screening and it was considered
the predictor of cancer screening for Korean Americans (Juon, Kim, Shankar & Han, 2004; Lee,
Fogg & Menon, 2008; Lee, Kim & Han, 2009; Ma, Shive, Wang & Tan, 2009; Sohn & Harada
2005).
Perceived barriers refer to one’s beliefs about the perceptible and psychological costs of
the advised actions. These are the possible negative aspects of taking health actions, and may
lead one to undertake advised behaviors. For example, perceived barriers may be cost, negative
side effects, unpleasantness, inconvenience, or time consumption (Champion & Skinner, 2008;
NCI, 2009).
24
Several factors are considered as perceived barriers in behavioral changes or
recommended actions such as cancer screening: (1) systemic issues include lack of adequate
health insurance, lack of healthcare provider’s recommendation, lack of referral systems, and
access issues such as no transportation, no time off from work, or distant location of facilities; (2)
cognitive issues include ignorance of personal risk and recommendation, and knowledge deficits
by misconceptions about screening benefits or harms; (3) psychological issues are anxiety about
screening or concern about distrustful medical services; (4) linguistic issues include lack of
translator services and low oral and written health literacy; (5) monetary issues include not being
able to afford screening tests or to take time off for screening; and (6) spiritual and religious
issues include fatalism or God’s will (Costanza, 2008).
Cancer fatalism, lack of health care access and low health literacy had been identified as
perceived barriers to cancer screening among Korean Americans from the literature. Cancer
fatalism is defined as a belief that death is inevitable when cancer is present, and it is
demonstrated as fear and pessimism for cancer diagnosis and cancer disease (Powe & Finnie,
2003). Korean Americans believe that cancer cannot be cured and a cancer diagnosis is
considered a death sentence. They are afraid and do not want to know the diagnosis of cancer
because they will not be able to cope with the disease (Juon, Choi, Klassen & Roter, 2006; Lee,
2000).
Lack of health care access was the most often selected barrier for cancer screening in
Korean Americans. Many Korean Americans do not have health insurance and a usual source of
health care compared to the general U.S. population. This enhances the low cancer screening
rates of this group (Jo, Maxwell, Wong & Bastani, 2008; Kagawa-Singer, Dadia, Yu & Surbone,
2010; Lee, Kim & Han, 2009; Maxwell, Crespi, Antonio & Lu, 2010; Song, Han, Lee, Kim, Kim,
25
Ryu & Kim, 2010).
Low health literacy including language barriers have been identified as barriers for
Korean Americans in cancer screening. Lack of oral and/or written health literacy makes it
difficult for Korean Americans to understand educational materials containing medical
terminology without interpretation (Juon, Choi, Klassen & Roter, 2006), and to find the
necessary resources for screening (Jo, Maxwell, Wong & Bastani, 2008; Lee, Kim & Han, 2009).
As perceived barriers, cancer fatalism, lack of health care access, and low health literacy may
contribute to lower cancer screening rates, later stage diagnoses, and higher morbidity and
mortality rates for Korean Americans (Kagawa-Singer, Dadia, Yu & Surbone, 2010), and they
will be measured in this study.
Cues to action refer to the strategies or triggers used to promote one’s readiness to
participate in the recommended action. Cues to action can influence a variety of behaviors.
Examples of cues to action are information provided by healthcare providers, awareness
promoted by media campaigns, or appropriate reminder systems. Cues to action will have a
greater influence on behavior in situations where perceived threat and perceived benefits are high
and perceived barriers are low (Abraham & Sheeran, 2008; Champion & Skinner, 2008; NCI,
2009).
A physician’s recommendation for screening will be measured for cues to action in this
study. Although a physician’s recommendation is one of the most powerful influencting factors
on individuals’ decision to undergo cancer screening in many studies (Kagawa-Singer, Dadia,
Yu & Surbone, 2010; Maxwell, Crespi, Antonio & Lu, 2010), the role of a physician’s
recommendation for cancer screening in Korean American remains in question. Most Korean
Americans prefer to go to physicians of the same ethnicity because of language barriers;
26
however, Korean American patients receive fewer cancer screening recommendations from
Korean physicians (Jo, Maxwell, Rick, Cha & Bastani, 2009; Maxwell, Crespi, Antonio, & Lu
2010), than from non-Korean physicians (Lew et al., 2003).
Self-efficacy refers to one’s intention or confidence in one’s ability to take the
recommended actions. Individuals must have the confidence to overcome perceived barriers to
succeed in a behavior change (Champion & Skinner, 2008). Self-efficacy was not integrated into
the early formulations of the HBM, but in 1988, Rosenstock, Strecher, and Becker proposed that
self-efficacy be integrated into the HBM. The addition has improved the HBM’s applicability.
Self-efficacy plays an important role in initiation and maintenance of behavioral change
(Champion & Skinner, 2008; Ham, 2006; Wood, 2008)
Modifying factors such as demographics (socioeconomic status, gender, ethnicity, age,
education) and socio-psychological and structural factors may influence perceptions of
susceptibility, severity, benefits, and barriers. These factors indirectly influence health beliefs
and behaviors (Champion & Skinner, 2008; Lee, 2000).
Acculturation, gender, and length of U.S. residence are considered modifying factors to
CRC screening behaviors among Korean Americans in this study. These modifying factors may
influence CRC screening behaviors and perceived susceptibility, but the roles of acculturation,
gender, and length of U.S. residence on CRC screening behaviors in Korean Americans are still
unclear.
Acculturation is defined as a process in which an individual’s psychosocial adjustment
and adaptation from the culture of origin toward the dominant culture including beliefs,
behaviors, attitude, values, identities, and customs (Kim, 2009; Lim, Yi & Zebrack, 2008; Shim
& Schwartz, 2008). The impact of acculturation has shown inconsistent results in cancer
27
screening studies among Korean Americans. Some studies have reported that acculturation is
significantly associated with cancer screening (Jacobs, Karavolos, Rathouz, Ferris, & Powell
2005; Juon, Kim, Shanker & Han, 2004; Yip, Tu, Chun, Yasui & Taylor, 2006), whereas others
have reported that there is no significant relationship between acculturation and cancer screening
(Chen & Bakken, 2004; Lee, Kim & Han, 2009; Shin, Song, Kim & Probst, 2005; Sohn &
Harada, 2005; Song et al., 2004).
Although there are gender differences in cancer screening behaviors for other ethnic
groups in the literature (Bass et al., 2011; Molina-Barcelo, Salas-Trejo, Peiro-Perez & Malaga
Lopez, 2011), gender differences have not been studied in cancer screening practices among
Korean Americans (Im, Lee & Park, 2002). The relationship between gender and cancer
screening behaviors is still unclear among Korean Americans, yet gender differences may exist.
Confucianism-based Korean culture expects Korean women to sacrifice their own needs for the
other family members’ needs (Kagawa-Singer, Dadia, Yu & Surbone, 2010; Im, Lee, & Park
2002). On the other hand, media campaign for awareness of women’s cancer may be assumed to
lead the difference of their cancer screening behaviors between Korean American men and
women.
Length of U.S. residence is one of the important factors in immigrant studies. It
influences immigrants’ health behaviors and health-related problem. The national statistics and
studies have reported that length of U.S. residence is one of the important predictors for cancer
screening (Ferrer, Ramirez, Beckman, Danao & Ashing-Gina, 2012; Kandula, Wen, Jacobs &
Lauderdale, 2006; Klabunde et al., 2012; Pons-Vigues et al., 2012; Remennick, 2003). However,
a few studies investigated the relationship between length of U.S. residence and cancer screening
28
behaviors among Korean Americans (Juon, Han, Shin, Kim & Kim, 2003; Maxwell, Bastani &
Wards, 2000).
Relationships among Constructs
According to the HBM (Figure 1), individuals undertake preventive or curative actions
when they: (1) consider themselves as susceptible to a specific disease or condition; (2) believe a
specific disease or condition would have a potentially serious consequences in order to engage in
certain health protective behaviors; (3) believe that behavioral changes, treatments, or a course of
action would bring personal benefits and the anticipated benefits of taking action can eliminate
or reduce risk and outweigh the barriers to action; (4) must overcome barriers that could prevent
individuals from adopting the desired behavior; and (5) believe in their own ability to implement
and sustain the required behavioral change or actions (Champion & Skinner, 2008; Ham, 2006;
Remennick, 2003). Modifying factors may influence the individual’s perceptions and beliefs. An
individual’s perception and beliefs include the major constructs of the HBM. The combination of
beliefs leads to behaviors with cues to action.
Modifying Factors
Individual Beliefs
Perceived
Susceptibility
Age
Gender
Ethnicity
SES
Action
Perceived Threat
Perceived Severity
Perceived Benefits
Perceived Barriers
Self-Efficacy
FIGURE 1. Health Belief Model Constructs and Linkages
Individual
Behaviors
Cues to
Action
Source: Champion & Skinner (2008). The Health Belief Model. In Glanz, K., Rimer, B. K., & Viswanath, K. (4 th
Eds.), Health behavior and health education (pp. 49). San Francisco, CA: John Wiley & Sons, Inc.
29
Adherence to cancer screening has been significantly associated with greater perceived
susceptibility, lower barriers, higher benefits, and cues in the form of recommendations from
health care providers (Champion & Skinner, 2008; Wackerbarth, Peters & Haist, 2005). It can be
hypothesized when Korean Americans believe that CRC would have potentially serious results,
they would consider themselves as susceptible to CRC (Figure 2). When they recognize CRC
screening is available to them and realize taking CRC screenings has more benefits in reducing
susceptibility or severity of the CRC than barriers, they will engage in CRC screening to reduce
their risk of cancer. Health education, media campaigns and/or physician’s recommendation will
act as cues to action for CRC screening. It is hypothesized that greater susceptibility to CRC and
higher benefits from cancer screening than barriers, with cues to action, will promote Korean
Americans to engage in CRC screening.
Perceived Susceptibility
Cultural Belief
Perception of Cancer Screening
Modifying Factors
Acculturation
Gender
Length of U.S. residence
?
_
?
Perceived Benefits
Knowledge
Perceived Barriers
Cancer Fatalism
Low Health Literacy
Limited Health Care Access
+
CRC Screening
Behaviors among
Korean
Americans
_
-
?
Cues to Action
Physician’s Recommendation
FIGURE 2. HBM to Predict Cancer Screening Behaviors in Korean Americans
30
The HBM explains complex interaction between health beliefs and behaviors. Although
the relationships among constructs are applicable in many situations, the relationship between
beliefs and behaviors implied by the HBM may be less applicable to members of marginal social
groups, such as recent immigrants. In the study of Russian immigrants (Remennick, 2003), most
of the informants believed in their own susceptibility to cancer, but these beliefs and attitudes did
not necessarily translate into cancer screening behaviors. As recent immigrants, they faced many
difficulties while surviving and adjusting to a new society with cultural differences. Different
health systems, limited health care access, language and cultural barriers can influence cancer
screening practices even though immigrants are knowledgeable to disease and cancer screening,
and believe they are susceptible to cancer. The gap between health beliefs and behaviors may be
wider among recent immigrants than non-immigrants. High susceptibility to cancer does not
always guarantee action or cancer screening, for new immigrants who have many difficulties to
survive in a new society.
Champion and Skinner (2008) proposed that one of the limitations of the HBM in both
descriptive and interventional research has been variability in the measurement of the major
HBM constructs. Construct definitions need to be consistent with the HBM theory as originally
conceptualized, and measures need to be specific to the behavior.
The HBM has been extensively used to explain and predict cancer screening behaviors,
but it has been rarely used in CRC screening research, especially with Korean Americans. The
HBM has identified predictors and barriers, and explained their relationships for many health
behaviors in numerous studies with different situations and ethnic groups (Champion & Skinner,
2008; NCI, 2009; Rimer, 2008). The major purpose of this study is to identify the predictors and
barriers to CRC screening behaviors among Korean Americans. Therefore, the HBM will be the
31
theoretical framework to guide this study. However, although the HBM proposes that the
behaviors are based on one’s beliefs, it remains in question whether beliefs can put into action
(cancer screening) for new immigrant populations, such as Korean Americans, given the many
structural barriers are experienced by this population. In this study, the HBM will be tested to
determine its usefulness in explaining CRC screening behaviors among Korean Americans.
Purpose of Study
The purposes of this study are to: 1) describe CRC screening behaviors among Korean
Americans, 2) identify predictors and barriers influencing CRC screening behaviors, 3) identify
the difference in the barriers and predictors to CRC screening behaviors between Korean
American men and women, and 4) identify the difference in the barriers and predictors to CRC
screening behaviors between Korean Americans who have lived in the U.S. less than 10 years
and those who have lived in the U.S. more than 10 years.
Research Questions
This study will answer four research questions.
1. What are the predictors of CRC screening behaviors among Korean Americans?
2. What are the barriers to engaging in CRC screening behaviors among Korean
Americans?
3. Which predictor or barrier has the greatest influence on CRC screening behaviors?
4. What are the differences in the predictors and barriers to CRC screening behaviors
between Korean American men and women?
5. What are the differences in the predictors and barriers to CRC screening behaviors
between Korean Americans who have lived in the U.S. less than 10 years and those
who have lived in the U.S. more than 10 years?
32
Significance of Study
This study will contribute to health research and clinical practice. First, this study
responds to national and state recommendations for minority health and on increasing national
interest in health promotion and promotion that targets high-risk, vulnerable individuals. Second,
it pursues the goals of the Healthy People 2020, which forces new strategies to deliver primary
and secondary prevention: (a) increase quality and years of healthy life, and (b) increase the
proportion of adults who receive a colorectal cancer screening based on the most recent
guidelines (U.S. Department of Health and Human Services, 2011). Third, it will provide
important knowledge about Korean Americans’ CRC screening practices, especially for men,
which is understudied and under represented in cancer studies. Fourth, the potential impact is to
enhance health care professionals’ understanding of Korean Americans’ cancer health behaviors
and increase awareness of cancer health disparities in practice. Fifth, the outcomes of this study
will provide a rationale for developing culturally tailored strategies to increase the rates of CRC
screening and to reduce cancer health disparities among Korean Americans.
Korean Americans are predominately foreign-born in the U.S. (Lee, Kim & Han, 2009;
U.S. Bureau of the Census, 2007) and traditional cultural beliefs and structural barriers may
influence their CRC health belief and behaviors. Culturally tailored interventions with health
care system navigation assistance may be an effective strategy to increase rates of CRC
screening for resource-poor and linguistically isolated Korean American groups.
Summary
Despite the decreasing CRC incidence in the general U.S. population, CRC incidence and
prevalence have been increasing in Korean Americans. Korean Americans have experienced
CRC disparities with social determinants of health disparities as new immigrants. Chapter 1
33
stated the necessity of this research for the understudied CRC screening behaviors and disparities
of CRC disease among Korean Americans with epidemiologic data. The HBM was selected to
guide this study and the utilization of the HBM in cancer screening studies was addressed and
criticized. Chapter 2 will review and synthesize literature about cancer screening behaviors of
Korean Americans.
34
CHAPTER II: REVIEW OF RESEARCH
The HBM provided the conceptual framework for this study. In this chapter, the 10
concepts will be discussed in the HBM. The 10 concepts considered possible predictors and
barriers for influencing cancer screening behaviors among Korean Americans include: (1)
cultural beliefs; (2) perception of cancer screening as perceived susceptibility; (3) knowledge for
perceived benefit; (4) cancer fatalism; (5) limited health care access; (6) low health literacy for
perceived barriers; (7) a physician’s recommendation for cues to action; (8) acculturation; (9)
gender differences; and (10) length of U.S. residence for modifying factors. There is minimal
literature found in CRC screening among Korean Americans; therefore the literature review was
extended to general cancer screening behaviors in Korean Americans to provide a content of
their beliefs and behaviors of cancer screening.
Perceived Susceptibility
Cultural Beliefs
Culture is considered to be one of the most powerful factors influencing health beliefs
and health practices, and is a core element now emerging in health disparities research (Lee, Kim
& Han, 2009). Culture is the core and fundamental organizing system of life, and this system
comprises beliefs, values and lifestyles. Culture in cancer health is defined as cultural influences
on an individual’s perceptions of cancer risk and his or her approach to prevention, cancer
screening, treatments, physician-patient relationship, and end-of-life care choices (KagawaSinger, Dadia, Yu & Surbone, 2010). Cultural beliefs and norms profoundly affect one’s
perception for cancer and cancer prevention, participation in early detection and screening
programs, attitudes and compliance with treatment, coping strategies (Liora, 1999), and healthseeking behaviors and health outcomes (Russell, Champion & Perkins, 2003).
35
Different racial and ethnic groups have different cultural beliefs about susceptibility,
benefits, and barriers. These different beliefs about the causes of cancer can affect perceived
susceptibility (Guidry, Matthews-Juarez & Copeland, 2003). In this study, cultural beliefs are
limited to the cultural beliefs for cancer disease and causes of cancer among Korean Americans
and this section will discuss how cultural beliefs affect their perceived susceptibility for cancer
and cancer screening behaviors.
Studies have reported that cultural beliefs are strongly associated with cancer screening
among Korean Americans (Kagawa-Singer, Dadia, Yu & Surbone, 2010; Lee, Tripp-Reimer,
Miller, Sadler & Lee, 2007; Suh, 2007). Lee et al. (2007) examined Korean American women’s
beliefs about breast and cervical cancer, and addressed how their cultural beliefs affected their
cancer screening behaviors. Thirty-three Korean American women were conducted in-depth
interviews from the community. Korean American women addressed that major causes of cancer
are a family history of cancer, improper diet, stress, and fate.
In Lee’s (2007) study, fourteen of the women (42%) believed that a family history of
cancer is the major cause of cancers, and half of them clearly pronounced they were not
susceptible to cancer because of negative family history of cancer. Even though the majority of
participants did not acknowledge a specific diet as a factor for a specific cancer, they believed
sweetened food, high-protein and high-fat diets, and chemicals in food such as preservatives can
cause any type of cancer. Many of them believed that they would be safe and less susceptible to
cancer if they have healthy food because it has less fat.
Six participants (18%) believed that stress causes cancer, especially too much concern of
getting cancer could cause of cancer (Lee et al., 2007). Not worrying about cancer would keep
them from getting cancer. This belief led them not to screen for cancer because they believed
36
stress or anxiety caused by cancer screening could be harmful to their health. Many participants
believed that getting cancer is fate or destiny; therefore, they would get cancer no matter what
they screen or not. The majority of participants did not perceive themselves to be at risk for
cancer, and they believed they would not be susceptible to cancer if they did not have a family
history of cancer, ate a healthy diet, and did not worry about getting cancer (Lee, Tripp-Reimer,
Miller, Sadler & Lee, 2007). These cultural beliefs lead Korean American women to have a low
perceived susceptibility to cancer and relatively low cancer screening.
However, the role of cultural beliefs on CRC screening behaviors among Korean
Americans is still unclear, even though the influences of cultural beliefs are strongly assumed to
be associated with other types of cancer screening. Lee et al. (2009) investigated how cultural
factors predicted mammography behavior among Korean Americans. The investigators
examined cancer screening behaviors related to health beliefs, modesty, and use of Eastern
medicine in 100 Korean American women to identify the relationship between cultural beliefs
and breast cancer screening behaviors. The reason the investigators chose these cultural factors
was that cultural attitudes and the use of Eastern medicine may influence their decision to have a
mammogram. In conclusion, cultural factors were not predictive of the cancer screening
experiences among Korean American women (Lee, Kim & Han, 2009). This result is
inconsistent with other similar studies and it may be that a different measurement of cultural
factors was used in this study. Lee et al.’s (2009) findings remain in question as to whether
selected cultural factors are valid to measure cultural beliefs for cancer screening behaviors.
The concept of culture and its relation to cancer care remain poorly understood. The indepth understanding of the multifaceted relationships between culture and cancer care would
enable health care providers to provide quality cancer care equally to all their patients and help to
37
improve cancer control efforts (Kagawa-Singer, Dadia, Yu & Surbone, 2010). Korean
Americans are predominantly foreign-born first-generation immigrants; therefore, traditional
cultural influences may be considered as important correlates of cancer screening behaviors.
Understanding cultural beliefs and its influences on an individual’s perception of cancer risk and
approach to the screening program and treatments will be one of the key roles to reducing cancer
health disparities in this population.
Perception of Cancer Screening
The perception of cancer screening is the conscious recognition and appreciation for
cancer screening based on understanding, learning and knowing about cancer screening. In this
study, the perception of cancer screening refers to Korean Americans’ perceptions and attitudes
of cancer screening as a preventive health practice. Annual physical examination, rectal exam,
mammography, and Pap smear will be measured to examine the perception of cancer screening.
Cancer screening disparities among non-Hispanic whites, Latinos, and African
Americans are explained by socioeconomic status (SES) and access to health care. However,
lower cancer screening rates in Asian Americans have persisted even after controlling of SES
and access to health care. The perception of cancer risks and screening benefits for asymptomatic
conditions in Asian immigrants may differ from those of individuals who were born in the U.S.
(Kandula, Wen, Jacobs & Landerdale, 2006).
Studies have reported that Korean Americans are not oriented to prevention and this
attitude contributes to their low cancer screening utilization (Kagawa-Singer, Dadia, Yu &
Surbone, 2010; Kandula, Wen, Jacobs & Landerdale, 2006; Lee, Fogg & Menon, 2008; Lee,
Fogg & Sadler, 2006; Ma et al., 2009; Maxwell, Bastani & Ward, 2000). A general periodic
health examination provides an opportunity to discuss preventive examination and counseling
38
that could lead to prevention and early detection of CRC (Smith, Cokkinides, Brooks, Saslow &
Brawley, 2010). Regular checkups could reflect an individual’s preventive health orientation.
Receiving routine checkups was a strong factor for cancer screening in many studies with
Korean Americans (Lee, Fogg & Sadler, 2006; Lee, Fogg & Menon, 2008). Lee et al. (2008)
reported that women who have access to routine care and regular checkups without symptoms
are more likely to receive a routine cancer screening than women who do not have access to
routine care. Korean American women who had a Pap smear and CRC screenings by the
screening guidelines reported regular checkups two times higher compared with women who
never had a regular checkup (Maxwell, Bastani & Warda, 2000).
Korean Americans believe that the lack of pain or symptoms means they have no illness
(Lee, 2000). Korean Americans perceive that cancer screenings are a response to a specific
symptom of cancer rather than tests that are used prior to the development of symptoms (Juon,
Seung-Lee & Klassen, 2003; Kandula, Wen, Jacobs & Lauderdale, 2006). In the study by Kim et
al. (1999), 70% of 159 Korean Americans responded that the primary reason for not having had
cancer screening was not having symptoms or health problems. They believe that they were
healthy if they did not have any symptoms of a disease or did not experience discomfort;
therefore screening or testing was unnecessary (Jo, Maxwell, Rick, Cha & Bastani, 2009;
Kandula, Wen, Jacobs & Lauderdale, 2006).
In 2001, 2003 and 2005, 675 Korean Americans responded to the CHIS telephone survey
for CRC screening. Reasons for not receiving CRC screening were asked. Thirty-seven percent
of recipients who were not up to date with CRC screening reported that the most common
reasons for not receiving CRC screening was that they had no health problems or symptoms of
39
disease. Korean Americans are unfamiliar with the concept of routine screening to detect health
problems before the onset of symptoms of disease (Maxwell, Crespi, Antonio & Lu, 2010).
Despite the benefits of cancer screening tests, many Korean Americans are less familiar
with the concept of preventive health and they do not view preventive health as a priority.
Therefore, they have neither been screened nor are screened regularly. Korean Americans’
perception of preventive health, such as periodic cancer screenings, leads them to low
participation in CRC screening and it increases the risk for cancer diseases because of their
curative health practices rather than prevention.
Perceived Benefits
Knowledge
Studies have been reported that knowledge of cancer screening and screening guidelines
is strongly associated with having regular cancer screening, and educational approaches to
improve knowledge of cancer screening resulted in increasing the rates of cancer screening (Lee,
Kim & Han, 2009; Ma, Shive, Wang & Tan, 2009; Maxwell, Crespi, Antonio & Lu, 2010; Sarna
et al., 2001). However, Korean Americans have shown a lack of information and knowledge of
cancer screening tests and screening guidelines in many studies (Juon, Kim, Shankar, & Han
2004; Lee, Fogg & Menon, 2008; Lee, Kim & Han, 2009; Ma, Shive, Wang & Tan, 2009; Sohn
& Harada, 2005). In this study, knowledge of CRC screening behaviors will be measured by the
knowledge of CRC disease and CRC screening guidelines.
In the data analysis of the CHIS 2001 to 2005, the most common reason for not having
CRC screening was being unaware of the test. Forty-seven percent of Korean American
participants (N=675) had reported being unaware of endoscopy in CRC screening and 59% of
40
them had reported being unaware of FOBT (Maxwell, Crespi, Antonio & Lu, 2010). This
analysis showed that Korean Americans have a lack of awareness of CRC screening tests.
Sarna et al. (2001) measured knowledge of CRC screening among 149 Korean
Americans. Only 23 and 34% of participants responded that FOBT and sigmoidoscopy were
effective ways to screen for CRC. They demonstrated low rates of participation, 26% ever had a
FOBT and 15% ever had undergone a sigmoidoscopy. Despite an average of 15 years in
residence in the U.S. and a high level of education (89.2% above high school education), Korean
Americans had limited knowledge about cancer screening tests (Sarna, Tae, Kim, Brecht &
Maxwell, 2001).
Ma et al. (2009) identified inadequate knowledge about CRC screening and its benefits
among Korean Americans and their low perceived risk of CRC directly led to lower rates of
CRC screening. They conducted focus groups before an intervention and a two group quasiexperimental study with a baseline, post-intervention and a 12-month follow-up on screening.
Focus group participants showed a lack of knowledge about CRC and screening and they
believed that CRC is less critical than other cancers because one can survive even though part of
the colon is removed. They expressed unfamiliarity with cancer screening tests, guidelines, and
the health care systems for screening. The intervention group received culturally and
linguistically appropriate education programs including information on CRC risks, counseling
about psychosocial and access barriers, and patient navigation assistance. At baseline, 13.1% of
participants in the intervention group had ever obtained CRC screening; however, screening rates
increased from 13.1 to 77.4% at 12-month post-intervention. On the other hand, the rates of CRC
screening increased from 9.6 to 10.8% in the control group. There was a significant improvement
of perceived susceptibility and benefits for CRC in the intervention group (Ma, Shive, Wang &
41
Tan, 2009). This study found that Korean Americans have a lack of knowledge of CRC disease
and screening, and that an educational approach was effective to improve the participation in
CRC screening.
In Juon et al.’s (2004) study, about 79.7% of participant (N=459) had heard of
mammography and 65.4% had ever had a mammography in their lifetime; however, less than
half (45.3%) reported that they had a mammography within the past two years and only 32.6%
have obtained mammography regularly. Knowledge of mammography guidelines was the
statistically significant predictor of regular mammography. Many Korean American women
misunderstood the concept of cancer screening. They did not know that they should receive
cancer screening on a regular basis and assumed that screening was unnecessary if they have
received a cancer screening once in their lifetime. Women who had knowledge of cancer
screening guidelines had more than 10 times greater odds of having regular mammograms than
those did not have much knowledge (Juon, Kim, Shankar & Han, 2004). Juon (2006) conducted
an educational intervention study to improve the rates of mammography. At the 6-month followup, intervention groups reported 2.96 times greater post-test intention to have mammography
than did the control group (Juon, Choi, Klassen & Roter, 2006).
Juon et al.’s (2003) and Lee et al.’s (2008) cervical cancer screening studies had
consistent results. Women who had knowledge about cervical cancer and a Pap smear, were 3 to
5 times more likely to have had a Pap smear than those who did not have this knowledge (Juon,
Seung-Lee & Klassen, 2003; Lee, Fogg & Menon, 2008). In Kim et al.’s (1999) study, 32% of
study participants (N=159) knew screening guidelines and only 4% of them correctly identified
warning signs and symptoms of cervical cancer (Kim, Yu, Chen, Kim, Kaufman & Purkiss,
1999). Sohn and Harada (2005) also reported Korean Americans’ lack of knowledge on cancer
42
screening practice. Approximately 48.4% of 656 Korean American women responded having no
awareness of breast self-examination, 41.7% had never performed it, and 37.1% never had a Pap
smear because of the lack of knowledge. Korean American women had no awareness and
incorrect knowledge of cancer screening (Sohn & Harada, 2005).
Lee et al.’s (2007) study of breast and cervical cancer screenings identified Korean
American women’s lack of knowledge of causes of cancer. Korean American women believed
that cervical cancer could be prevented by hygiene, healthy diets, religion, or a positive mind sets
and believed they were not at risk if they did not have a family history of cancer (Lee, TrippReimer, Miller, Sadler & Lee, 2007).
Many studies have examined knowledge of breast and cervical cancer screenings of
Korean Americans. These studies showed Korean American women’s lack of knowledge about
breast and cervical cancer, screening tests and guidelines. Limited knowledge about disease and
screening resulted in low utilization of screening. Even though the benefits and importance of
breast and cervical cancer screenings have been more stressed than CRC screening to Korean
Americans at the community level, the knowledge of breast and cervical cancer screenings
remain poor in Korean Americans.
Although studies have reported that knowledge of cancer and screening guidelines play
an important role in participation of cancer screening, Weinberg et al. (2009) found knowledge
was not an adequate stimulus to CRC screening adherence. The 318 women who are age 50
years and older at average risk for CRC and noncompliant with standard CRC screening
recommendations, were recruited from the database of routine gynecological visit patients.
Researchers examined knowledge of CRC and CRC screening guidelines, risk perception, and
screening intention to identify the role of knowledge of CRC and screening guidelines.
43
Participants were predominantly Caucasians (96.2%) with over 65% reporting some college
attendance and over 70% of them reported having preventive care services such as physical and
clinical breast examinations with mammogram in the past year. Despite greater knowledge of
CRC and screening guidelines, most participants underestimated their personal risk as lower than
average, and almost two-thirds (65.7%) had no intention to participate in CRC screening
(Weinberg et al., 2009). The findings of this study were different from other cancer screening
studies for the role of knowledge on cancer screening behaviors.
There is a very limited literature of knowledge about CRC and screening guidelines for
Korean Americans. This study will examine knowledge of CRC disease and screening guidelines
by the Colorectal Cancer Knowledge Questionnaire and identify the role of knowledge on CRC
screening behaviors among Korean Americans.
Perceived Barriers
Cancer Fatalism
The concept of cancer fatalism has been considered a psychological barrier that may have
an impact on cancer screening and treatment; however, the impact of fatalism on cancer care has
received limited research in Korean Americans. Cancer fatalism has never been investigated in
CRC screening among Korean Americans. Most of the studies for cancer fatalism had been
conducted in African Americans and Hispanics (Austin, Ahmad, McNally & Stewart, 2002;
Monteros & Gallo, 2011; Morgan, Fogel, Tyler & Jones, 2010; Powe, 1995a, b; Powe & Finnie,
2003).
Fatalism is the consequence of a complex psychological perception of hopelessness,
worthlessness, meaninglessness, and powerlessness (Powe, 1995a), and it is defined as negative
or pessimistic attitudes for preventive health practices and disease outcomes (Moneros & Gallo,
44
2011). Cancer fatalism is a situational demonstration of fatalism in which individuals feel
hopeless or powerless when they face a diagnosis of cancer. Cancer fatalism is defined as the
belief that death is inevitable when cancer is present, and it is demonstrated as fear and
pessimism for a cancer diagnosis. It is also considered a belief that health issues are beyond
human control on the basis of certain views about luck, fate, and destiny.
Many factors may have an impact on the development of cancer fatalism. These include
age, poverty, level of education, lack of knowledge of the disease process, fear of treatments, and
distrust of health care providers. Studies addressed that cancer fatalism develops over time and is
frequently reported among medically underserved individuals, those with lack of knowledge of
cancer and elderly (Powe, 1995a; Powe & Finnie, 2003). Cancer fatalism has been known to
influence an individual’s decision to seek health care and cancer screening practices (Austin,
Ahmad, McNally & Stewart, 2002; Monteros & Gallo, 2011; Morgan, Fogel, Tyler & Jones
2010; Powe & Finnie, 2003).
Powe (1995a, b, 1997, 2001) conducted a series of studies about cancer fatalism and
CRC screening with the Powe Fatalism Model. Powe (1995a) examined the demographic
predictors of cancer fatalism and the relationship between cancer fatalism and participation in
FOBT among African Americans (N=192). Lower levels of education and lower income were
associated with higher levels of cancer fatalism and it resulted in the low participation rate of
FOBT. Although demographic factors were controlled, cancer fatalism was a significant
predictor of participation of FOBT.
In a similar study in 2001 (Powe, 2001), individuals with higher cancer fatalism scores
were older, had less knowledge of CRC, and had lower levels of formal education than those
who had lower cancer fatalism scores. Powe (1997) examined the relationship between cancer
45
fatalism and spirituality among African Americans and Caucasians. There were no significant
differences in spirituality scores between African Americans and Caucasians, but cancer fatalism
scores were significantly higher among African Americans. Therefore, the level of spirituality
was not significantly related to the level of cancer fatalism. The Powe’s series of studies had
explored the concept of cancer fatalism and examined the relationship between cancer fatalism
related to demographic predictors or spirituality and CRC screening practices, and provided indepth knowledge of cancer fatalism on CRC screening.
Morgan and colleagues (2010) conducted an intervention study related to cancer fatalism
and CRC screening, colonoscopy. A total 539 African Americans participated. After the
educational intervention, their cancer fatalism was significantly decreased, CRC knowledge
significantly increased in the post-test, and the intervention group had a significantly greater
percentage of those (25%) received a colonoscopy within three months after the education
session than did the control group (4.4%). The researchers addressed that decreased cancer
fatalism through culturally tailored educational sessions led to increased participation of CRC
screening among African Americans.
Cancer fatalism has been posited as powerful predictors of lower cancer screening among
Hispanics. Studies have identified that fatalism among Hispanics was associated with limited
access to health care, poverty, lack of knowledge, limited English ability, lower levels of
education, and lower level of acculturation (Austin, Ahmad, McNally & Stewart, 2002; Gorin,
2005; Monteros & Gallo, 2011). After accounting for structural barriers, such as age,
socioeconomic status (SES), and access to health care, cancer fatalism still acted as a barrier to
cancer screening among Hispanics (Monteros & Gallo, 2011). Gorin’s (2005) intervention study
to assess the compliance of CRC screening also had a similar result. Participants who received a
46
free FOBT kit with instructions had a rate of FOBT compliance of 77.3% after 90 days.
Participants who had expressed more cancer fatalism were less likely to return a FOBT kit, and
cancer fatalism remains a statistically significant influence on FOBT.
Austin et al. (2002) addressed cancer fatalism among Hispanics in their literature review.
Most Hispanic women believed that cancer cannot be cured and a diagnosis of cancer was
considered a death sentence; therefore, they preferred not to know the diagnosis of cancer
because they were afraid that they would not be able to cope with the disease. Low-acculturated
Hispanic women expressed stronger cancer fatalism than high acculturated ones.
Fear and fatalism are major psychosocial barriers to cancer screening practices among
Korean Americans. Korean Americans believe that cancer cannot be cured, and a diagnosis is
considered a death sentence. Korean Americans prefer not to know the diagnosis of cancer and
they are afraid that they will not be able to cope with the disease (Lee, 2000). It is similar with
Hispanics (Austin et al., 2002). In Lee et al.’s (2000) study, 98 Korean American women
participated in focus groups to be examined in their knowledge and barriers of cervical cancer
screening. Cancer fatalism was found as one of the major psychosocial barriers. They believed
that getting cancer is in God’s control and fate; therefore, human beings cannot do anything to
prevent cancer. They had a negative attitude to the value of cancer screening because whatever
will be will be. Korean American women showed that the knowledge deficits of cancer disease
and cancer screening accelerated cancer fatalism. It is consistent with the Powe and Morgan’s
studies.
In summary, cancer fatalism is commonly understood as a psychological distress and
barrier in the cancer continuum (Kagawa-Singer, Dania, Yu & Surbone, 2010), that influences
decision making for cancer screening and treatments. It leads to a diagnosis of cancer at later
47
stages and decreases survival. Therefore, it is essential for clinicians and researchers to
understand cancer fatalism and its influence on screening behaviors to provide comprehensive
quality cancer care. However, there is limited literature for Korean Americans. This research will
examine cancer fatalism by the Powe Fatalism Inventory, and identify whether cancer fatalism
affects CRC screening behaviors among Korean Americans. In this study, analysis of the
relationships between cancer fatalism and other variables, such as knowledge or health care
access, will help to understand the role of cancer fatalism on cancer screening practices in this
population.
Lack of Health Care Access
Individuals with no health insurance coverage have significant barriers in accessing
screening, and are less likely to have cancer screening compared to their insured counterparts
(ACS, 2010). In this study, access to healthcare refers to having health insurance and a usual
source of care, and health care utilization.
Many Korean Americans do not have health insurance and a usual source of health care
compared to the general U.S. population, because of lack of employment-based health insurance,
unfamiliarity or limited understanding of the U.S. health care systems, and language and cultural
barriers (Maxwell, Crespi, Antonio & Lu, 2010; Shin, Song, Kim & Probst, 2005; Song, Han,
Lee, Kim, Kim, Ryu & Kim, 2010). Koreans have mandatory national health insurance in Korea
before moving to the U.S., however, they lose their health insurance when Koreans migrate to
the U.S. (Colombo & Hurst, 2002). Most Korean Americans are self-employed or employed in
small businesses that do not offer health insurance which explains the higher proportions of
uninsured Koreans. Public health insurance programs, such as Medicare or Medicaid, are not
48
eligible to new immigrants because of residency requirements (Jang, Kim & Chiriboga, 2005;
Sohn & Harada, 2004; Song et al., 2009).
Studies have reported that Korean Americans were the least likely to have health
insurance and a usual source of care, and their insured rates were much lower than other ethnic
groups in the U.S. (Barnes, Adams & Powell-Griner, 2010; Jo, Maxwell, Wong & Bastani, 2008;
Kandula, Wen, Jacobs & Lauderdale, 2006). In the 2004 and 2006 National Health Interview
Survey (NHIS), 36% of Korean Americans under-65 years of age were most likely to be
uninsured and 25% of them were most likely to be without a usual place for health care (Barnes,
Adams & Powell-Griner, 2010). However, according to data collected from the Los Angeles
County, in which majority of Korean Americans lives, nearly a half of the respondents (46%)
were uninsured and 48.7% of non-elderly were uninsured. The difference from the NHIS might
be explained that individuals who have limited English proficiency may have been dropped from
the national survey. In another study, 59.1% of the 445 Korean Americans age 40 to 65 had no
health insurance. The primary reasons to not have health insurance were high costs of premium
and employers not providing insurance (Song et al., 2010). Ambulatory care utilization by
Korean Americans is lower than that of the general U.S. population due to the lack of health
insurance. Korean Americans seek ambulatory care only when they have significant discomfort.
This leads to underuse of preventive services, such as cancer screening (Shin, Song, Kim &
Probst, 2005). High proportions of Korean Americans are uninsured. Lack of or limited health
care access results in reducing health care utilization and it prevents from cancer screenings in
Korean Americans.
Lack of health care access and a usual source of care make it less likely for an individual
to receive preventive care and a physician’s recommendation for cancer screening, and it was the
49
most frequently selected barrier for cancer screening in Korean Americans (Jang, Kim &
Chiriboga, 2005; Jo, Maxwell, Crespi, Antonio & Lu, 2010; Maxwell, Wong & Bastani, 2008;
Juon, Kim, Shankar & Han, 2004; Kagawa-Singer, Dadia, Yu & Surbone, 2010; Kandula, Wen,
Jacobs & Lauderdale, 2006; Lee, Fogg & Menon, 2008; Shin, Song, Kim & Probst, 2005; Smith,
Cokkinides, Brooks, Saslow & Brawley, 2010). According to the 2001, 2003 and 2005 CHIS,
Korean Americans were the least likely to have health insurance in California and they had the
lowest CRC screening prevalence and were the only group in the analysis that had a significant
decline in CRC screening (Maxwell & Crespi, 2009). Only 41.3% of Korean Americans reported
they have ever had a FOBT or a sigmoidoscopy (vs. 61.1% of non-Hispanic whites) (Kandula,
Wen, Jacobs & Lauderdale, 2006). In Jo’s study (2008), about 60% of 151 Korean Americans
aged 40 to 70 recruited from a community-based organization were uninsured and only 17% had
received a FOBT within the past year or sigmoidoscopy or colonoscopy within the past five
years. About 41% of respondents selected lack of health care access for the strongest barrier to
have CRC screening. Low adherence of CRC screening among Korean Americans was strongly
associated with their lack of health care access and a usual source of care.
The most frequently mentioned structural barrier for cancer screening was lack of
insurance in Lee et al.’s (2000) study. A number of focus group participants in Lee’s study stated
that they were going back to Korea for screening tests and treatments of cancer or other medical
conditions because they did not have health insurance and could not afford the high medical
costs in the U.S.
Although lack of access to the health care and a usual source of care is the most
commonly cited barrier for cancer screenings for Korean Americans, some have also addressed
that costs and health insurance may not be primary reasons for not having had cancer screenings
50
among Korean Americans (Juon, Choi, Klassen & Roter, 2006; Lee, Fogg & Sadler, 2006;
Maxwell & Crespi, 2009). In this study, health care access will be measured whether Korean
Americans have health insurance and a usual source of care, and examined their health care
service utilization to determine the role of health care access to CRC screening.
Low Health Literacy
Health literacy is defined as the degree of an individual’s capacity to obtain, interpret,
and understand health information and services, and competence to use such information and
services to make appropriate health decisions and promote health (Han, Kim, Kim & Kim, 2011;
National Network for Libraries of Medicine, 2011; Peterson, Dwyer, Mulvaney, Dietrich &
Rothman, 2007; Todd & Hoffman-Goetz, 2011).
As the consequences of limited health literacy, unexpected health outcomes may occur,
such as inadequate utilization of preventive services, increased hospital visits and longer stays in
the hospital, poor adherence of medical regimens, misunderstanding of medical instructions,
missing follow-up appointments, and medication errors (Han, Kim, Kim & Kim, 2011; NNLM,
2011; Pedlimari, Holubar, Hanssinger & Cima, 2011; Todd & Hoffman-Goetz, 2011). Low
health literate adults have less knowledge about their own health conditions and experience
difficulty obtaining health knowledge, maintaining chronic diseases, and accessing to health
services (Han, Kim, Kim & Kim, 2011; Lee, Kang, Lee & Hyun, 2009; Pedlimari, Holubar,
Hanssinger & Cima, 2011). Adults with low health literacy had negative attitudes toward
information-seeking because of lack of interests in reading materials (Shaw, Ibrahim, Reid,
Ussher & Rowlands, 2009). They were less likely to seek out and engage with the necessary
health information and showed poorer comprehension and misunderstood prescriptions and
instructions compared to those with adequate health literacy (Wolf et al., 2007).
51
Limited or low health literacy has been considered as a barrier to cancer screening and an
important risk factor for cancer health disparities (Jo, Maxwell, Wong & Bastani, 2008; Lee,
Kim & Han, 2009; Pedlimari, Holubar, Hanssinger & Cima, 2011; Peterson et al., 2007; Todd &
Hoffman-Goetz, 2011). Adults with low health literacy are less likely to adhere to cancer
screening than those with adequate health literacy because they have poor knowledge about
cancer control concepts, more misunderstandings about cancer susceptibility and benefits of
early cancer detection, lack numeracy skills to understand risk reduction, and lack
communication with health care providers for cancer health information (Price-Haywood, Roth,
Shelby & Cooper, 2010; Miller, Brownlee, McCoy & Pignone, 2007).
Participants with limited health literacy in a CRC focus group showed a lack of
knowledge of cancer awareness and the concept of cancer screening even though they were
educated about CRC and screening (Davis et al., 2001). Participants with limited health literacy
expressed negative attitudes toward CRC screening using fecal occult blood testing. Even though
physicians recommended fecal occult blood test, they were four times more likely to refuse this
test than those with adequate health literacy (Dolan et al., 2004).
Health literacy may directly influence an individual’s willingness and/or ability to engage
with necessary information about cancer screening. Von Wagner et al. (2009) studied the role of
health literacy on self-efficacy of CRC screening. Researchers measured numbers of information
links accessed for information-seeking, average reading time for information link,
comprehension of CRC screening knowledge, and self-efficacy with health literacy. Lower
health literacy was associated with less information-seeking, greater effort in reading and
comprehension, and less self-efficacy for CRC screening. However, there was no association
between health literacy and CRC screening knowledge. As researchers addressed, this study had
52
a limitation that they did not measure prior CRC screening knowledge before accessing
information links (Von Wagner, Semmler, Good & Wardle, 2009). Health literacy influenced
self-efficacy of CRC screening in information seeking and utilization, and low health literacy
was significantly associated with low utilization of CRC screening.
Elderly, minority populations, immigrants, and people with chronic mental and/or
physical health conditions are vulnerable to health literacy (Kagawas-Singer, Dadia, Yu &
Surbone, 2010; NNLM, 2011). For immigrants who speak English-as-a-second language, health
literacy may be a greater barrier to cancer screening than those who speak English-as-a-first
language. Todd and Hoffman-Goetz (2011) examined the level of health literacy among older
Chinese immigrant women and identified predictors of low health literacy on CRC screening.
Functional health literacy and comprehension of the colon cancer information in English or
Chinese were measured among randomly assigned 106 Chinese immigrant women.
Comprehension of the colon cancer information was significantly lower among women
who received the information in English (15.8%) compared to those who received the
information in Chinese (76.1%). Acculturation, age, level of proficiency reading English and
education were significant predictors of health literacy among this group. Less acculturated and
less educated older women who have low levels of English proficiency had lower health literacy
and greater difficulty understanding the information presented (Todd & Hoffman-Goetz, 2011).
This study emphasized the importance of primary language on health literacy. This factor should
be considered when health literacy is measured among immigrants who speak English-as-asecond language.
Little is known about the impact of health literacy on cancer screening behaviors among
Korean Americans. Health literacy has rarely been studied and never been measured for cancer
53
screening among Korean Americans. Most studies measured the level of English proficiency
rather than health literacy and focused on the impact of language barriers to cancer screening
practices (Jo, Maxwell, Wong & Bastani, 2008; Juon, Choi, Klassen & Roter, 2006; Kandula,
Wen, Jacobs & Lauderdale, 2006; Lee, Kim & Han, 2009).
Although Korean Americans had highly educated and skilled backgrounds in Korea, most
Korean immigrants could not speak English well (Im & Yang, 2006; Nash, 2010). According to
the American Community Survey, about 80% of the 1.2 million Korean Americans in the U.S.
are foreign-born (U.S. Bureau of the Census, 2007). About 70% of Korean Americans do not
speak English well (Han, Kim, Kim & Kim, 2011) and 78% do not speak English at home (U.S.
Census Bureau, 2002).
In Lee’s (2009) mammography study, 91% of Korean participants reported poor or
limited language skills even though they have lived in the U.S. for more than 17 years. The other
study had a similar result. The average length of U.S. residency was 18.9 years and more than a
half (55%) of participants had lived longer than 20 years; however, 51% of them spoke little to
no English and 86% spoke Korean at home (Lee, 2006). These findings were consistent with
Sohn and Harada’s (2005) findings; 91.3% of study participants spoke Korean and 87% did not
speak English at home, and over 30% reported either poor capacity in written English or never
writing in English. These studies have consistently reported that English proficiency was not
associated with the length of U.S. residency and limited English proficiency as one of the
important barriers in cancer screening behaviors among Korean Americans.
Spoken English proficiency was positively correlated with cancer screening and limited
English proficiency was one of the major barriers in cancer screening for Korean Americans (Jo,
Maxwell, Wong & Bastani, 2008; Juon, Choi, Klassen & Roter, 2006; Lee, Kim & Han, 2009).
54
Even after controlling for SES and access to health care, English proficiency played an important
role in explaining cancer screening disparities among Korean Americans because it influenced
health beliefs, knowledge, and communication with health care providers regarding cancer
screening (Kandula, Wen, Jacobs & Lauderdale, 2006). Participants reported that their English
skills were not enough to get mammograms and they had difficulty getting information about
tests because of language barriers (Lee, Fogg & Sadler, 2006; Lee, Kim & Han, 2009; Sohn &
Harada, 2005).
Lack of proficiency in English makes it difficult for Korean Americans to understand
educational materials containing medical terminology without interpretation. Not knowing where
to go for testing and difficulties finding the necessary resources for screening were considered
major barriers for Korean Americans when taking CRC screening (Jo, Maxwell, Wong &
Bastani, 2008; Lee, Kim & Han, 2009). Korean Americans who are unable to speak or read
English have many difficulties in accessing health care services, communicating with medical
staff, and obtaining information on free or low-cost cancer screening programs (Han, Lee, Kim
& Kim, 2009; Juon, Kim, Shankar & Han, 2004). Limited English skills enhanced low health
literacy, and low health literacy leaded Korean Americans to have low rates of cancer screening.
Health literacy is not solely reading ability, it is the ability to interpret and apply health
information to maintain and promote health. Generally, many factors may influence health
literacy such as age, gender, and education (Peterson, Dwyer, Mulvaney, Dietrich & Rothman,
2007; von Wagner, Semmler, Good & Wardle, 2009). However, proficiency of English plays an
important role in health literacy among immigrants like Korean Americans. Korean Americans
may be less familiar with U.S. health care systems and do not receive adequate health
information about cancer screening and treatment options because of limited English proficiency.
55
When health care providers provide health information to Korean Americans, low health literacy
may not be considered because health care providers lack of knowledge about Korean
Americans’ low health literacy with limited English skills. Although studies have identified that
limited English proficiency related to health literacy was one of the important barriers to cancer
screening for Korean Americans, there are only a few studies have addressed health literacy.
There is no study that systemically measure health literacy related to CRC screening behaviors
among Korean Americans.
Several instruments have been developed to assess general health literacy based on
reading and numeracy skills. The Rapid Estimates of Adult Literacy in Medicine (REAL), the
Test of Functional Health Literacy in Adults (TOFHLA), and Newest Vital Sign (NVS) have
been widely used to measure health literacy. The REAL measures the ability to pronounce a list
of common medical terms, the TOFHLA measures comprehension including the ability to read
and understand health-related materials and numerical information, and the NVS measures health
literacy using nutrition labels (Baker, Williams, Parker, Gazmararian & Nuess, 1999; Lee, Kang
Lee, & Hyun, 2009; Pedlimari, Holubar, Hanssinger & Cima, 2011). However, these instruments
have limitations to measure accurate health literacy. Despite the fact that the REAM can be
administered in less than three minutes, it only assesses reading and pronouncing abilities.
Although the TOFHLA has adequate psychometric properties to measure health literacy and is
available in English, Spanish, and Hebrew, the time required for administration is 18 to 22
minutes for the full version and 7 to 10 minutes for the short version of TOFHLA (S-TOFHLA)
(Baker, Williams, Parker, Gazmararian & Nuess, 1999; Lee, Kang, Lee & Hyun, 2009; Johnson
& Weiss, 2008). The NVS is a brief assessment tool using nutrition labels, but it measures
limited health literacy (Lee, Kang, Lee & Hyun, 2009).
56
Even though the National Adult Literacy Survey report frequently addresses the necessity
of assessment of health literacy, the assessment of health literacy is not standardized in health
care (Agre, Stieglitz & Milstein, 2006). It is particularly difficult to find valid health literacy
instruments for linguistic minorities (Han, Kim, Kim & Kim, 2011) because different cultures,
different lifestyles and language structures should be considered to measure accurate health
literacy (Lee, Kang, Lee & Hyun, 2009). Most health literacy research has focused on Englishor Spanish-speaking populations.
Han et al. (2011) translated the REAM and the S-TOFHLA into Korean, and validated
these instruments among 98 Korean Americans. Even though the REAL and the S-TOFHLA
have been proved as valid instruments to measure health literacy and widely used in English- and
non-English speaking populations, the translation of REAM and S-TOFHLA into Korean
language did not lead to a valid assessment of health literacy for Korean Americans in their study.
More than 90% of participants were categorized in the highest range of both instruments, and
little variance in health literacy scores. Because Koreans have high literacy rates in Korean,
simple reading tests like the REAM may not be a sensitive tool to measure health literacy and it
does not indicate their comprehension of words. Even though they can simply pronounce words
and read sentences in English, they would still have difficulties in health literacy while
navigating health systems to get health services and communicating with health care providers
(Han, Kim, Kim & Kim, 2011).
The needs for disease-specific health literacy assessments were identified. Although
patients have sufficient general literacy in the REAM and NVS, they may have low diseasespecific literacy which they need for decision-making or disease management. For example,
cancer patients with low cancer health literacy may have a lack of understanding of treatment
57
choices, expected outcomes, self-care directions, and medication administration (Agre, Stieglitz
& Milstein, 2006; Pedlimari, Holubar, Hassinger & Cima, 2011). Therefore, disease-specific
health literacy will be more effective and efficient to measure accurate health literacy.
Pedlimari et al. (2011) validated a colon cancer-specific health literacy assessment tool,
“Assessment of Colon Cancer Literacy (ACCL)” against a standard measure of health literacy,
the NVS. Sixty one patients, who were going to have a colonoscopy, completed both instruments.
The limited literacy patients identified on the NVS were also recognized with the ACCL.
However, many patients scored well on the NVS but poorly on the ACCL. The ACCL has high
sensitivity (91.3%) in the identification of possible limited literacy patients. Therefore, the
ACCL is a valid tool for assessing health literacy and colon cancer literacy in CRC screening
patients. It identifies patients with colon cancer-specific limited literacy in addition to those with
general limited literacy. The ACCL is a useful instrument to measure health literacy and colon
cancer literacy for several reasons. It is a self-report survey and takes less than three minutes,
including relevant topics of colon cancer management.
In this study, the ACCL will be used to measure health literacy among Korean Americans.
Korean Americans have high literacy rates in Korean (97% for Korean women and 99% for
Korean men); therefore a simple measure of reading skills cannot reflect their health literacy.
The ACCL will be more appropriate to assess health literacy with colon cancer literacy than
other health literacy tools in this group.
Cues to Action
Physician’s Recommendation
A physician’s recommendation has been identified as one of the most important
predictors on an individual’s decision to undergo CRC screening across populations. However,
58
there are disparities in the quality of cancer care (e.g., giving recommendations for screening) by
physicians. Minority patients were less likely to receive information and recommendation for
preventive care including CRC screening from physicians than non-Hispanic white patients
(Kagawa-Singer, Dadia, Yu & Surbone, 2010; Maxwell, Crespi, Antonio & Lu, 2010; Sarfaty &
Wender, 2007).
The relationships between physician’s recommendation and cancer screening, and the
role of a physician’s recommendation for CRC screening are still unclear in Korean Americans
(Jo, Maxwell, Rick, Cha & Bastani, 2009; Maxwell, Crespi, Antonio & Lu, 2010). According to
the 2005 CHIS, only 11% of Korean Americans reported they received a physician’s
recommendation for CRC screening and it was significantly the lowest rate among Asian
subgroups (Maxwell, Crespi, Antonio & Lu, 2010). Less than one-quarter (24%) of Korean
American participants reported that they received a physician’s recommendation to have breast
cancer screenings (Lee, Kim & Han, 2009). In Jo’s (2008) study, only 29% of respondents
received CRC screening recommendation from physicians even though 64% of them have a
primary care physician. Although receiving a physician’s recommendation is the most strongly
associated with having received CRC screening in the general U.S. population, a physician’s
recommendation was significantly associated with only having symptoms of the disease for
Korean Americans (Jo, Maxwell, Wong & Bastani, 2008).
Most Korean Americans seek and prefer to go to Korean American physicians if they
have an opportunity because of language barriers; however, only a few Korean American
patients received cancer screening recommendations from Korean physicians (Jo, Maxwell,
Rick, Cha & Bastani, 2009; Lew et al., 2003; Maxwell, Crespi, Antonio & Lu, 2010). Jo and
colleagues (2009) explored why Korean American physicians are reluctant to recommend CRC
59
screening to Korean American patients. Fourteen Korean American physicians who primarily
serve Korean American patients in Los Angeles were individually interviewed. Sixty-five
percent of the 14 Korean physicians in the study stated that they do not routinely recommend
CRC screenings to Korean patients, and they refer their patients to specialists only when patients
have symptoms. Fifty percent of 14 physicians do not discuss cancer screenings or physical
examinations with Korean patients even though they are aged 50 and over.
Jo’s (2009) study identified that Korean physicians were reluctant to recommend CRC
screening because of their own lack of knowledge, lack of referral networks and reimbursement
of screening for low-income and under insured patients, and their patient’s unawareness of
concept of screening. Most of the physicians lacked knowledge about the incidence and
prevalence of CRC in Korean Americans and CRC screening guidelines. They stated that the
incidence and prevalence of CRC among Korean Americans were much lower than the general
U.S. population; therefore, routine recommendation or the development of any programs to raise
CRC screening rates is not necessary. The second reason was the insufficient referral network
and reimbursement for screening for low-income or uninsured patients. The physicians expressed
reluctance to offer CRC screening because a FOBT has a high rate of false positive and high cost
of colonoscopy; therefore they do not offer FOBT or colonoscopy routinely to their underinsured
and low-income patients. Another reason was the patient’s unawareness of the concept of
screening or preventive medicine. Physicians stated that explaining the purpose and necessity of
routine screening takes extra time and effort because Korean American patients do not
understand routine screening if they do not have symptoms (Jo, Maxwell, Rick, Cha & Bastani,
2009).
60
Having a Korean physician may indicate less access to cancer screening and preventive
health services. This result may be explained from Korean physicians’ understanding of Korean
Americans who have structural barriers and unique circumstances as immigrants. However, this
finding remains in a question whether Korean physicians do not recommend CRC screening to
all their patients or just to Korean American patients.
The effect of provider status on cancer screening is important for non-English speaking
minorities. Having a physician of the same ethnicity may be associated with lower rates of breast
and cervical cancer screenings in some Asian American women (Juon, Kim, Shankar & Han,
2004). The effect of healthcare provider status on preventive screening was evaluated in
Alameda County, California. Twenty-nine percent of the 339 Korean American women reported
they have a Korean physician. Women who had a Korean physician were more likely to be older
and less educated, and have spent less of their lifetime in the U.S. compared to those who have a
non-Korean physician. Women who have a Korean physician were less likely to have received
Pap smears (56% vs. 72%), mammogram (57% vs. 89%), and clinical breast examinations (39%
vs. 73%) in the past two years prior to the survey compared to those who have a non-Korean
physician. Korean women who have a Korean physician were less likely to have had a cancer
screening compared to those who have a non-Korean physician (Lew et al., 2003).
A few factors may influence this result. Korean physicians may be less likely to perform
or recommend breast and cervical cancer screenings because they aware Korean American
women’s modesty for male physicians. However, this reason would not apply to CRC screening.
Another possible reason is patient’s insurance status. It may influence the physician’s decision to
recommend or perform cancer screening. Korean physicians know that many Korean American
patients have no insurance or private insurances with large deductibles or policies that do not
61
cover preventive care. CRC screening tests will be burdened to their patients if patients have
limited or lack of health insurance.
Korean Americans receive less physicians’ recommendation of cancer screening
compared to the general U.S. populations. Korean physicians also less recommend cancer
screening to Korean American patients. Although the physician’s recommendation is considered
the most effective motivator for participating in CRC screening, the role of a physician’s
recommendation of CRC screening for Korean Americans is unclear and understudied.
Modifying Factors
Acculturation
Acculturation is defined as a process in which an individual’s psychosocial adjustment
and adaptation from the culture of origin toward the dominant culture, including beliefs,
behaviors, attitude, values, identities, and customs (Kim, 2009; Lee, Goldstein, Brown &
Ballard-Barbash, 2010; Lim, Yi & Zebrack, 2008; Shim & Schwartz, 2008). Acculturation is an
important psychological construct in ethnic minority research because it helps to explain withingroup variability in psychological and behavioral changes as well as individuals’ health
outcomes (Yoon, Lee & Goh, 2008).
Immigrants adopt the culture and lifestyle of their host country, and these affect their
health beliefs and practices, including cancer screening behaviors (Kagawa-Singer, Dadia, Yu &
Surbone, 2010). The impact of acculturation has shown inconsistent results in cancer screening
studies among Korean Americans. Some studies have reported that acculturation is significantly
associated with cancer screening. Less acculturated Korean Americans have lower rates of
cancer screenings than the more acculturated, and this is consistent with other Asian American
studies (Jacobs, Karavolos, Rathouz, Ferris & Powell, 2005; Juon, Kim, Shanker & Han, 2004;
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Maxwell, Bastani & Warda, 2000; Sohn & Harada, 2004; Yip, Tu, Chun, Yasui & Taylor, 2006).
However, studies also have reported that there is no significant relationship between
acculturation and cancer screening among Korean Americans (Lee, Kim & Han, 2009; Shin,
Song, Kim & Probst, 2005; Sohn, & Harada, 2005; Song et al., 2004). The impact of
acculturation on cancer screening is still unclear (Song et al., 2010).
A few studies have addressed that acculturation is significantly associated with cancer
screenings among Korean Americans. Korean Americans, who lived longer in the U.S. and were
more acculturated, have adhered more often to cancer screenings than those who were less
acculturated. Recent immigrants have been influenced by their own traditions and cultural
beliefs, and this, in turn, may influence screening practices (Juon, Kim, Shanker & Han, 2004;
Maxwell, Bastani & Warda, 2000). Although many studies have identified no significant
relationship between acculturation and cancer screening (Lee, Kim & Han, 2009; Shin et al.,
2005; Sohn, & Harada, 2005; Song et al., 2004), recently arrived and less acculturated Korean
Americans often experience cultural differences in health beliefs and practices with lack of
health care access and language barriers. These challenges make it difficult for Korean
Americans to use the U.S. health care system and it results in less-adherence to cancer screening
(Sohn & Harada, 2004). However, this result raises a question about the relationship between
acculturation and cancer screening among Korean Americans. Even though the less acculturated
have lower rates of cancer screening, it does not mean that the more acculturated have higher
rates of cancer screening.
Most Korean American cancer studies used proxies such as language proficiency or
length of U.S. residency to measure acculturation (Juon, Kim, Shanker & Han, 2004; Maxwell,
Bastani & Warda, 2000; Sohn & Harada, 2004), and only one study specifically utilized an
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acculturation scale, the Suinn-Lew Asian Self Identity Acculturation (Song et al., 2004). When
proxies are used to measure the level of acculturation, it is uncertain whether recently arrived
immigrants who are well-educated with English proficiency can be considered less acculturated
than those who lived longer in the U.S. but have language barriers.
Many acculturation scales primarily include language use and proficiency (Coronado,
Thompson, McLerran, Schwaartz & Koepsell, 2005), but it remains a question whether changes
in language use and proficiency provide an accurate reflection of acculturation or not. Language
use and proficiency could be related to health literacy, access to health care and communication
with healthcare providers rather than measuring cultural adaptations in attitudes, beliefs and
behaviors (Etnyre et al., 2006; Thompson & Hoffman-Goetz, 2009). Length of U.S. residence
only means an individual has more exposure to the host county. As Tropp (1999) identified,
mere exposure to a dominant culture should be distinguished from the psychological changes of
acculturation (Tropp, Erkut, Coll, Alacon & Garcia, 1999).
Proxy measures are widely used in minority and immigrant health research as indicators
of acculturation. The most frequently used proxy measures have been nativity, immigration
status, length of residency, and language use. Proxy measures are convenient and easy to obtain
data. However, many researchers have criticized the use of proxies to measure acculturation
because of their limited scope and sensitivity (Hunt, Schneider & Comer, 2004; Thompson &
Hoffman-Goetz, 2009). Proxy measures may be less suited in immigrants’ ability to capture
different aspects of acculturation (Beck, Froman & Bernal, 2005; Lee et al., 2010) and this may
lead to less a comprehensive understanding of the relationship between acculturation and health.
The proxy measurement cannot accurately measure the level of acculturation of recently
arrived Korean immigrants. Therefore, the influence of acculturation on cancer screening
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behaviors needs to be reassured in previous cancer screening studies among Korean Americans.
This study will comprehensively measure the level of acculturation of Korean Americans by the
Asian American Multidimensional Acculturation Scale (AAMAS) to determine the effect of
acculturation on CRC screening behaviors.
Gender Differences
The international trends in CRC incidence rates have increased for both men and women.
Over the last two decades, CRC has rapidly increased, especially in men, in economically
transitioning countries including most parts of Asia. However, limited studies were found
regarding gender differences in CRC incidence and CRC screening behaviors based on regional
or country-specific trends (Center, Jemal & Ward, 2009; Umar & Greenwald, 2009).
Molina-Barcelo et al. (2011) investigated the influence of gender in CRC screening.
There were no significant differences in the level of knowledge and beliefs about CRC disease
and cancer screening programs by gender; however, the reason for participation and nonparticipation in cancer screening program was different between men and women.
In giving the reasons for participation, women identified themselves as being caregivers,
and were afraid to have the disease because they do not want personal and family suffering.
Women valued the importance of self-care and it enhanced their participation in CRC screening.
Men showed their dependence on women in making the decision for participation and they only
participated when their wives or partners were involved. In giving reasons for non-participation,
women addressed the embarrassment for the screening tests or fear of being diagnosed with
cancer. Men showed carelessness for their health and lack of knowledge about the disease and
screening. Men were reluctant to seek medical attention, which influenced their low motivation
to participate in CRC screening. Men were more vulnerable because they were less motivated to
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get screened than women even though generally men have a higher incidence and mortality rate
of CRC.
This result is consistent with Bass et al. (2011) study. In Bass et al. (2011) study, African
American women had more sense of the necessity of CRC screening and positive relationship
with physicians than African American men, and men had fears of going to physicians. These
studies seem to be similar to Korean American’s general health practices for disease
management and health promotion.
Although there are gender differences in cancer screening behaviors for other ethnic
groups in the literature (Bass et al., 2011; Molina-Barcelo, Salas-Trejo, Peiro-Perez & Malaga
Lopez, 2011), gender differences have rarely been studied in cancer screening behaviors among
Korean Americans (Im, Lee & Park, 2002). Korean culture, traditions, and family values have
been influenced by Confucianism, and the Confucian tradition supports men centrism and gender
discrimination against women in Korea (Bernstein, 2007; Nash, 2010). Korean family structure
is patriarchal and hierarchical; parents remain above children, and men above women. The
family unit is valued over the individual, and the individual is expected to sacrifice personal
desires for family needs. The ideal traditional Korean women are humbly obedient and sacrifice
their desires (Park & Bernstein, 2008). Although gender roles have been changing in most
developed countries, these traditional values and gender roles remain in both Korean and Korean
American families in the U.S. In addition, immigrant women often forced to take increased
responsibility to join the workforce with the primary role of caregivers in the family. Over 70%
of Korean American women are currently employed full-time outside of the home in the U.S.
Health promotion or screening is not a higher priority than work in the immigrant families (Han,
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Kang, Kim, Ryu & Kim, 2007; Lim, Yi & Zebrack, 2008; Molina-Barcelo et al., 2011) and these
factors may influence cancer screening behaviors among Korean American women.
However, most cancer screening studies for Korean Americans have been focused on
breast and cervical cancers and there is a dearth of studies that have included Korean American
men. Thus even less is known about Korean American men’s cancer health behaviors than
Korean American women’s. Breast and cervical cancer awareness have increased among Korean
American women through research studies, health policy, and media. However, cancer screening
behaviors of Korean American men have rarely been studied. According to the 2010 California
Cancer Statistics, CRC incidence ranked first among all cancers in Korean American men and
ranked second in Korean American women (ACS, 2010).
Despite rapidly increasing CRC incidences among Korean American men as represented
in current cancer statistics, there is little known about their cancer practices. Therefore, it is
important to explore and understand Korean American men’s cancer health practices. If men and
women have different perceptions, attitudes, barriers, and predictors for CRC cancer screenings,
the outcomes of this study will respond to the gap in our knowledge and contribute to developing
strategies to increase the rates of CRC screening by gender among Korean Americans. In this
study, gender differences will be analyzed by how CRC screening behaviors are different
between men and women.
Length of U.S. Residence
The 2010 National Health Interview Survey (NHIS) reported that respondents of the
survey who had been in the U.S. less than 10 years were one of the highest risk groups.
Screening rates for breast, cervical, and CRC were significantly lower among Asians than among
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whites and blacks. Higher screening rates were positively associated with length of U.S.
residence (Klabunde et al., 2012).
Immigrants may experience common health-related problems, and these problems are
shaped by the migration experience and the immigrants’ marginal status in the host societies. In
the study of Pons-Vigues (2012) in Spain, all immigrant women showed markedly different
patterns of cancer screening behaviors than native women. Immigrant women had poorer
knowledge, less positive attitude, perceived fewer benefits, and more barriers to cancer screening
compared to native women. This difference was not only cultural factors, but also may be from
the migration process and length of residence in the host country.
In the study of Russian immigrants (Remennick, 2003), even though most respondents
were educated immigrant women who acknowledged their personal risk and the importance of
breast cancer screening tests, they had low rates of screening. Most of their susceptibility to
cancer and attitudes did not translate into cancer screening practices. As recent immigrants, they
faced many difficulties while surviving and adjusting to a new society. Different health systems,
limited health care access, language and cultural barriers can influence cancer screening
practices even though immigrants are knowledgeable to disease and cancer screening. The gap
between health beliefs and practices may be wider among recent immigrants than nonimmigrants. For new immigrants who are in marginal status in new societies, high susceptibility
to cancer does not always guarantee to action, cancer screening.
A few studies addressed the relationship between length of U.S. residence and cancer
screening behaviors among Korean Americans. The demographic predictors of cancer screening
among Korean American women (N=229) were investigated (Maxwell, Bastani & Wards, 2000).
Korean women who had spent more of their lifetime in the U.S. were more adherent to breast
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and cervical cancer screening than those who had spent less of their lifetime in the U.S., with no
significant effect on CRC screening. Length of U.S. residence was the second most important
predictor of cancer screening in this study. Juon et al.’s (2003) CRC screening study had similar
findings with this study. Korean Americans who had spent more than 25% of their lifetime in the
U.S. were two times likelier to have had a sigmoidoscopy compared with those who had spent
less than 25% of their lifetime. This result was consistent with other Asian American studies
(Ferrer, Ramirez, Beckman, Danao & Ashing-Gina, 2012; Kandula, Wen, Jacobs & Lauderdale,
2006).
Length of U.S. residence is the one of the important factors in immigrant studies. It
influences immigrants’ health behaviors and health-related problem. However, limited studies
investigated the relationship between length of U.S. residence and cancer screening among
Korean Koreans. Korean Americans have a shorter immigration history than other ethnic groups
and most of them are foreign born new immigrants. As a few studies reported, there are the
differences between Korean Americans who had spent longer of their lifetime in the U.S. and
those who had spent less of lifetime in the U. S. This study will investigate the role of length of
U.S. residence on CRC screening behaviors among Korean Americans.
Summary
Although CRC incidence and prevalence have been increasing among Korean
Americans, there is little known in regards to the predictors and barriers that influence this
population’s CRC screening behaviors. Because of the limited literature of CRC screening
among Korean Americans, the literature review included breast and cervical cancer screening
studies to understand their general beliefs and behaviors of cancer screening.
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The HBM guides this study. The 10 concepts were discussed, and these are considered
possible predictors and barriers influencing cancer screening behaviors in Korean Americans. As
perceived susceptibility, cultural beliefs about the cause of cancer and perception of cancer
screening are considered negative factors influencing CRC screening behaviors. Knowledge of
cancer screening and guidelines is considered a perceived benefit, and it plays a positive role in
cancer screening. Cancer fatalism, low health literacy, and limited health care access are
considered as perceived barriers and negatively influence cancer screening among Korean
Americans. As the cues to action, the role of physician recommendation is unclear on CRC
screening for Korean Americans even though there are many positive results in other ethnic
groups. The relationship between acculturation and cancer screening is inconsistent and the
effect of acculturation on cancer screening is unclear. As the other modifying factor, differences
in gender and length of U.S. residence on cancer screening practice have rarely been studied
among Korean Americans. There is little known about CRC screening behaviors by gender.
From the literature, limited knowledge was found especially CRC screening behaviors
among Korean Americans men. Since the incidence and prevalence of CRC have been increasing
in Korean American men, there is an urgent need to identify the predictors and barriers
influencing CRC screening behaviors among men. Investigating the relationship between gender
and cancer screening among Korean Americans will contribute to knowledge of predictors and
barriers to CRC screening behaviors and insight into CRC health disparities among Korean
Americans. Chapter 3 will discuss the methodology for this study.
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CHAPTER III: METHODOLOGY
This chapter described the methodology for this research study. The research design,
sample criteria and sampling methods, settings, measurements, instrument translation, data
collection procedures, data analysis, as well as the procedure for the protection of human
subjects were addressed.
Research Design
This study employed a cross-sectional descriptive design. A cross-sectional descriptive
research design was appropriate to achieve the purpose of this study which is to describe current
CRC screening behaviors among Korean Americans by using a survey at a single point in time,
and to examine the relationships among variables to identify the predictors and barriers of their
CRC screening behaviors. The outcomes of this study will help health care providers and
researchers to develop the strategies of interventions to improve CRC screening rates among
Korean Americans, and provide critical knowledge to understand factors that contribute to CRC
disparities among Korean Americans in practice and research.
Sample
Purposive stratified sampling was used to ensure there were sufficient Korean American
participants of each gender and length of U.S. residence (≤10 years and >10 years). Inclusion
Criteria were: (1) Korean American men and women living in the Greater Los Angeles area; (2)
foreign-born; (3) age 50 years and older; (4) 125 Korean Americans who have lived in the U.S.
less than 10 years; and (5) 125 Korean Americans who have lived in the U.S. over 10 years.
Exclusion Criteria were visitors to the U.S. or those who cannot read or speak Korean or English,
and under 50 years of age.
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Power Analysis
Adequate power indicates that there are enough subjects to detect a significant difference
in the outcome variable and that the results can be trusted. When power is insufficient, a type II
error commonly occurs that cannot find any significant difference or relationship even it exists in
the outcome variable. Power analysis assists in planning and determining adequate sample size to
obtain significant results. To calculate power, the level of significance, a number of variables,
number of subgroups, research designs, and effect size should be considered. Larger samples
have more power and less sampling errors because larger samples generally represent the
population well. Generally at least 15 subjects per variable are suggested to obtain adequate
power (Houser, 2008; Polit & Beck, 2004). There were ten variables in this study; therefore, at
least 150 subjects were required for adequate power. This study recruited 254 subjects; thus had
adequate power to detect any differences.
Settings
About 23% of all Korean Americans in the U.S. are condensed in the Los Angeles
County and the Orange County in California (Korean American Coalition, 2011; U.S. Census
Bureau, 2011). These two counties were the primary places for data collection.
Data collection was mainly in Korean churches, Korean grocery stores, and shopping
centers in the Greater Los Angeles area, especially Los Angeles County and Orange County. The
rationale for selecting Korean churches is that high percentages of Korean Americans attend
church on a regular basis with estimates ranging from 65% to over 80% (Juon, Choi, Klassen &
Roter, 2006; Ma et al., 2009). Korean churches serve as sites for social activities for immigrants
and limited health services, such as flu shots or cancer screening to those who have no access
(Jo, Maxwell, Wong & Bastani, 2008; Sarna, Tae, Kim, Brecht & Maxwell, 2001).
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Korean grocery stores were also considered good places for data collection. Korean
Americans tend to keep their culture, norms and preferences and most go to Korean grocery
stores at least two or three times a month to buy ethnic food. The grocery stores are important
places for Korean Americans to get ethnic newspapers and obtain community information. There
are about 70 Korean grocery stores in the Los Angeles area.
Churches and grocery stores from different geographical locations were selected
purposively to avoid sampling bias. According to the Southern California Association of
Government (SCAG) 2011 local profiles and the 2010 American Community Survey, Los
Angeles County and Orange County have different socioeconomic status: median household
income ($55,811 vs. $76,412); home ownership rates (48.6% vs. 61.5%); and high school
graduate or higher age 45 to 64 years (75.4% vs. 84.6%) (SCAG, 2011; U.S. Census Bureau,
2011).
Protection of Human Subjects
The Institutional Review Board (IRB) Human Subject Committees of the University of
Arizona and College of Nursing reviewed this study. After the study was approved, the study
was conducted. The purpose of the study, procedures for completing the questionnaire and
potential risks and benefits of the study were explained by the researcher to each participant.
Subjects were assured participation is completely voluntary and a subject is free to withdraw
from the study at any point without penalty. To protect the confidentiality of the human subject,
the maintenance of confidentiality was explained. All subjects were assured that the collected
data and information will be used for research purposes only and all collected data will be
deidentified by coded numbers. Participants were informed that only the researcher and the
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dissertation committee members have access to data for research purposes. Informed consent
was provided to participants and obtained before completing the questionnaire.
Measurements
Conceptually, ten independent variables (cultural belief, perception of the cancer
screening, cancer fatalism, knowledge, health care access, health literacy, physician’s
recommendation, acculturation, gender, and length of U.S. residence) were hypothesized to
influence the dependent variable (CRC screening behaviors). The measurement included
demographic data, addressed dependent and independent variables. For this study, seven
instruments were selected: (1) the 2009 California Health Interview Survey (CHIS) adult
questionnaire version 3.4; (2) the Jacobs’ HBM Scale for CRC; (3) the Han’s HBM Scale for
breast cancer; (4) the Colorectal Cancer Knowledge Questionnaire (CCKQ); (5) the Powe
Fatalism Inventory (PFI); (6) the Assessment of Colon Cancer literacy (ACCL); and (7) the
Asian American Multidimensional Acculturation Scale (AAMAS). Each scale was analyzed to
measure the internal reliability. The items were selected from these seven instruments and
translated into Korean using the Brislin’s guideline (Brislin, 1970) for cross-cultural research.
The translation procedures were discussed in the instrument translation section. The instruments
are found in Appendix G and H.
Demographic Information
Demographic information was collected by gathering pertinent information of study
participants. It included questions asking basic demographic information about the participants
such as gender, age, marital status, employment status, education level, household income,
insurance status, English proficiency, and length of U.S. residence. The questionnaire consisted
of 10 questions.
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Cultural Beliefs
The cultural beliefs for CRC were measured by the Han’s scale (Lee, Kim & Han, 2009).
The Han’s scale was developed to measure cultural factors predicting mammography behaviors
among Korean Americans. Four items were derived from Han’s scale and respondents were
asked cultural beliefs for causes of cancer. Examples of questions are: “God’s will causes
colorectal cancer” and “Heredity causes colorectal cancer.” The answer is dichotomized as “yes
or no.” Permission to use of items was obtained from the original author, Han, and breast cancer
was substituted for the term colorectal cancer under Han’s permission.
Perception of Cancer Screening
The perception of cancer screening was measured by the 2009 California Health
Interview Survey (CHIS) adult questionnaire (CHIS, 2011). The CHIS is a population-based
random telephone survey of the population in California and it has been conducted biennially
since 2001. The CHIS is the one of the largest health surveys in the nation. The CHIS collects
extensive information for all age groups on health status, health conditions, health-related
behaviors, health insurance coverage, access to health care services, and other health and health
related issues of California’s diverse population. The CHIS data and results are extensively used
by federal and state agencies, local public health agencies and organizations, advocacy and
community organizations, hospitals, community clinics, and researchers. The data are widely
used for analyses and publications to assess public health and health care needs, and to develop
and advocate policies to meet those needs. The CHIS is especially known for hard-to-find data
on ethnic subgroups such as Asian Americans, and interviews are conducted in a language other
than English (CHIS, 2013).
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The CHIS questionnaires were well-developed and proved their validity and reliability,
and the 2009 CHIS adult questionnaire version 3.4 was used in this study. Permission to use of
the questionnaire was obtained from Abanilla, Data Access Center Coordinator of the CHIS.
Two items were derived from the 2009 CHIS adult questionnaire for the perception of cancer
screening. Questions were asked whether they have an annual physical examination and what
kinds of cancer screening have been done annually, and why they do not have annual cancer
screenings if they have never done.
CRC Screening Behaviors
CRC screening behaviors were measured by the 2009 CHIS adult questionnaire. Eleven
items were selected and respondents were asked about their awareness of CRC and screening
tests (fecal occult blood test, sigmoidoscopy, and colonoscopy), and previous and current CRC
screening behaviors with updated screening guidelines. The main reasons why CRC screening
was done/was not done were also asked to respondents. Examples of questions are: “When did
you do your most recent fecal blood test using a home kit to check for colon or rectal cancer?”
and “What is the one most important reason why you have never had one of these exams
recently?”
Cancer Fatalism
Cancer fatalism was measured by the Powe Fatalism Inventory (PFI). The PFI was
developed to assess the presence of cancer fatalism and items focusing on the defining attitudes
of fear, pessimism, inevitability of death, and predetermination. This inventory consists of 15
items with a possible range of score from 0 to 15. One point is added for each yes response and
higher scores on the inventory indicate higher levels of cancer fatalism. Items of the PFI can be
answered with a “yes” or “no” response. An example of a PFI item is, “I think bowel cancer will
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kill you no matter when it is found and how it is treated.” Reliability coefficients of the PFI have
ranged from 0.84 to 0.89 (Powe, 1995a, 1995b, 1997, 2001). In this study, internal consistency
of the PFI was .85, which indicates the good reliability of the scale.
Knowledge
Knowledge of CRC and cancer screening guidelines was measured by Weinrich’s
Colorectal Cancer Knowledge Questionnaire (CCKQ) (Weinrich, Weinrich, Boyd, Johnson &
Frank-Stromborg, 1992). This scale assesses knowledge of CRC and includes risk factors,
symptoms, and screening recommendations. It consists of 12 true or false questions with a
possible range of score from 0 to 12. Each correct response counts as one point. The answers for
each item are “True, False, or Don’t know.” An example of the CCKQ item is “You need to
check your bowel movement for blood even if your bowel habits are normal.” The reliability
coefficient ranged from 0.69 to 0.77 and the test-retest reliability was 0.65 (Weinrich, Weinrich,
Boyd, Johnson & Frank-Stromborg, 1992). In this study, internal consistency as measured by
Cronbach’s alpha for the CCKQ was .55, which is moderate criterion for a scale. Internal
consistency, given this is a knowledge scale, was considered satisfactory.
Healthcare Access
Health care access was measured by the 2009 CHIS adult questionnaire (CHIS, 2011).
Ten items were selected and included a usual source of care (two items), status of health
insurance (three items), and health service utilization (five items). Respondents were asked what
type of usual source of care and health insurance, and the health service utilization for the past 12
months. The main reason why a respondent does not have health insurance and whether costs or
lack of health insurance cause delay of care were asked. Examples of questions are: “What kind
of place do you go to most often for health care?” and “During the past 12 months, did you delay
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or not get any other medical care you felt you needed such as seeing a doctor, a specialist, or
other health professional?”
Health Literacy
Health literacy was measured by the Assessment of Colon Cancer Literacy (ACCL). The
ACCL was developed by Holubar et al. (2009) to measure colon cancer literacy in a communitybased study. After a focus group session, the instrument was modified and the ACCL was used
in two other intervention studies. The ACCL is a self-administered instrument consisting of 10
true-false statements and it includes basic definitions of cancer-related terms. The themes in the
ACCL are disease prevalence, causative factors, polyps, surgical management, chemotherapy,
and radiotherapy. The response includes true, false, or unsure. The ACCL scores range from 0 to
10 and scores of 7-10 is considered as adequate health literacy and scores of 0-6 are as possible
limited literacy (Holubar, Hassinger, Dozois, Wolff, Kehoe & Cima, 2009). Examples of
questions are: “Malignant means cancer has already spread” and “Colon cancer that has spread to
the lymph nodes is called metastatic.” Permission to use of this questionnaire for this study was
obtained by the original author, Holubar. In this study, Cronbach alpha for internal consistency
of the ACCL was .74, which is acceptable psychometric property.
Physician’s Recommendation
To reflect literature of a physician’s recommendation for CRC screening in Korean
Americans, three items were derived from the 2009 CHIS adult questionnaire. Respondents were
answered whether they have health care providers and a physician has recommended CRC
screening tests in the past five years, and the main reason they did/do not follow the physician’s
recommendation for CRC screening.
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Health Belief Model Scale
The Jacobs’ Champion Health Belief Model Scale (CHBMS) for CRC and the Han’s
modified CHBMS were used to collect information regarding the health beliefs of CRC and CRC
screening among Korean Americans. Champion developed items of the HBM constructs of
susceptibility, seriousness, benefits, barriers, health modification, and confidence, and these
items originally focused on breast self-examinations and breast cancer. Champion stated that the
scale could be used with substitution of a word or phrase for different types of cancer (Champion,
1984). Jacobs adapted the CHBMS by altering a few questions and by substituting colon cancer
for breast cancer in the wording in each of the six subscales. Adapted items were sent to three
experts including Champion for judgment of relevancy in measuring HBM constructs as applied
to CRC and content validity was adequate. Cronbach’s alpha for internal reliability ranged from
0.60 to 0.78 and test-retest correlations for this scale ranged from 0.47 to 0.86. The Jacobs’
HBMS consists of 36 items (Jacobs, 2002).
The Han’s modified CHBMS included additional barriers specific to immigrants such as
a lack of English proficiency, transportation, health insurance, and physician recommendation.
Exploratory and confirmatory factor analyses, and logistic regression for theoretical relationship
were used to establish construct validity. This scale was translated into Korean and tested with
Korean women. Cronbach alpha of internal reliability ranged from 0.85, 0.90 and 0.71 for
perceived susceptibility, benefits and barriers scales (Han, Lee, Kim & Kim, 2009).
The Jacobs’ CHBMS was mainly used to measure Korean Americans’ health beliefs for
CRC and screening and 11 items of the Han’s CHBMS were added to perceived barriers for this
study. The five items assessed perceived susceptibility to CRC and asked beliefs of personal
threat related to CRC (e.g., ‘It is extremely likely I will get colon cancer in the future’). The
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seven items assessed perceived seriousness to CRC (e.g., ‘If I develop colon cancer, I would not
live longer than five years), and the six items measured perceived benefits of CRC screening
(e.g., ‘If I had regular checkups to detect colon cancer, I wouldn’t worry as much about colon
cancer’). Perceived barriers to CRC screening were examined by the 17 items and asked
perceived physical, psychological and structural barriers related to CRC screening (e.g. ‘I am
afraid to have a colon cancer screening because I don’t really understand what will be done.’).
Respondents were asked to rate their health beliefs for CRC screening on a 5-point
Likert-type scale (1 = strongly agree to 5 = strongly disagree). Higher scores indicate higher
levels of perceived susceptibility, seriousness, benefits, and barriers. In this study, internal
consistency of the HBM was .91, and Cronbach’s alpha of internal reliability of four subscales
ranged from .89 to .93, which identified excellent reliability. Perceived susceptibility of the five
items was .93, perceived seriousness of the seven items was .90, perceived benefits of the six
items were .91, and perceived barriers of the 17 items were .89.
Acculturation
Acculturation was measured by the Asian Americans Multidimensional Acculturation
Scale (AAMAS) developed by Chung and colleagues (2004). This scale is a behavioral oriented
multidimensional scale. Three different tests were conducted for instrument development and
established psychometric properties. For internal reliability, coefficient alpha of the original
study was 0.78-0.87 of AAMAS, follow-up test 0.81-0.89, and test-retest reliability was 0.750.89. Test-retest reliability was tested among 44 Korean Americans from the community. To
establish the validity of this scale, criterion-related validity, concurrent validity, and divergent
validity were conducted with exploratory and confirmatory factor analysis. The English and
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Korean version of AAMAS were obtained from one of the original authors, Kim (Chung, Kim &
Abreu, 2004) and he gave permission to use for this study.
The AAMAS consists the 15 items: the 10 items measure cultural behavior; the three
items of cultural identify; and the two items of cultural knowledge. Respondents rated each item
on a 6-point Likert-type scale (1= not very well to 6= very well) according to three reference
groups: their culture of origin; other Asian Americans; and European Americans. For data
analysis, AAMAS scores were based on the average rating (ranging from 1 to 6) across each 15
items per group. In this study, internal reliability of AAMAS of the 45 items was .91, which
identified excellent reliability. Cronbach’s alpha for internal reliability of the 15 items of Korean
culture was .88, Asian culture was .90, and European culture was .93.
In summary, the instruments for this study included demographic characteristics, cultural
beliefs, perception of cancer screening, knowledge of CRC and cancer screening, cancer fatalism,
health care access, health literacy, physician’s recommendation, acculturation, the HBM Scale,
and CRC screening behaviors. The instruments were translated into Korean and the English- and
Korean- version of the instruments were available to Korean Americans to collect data.
Instrument Translation
Instruments for this study were translated into Korean using the Brislin’s Translation
model to obtain a valid and reliable translated instrument (Brislin, 1970). One bilingual expert
who speaks primarily Korean, translated the instrument from English into Korean, and a second
bilingual expert who speaks primarily English, blindly back-translates it into English. The backtranslated version had an error in meaning when compared to the original version, and the terms
in question were retranslated and again blindly back-translated by another bilingual expert.
These iterative processes were repeated until no error in meaning was found.
81
The instruments for this study was developed from seven scales: the 2009 CHIS adult
questionnaire version 3.4, the Jacob’s HBM Scale for CRC, the Han’s HBM Scale, the
Colorectal Cancer Knowledge Questionnaire (CCKQ), the Powe Fatalism Inventory (PFI), and
the Assessment of Colon Cancer literacy (ACCL), and the Asian American Multidimensional
Acculturation Scale (AAMAS). The Han’s HBM and the AAMAS have been previously
translated into Korean and established validity and reliability of the Korean version. For this
study, the 2009 CHIS adult questionnaire, the Jacob’s HBM, the CCKQ, the PFI, and the ACCL
were translated into Korean.
The 2009 CHIS questionnaire, the Jacob’s HBM, the CCKQ, the PFI, and the ACCL
were translated into Korean by the researcher and then a bilingual translator were blindly backtranslated into English. After that, the original and the back-translated versions were compared
for linguistic and cultural equivalence. There were inconsistencies between English and Korean
versions, the researcher and a bilingual translator discussed the cultural and linguistic differences
in meaning until a consensus is reached. Expert panels and pilot testing were considered to
validate the Korean version of the instrument. The bilingual Korean American cancer screening
expert reviewed and evaluated each item of the instrument to validate the content. According to
the recommendation of the expert, some items in the instrument were revised and modified. Pilot
testing needed to validate and estimate the initial content validity of the Korean versions of the
instrument. A pilot test was conducted with two Korean American men and two Korean
American women. They were eligible to the criteria of the study sample. It took 30 to 40 minutes
to complete the questionnaire. The questionnaire was revised using the respondents’ comments
and suggestions. These processes helped to ensure the comprehensiveness of the contents and
enhance the readability, as well as reduce ambiguity and eliminate redundancy.
82
Data Collection Procedures
Data were collected with a structured questionnaire at the recruitment site. Data
collection was about 30 to 40 minutes per each participant. Prior to the interview, participants
received a written recruitment letter and verbal information regarding the study including the
assurance on the confidentiality of the collected data and usage of data for research only by the
bilingual researcher. Informed consent was obtained from eligible participants who volunteered
to participate in the study. After obtaining informed consent, the researcher provided privacy
while the participant completed the questionnaires and assisted as needed to minimize missing
data. A U.S. $10 was provided to each participant who completed the questionnaires.
Data Analysis
The data analysis procedures involved descriptive statistics, bivariate correlation analysis,
independent t-test, and multiple logistic regression with path analytic techniques. All data were
entered and analyzed with a computerized statistical program, Statistical Package of Social
Science version 18 (SPSS 18.0). To answer the research questions, the following analyses were
conducted.
1. Descriptive statistics were performed to describe the variability of demographics and the
characteristics of each variable to determine the effects of independent variables on the
dependent variable, CRC screening behaviors. Demographics and other variables were
analyzed using frequencies and means.
2. Bivariate correlation analysis was used to examine the linear relationships between each
independent variable and dependent variable. Bivariate analysis is commonly used to
determine the correlation between two variables, and it is used to determine if a single
variable can predict a specified dependent variable. The variables that are significantly
83
correlated with the dependent variables will be used as predictors in the path analyses
(Houser, 2008). This analysis was responding to the first and second research questions
while determining the predictor or barrier in CRC screening among Korean Americans,
and the fourth and fifth research questions were to identify the differences in the
predictors and barriers of cancer screening behaviors between the groups by gender and
by length of U. S. residence. In this study, the correlation between ten independent
variables (cultural beliefs, perception of cancer screening, cancer fatalism, knowledge,
health care access, health literacy, physician’s recommendation, acculturation, gender,
and length of U. S. residence) and dependent variable (CRC screening behaviors) were
analyzed by bivariate correlation analysis.
3. Chi-square was used to determine the differences between gender and between the two
groups by length of U. S. residence in CRC screening behaviors. This analysis answered
the research question 4 and 5.
4. Multiple logistic regression was used to examine the association between ten variables
and CRC screening behaviors. This analysis responded to the third research question:
which predictor or barrier has the greatest influence on CRC screening behaviors among
Korean Americans. Stepwise multiple regression analyzed the likelihood of CRC
screening behaviors across various levels of predictors and identify the most important
predictors of CRC screening among Korean Americans.
84
Summary
In Chapter 3, the methods of research were discussed: research design, sample, settings,
measurements, instrument translation, data collection procedures, data analysis procedures with
the procedure for the protection of the human subjects. The methodology for this research study
was a cross-sectional descriptive design with a survey to describe current CRC screening
behaviors among 254 Korean Americans. Bivariate analysis and multiple logistic regression
allowed determining the predictors and barriers from independent variables and the most
influencing factor to CRC screening behaviors among Korean Americans, and Chi-square was
used to determine the differences in CRC screening behaviors between men and women, and
between the two groups divided by length of U. S. residence.
85
CHAPTER IV: RESULTS
The purposes of this study are to: 1) describe CRC screening behaviors among Korean
Americans, 2) identify the predictors and barriers influencing CRC screening behaviors, 3)
identify the differences in the predictors and barriers to CRC screening behaviors between
Korean American men and women, and 4) identify the differences in the predictors and barriers
to CRC screening behaviors between Korean Americans who have lived in the U.S. ≤ 10 years
and those who have lived in the U.S. > 10 years. The results of this study are presented as
follows: (1) description of the study sample; (2) descriptive data analysis of study variables; and
(3) findings addressing the research questions.
Characteristics of Sample
A total of 254 foreign-born Korean Americans aged 50 and older, living in the Greater
Los Angeles area, were purposely recruited from three Korean churches, four Korean grocery
stores, two shopping centers in Korea town, two community health seminars from the Modern
Chronic Diseases Care Institute, the Joong-Ang Cultural Center, two community organizations
working for new immigrants, and two Korean spas. To prevent sampling bias, three churches
were selected from three different areas. One church was located in Pasadena, the north of Los
Angeles, the second one was in the Korea town near downtown Los Angeles, and the third one
was in the Orange County, the south of Los Angeles.
The participants’ demographic and other characteristics are summarized in Table 2. The
mean age of participants was 60.52 years (SD=8.22), ranging from 50 to 85 years. About twothirds of the sample were under 65 years of age (70.5%). More Korean American women (55.5%)
were recruited than men (44.5%). The average length of U.S. residence was 17.59 years
(SD=12.46), ranging from 1 year to 50 years. About 49% of the sample were living in the U.S ≤
86
10 years and 51% were living in the U.S. > 10 years. The majority of the sample was married
(72%), and the mean number of households was 2.61 (SD=1.23) and 39.4% reported households
are 2. More than half of the sample was currently working full time (40.2%) or part time (19.7%),
and 20.5% were retired. About 56% reported an annual household income under $35,000. About
53.3% reported that they had health insurance and 46.5% did not have any health insurance.
About 72% of participants had at least a college education and 58.6% reported college graduate
and above. About 60% responded that their ability to speak English was not well or not at all.
TABLE 2. Characteristics of Demographics of Sample (N=254)
Characteristics
Gender
Male
Female
Length of U.S. Residence
≤ 10 years
> 10 years
Age (years)
50 -64
≥ 65
Marital Status
Married
Living with partner
Divorced / Separated
Widowed
Never married
Employment Status
Working full time (35 hrs or more a week)
Working part time (less than 35 hrs a week)
Retired
Unemployed
Disabled
Homemaker
Education
None
< High School
High school
Vocational/Technical school/Some college
College graduate
Graduate degree
N
(%)
113
141
44.5
55.5
125
129
49.2
50.8
179
75
70.5
29.5
183
15
24
27
5
72
5.9
9.4
10.6
2
102
50
52
13
5
31
40.2
19.7
20.5
5.1
2
12.2
4
15
51
35
120
29
1.6
5.9
20.1
13.6
47.2
11.4
87
TABLE 2. – Continued
Characteristics
Annual Income
< $20,000
$20,000-$35,000
$35000-$50,000
$50,000-$75,000
>$75,000
Number of Household
1
2
3
4
5
6
7
Health Insurance
Yes
No
English speaking
Very well
Well
Not well
Not at all
N
(%)
76
67
34
39
38
29.9
26.4
13.4
15.4
15
44
100
40
55
11
3
1
17.3
39.4
15.7
21.7
4.3
1.2
0.4
136
118
53.5
46.5
27
74
138
15
10.6
29.1
54.3
5.9
Table 3 lists the demographic differences by gender. There were significant differences
between men and women in marital status (X2 (4, N=254)=13.28, p=.010) and employment (X2
(6, N=254)=39.58, p=.000). More women (16.3%) were likely to be widowed than men (3.5%).
About 67% of men compared to 54% of women were working full time or part time. More men
were retired (27%) than women (15%) and 22% of women were homemaker.
88
TABLE 3. Demographic Differences by Gender (N=254)
Characteristics
Age
50-64
≥65
Length of U.S. Residence
≤10 years
>10 years
Marital Status
Married
Living with partner
Divorced /Separated
Widowed
Never married
Education
None
< High school
High school
Vocational/Technical/Some college
College graduate
Graduate degree
Employment
Working full time (≥35hrs a week)
Working part time (<35hrs a week)
Retired
Unemployed
Disabled
Homemaker
Annual Income
<$20.000
$20,000-$35,000
$35,000-$50,000
$50,000-$75,000
>$75,000
Health Insurance
Yes
No
English Speaking Ability
Very well
Well
Not well
Not at all
Men (%)
Women (%)
78 (69%)
35 (31%)
101 (71.6%)
40 (28.4%)
61 (54%)
52 (46%)
64 (45.4%)
77 (54.6%)
88 (77.9%)
9 (8%)
11 (9.7%)
4 (3.5%)
1 (0.9%)
95 (67.4%)
6 (4.3%)
13 (9.2%)
23 (16.3%)
4 (2.8%)
0 (0%)
3 (2.7%)
20 (17.2%)
15 (13.3%)
59 (52.2%)
16(14.2%)
4 (2.8%)
12 (8.5%)
31 (22%)
20 (14.2%)
61 (43.3%)
13 (9.2%)
57 (50.4%)
19 (16.8%)
31 (27.4%)
3 (2.7%)
2 (1.8%)
0 (0%)
45 (31.9%)
31 (22%)
21 (14.9%)
10 (7.1%)
3 (2.1%)
31 (22%)
31 (27.4%)
30 (26.5%)
14 (12.4%)
17 (15%)
21 (18.6%)
45 (31.9%)
37 (26.2%)
20 (14.2%)
22 (15.6%)
17 (12.1%)
62 (54.9%)
51 (45.1%)
74 (52.5%)
67 (47.5%)
15 (13.3%)
38 (33.6%)
56 (49.6%)
4 (3.5%)
12 (8.5%)
36 (25.5%)
82 (58.2%)
11 (7.8%)
Table 4 lists the demographic differences by length of U.S. residence. For length of U.S.
residence, there were significant differences between Korean Americans who have lived in the
89
U.S. ≤ 10 year and those who lived in the U.S. > 10 years for marital status, education,
employment, household annual income, health insurance, and English speaking ability.
Average length of U.S. residence of the participants who lived in the U.S. ≤ 10years was
6.8 years while those of participants who have lived in the U.S. > 10 years was 28.05 years (X2
(40, N=254)=254, p=.000). In marital status, 8.8% of the participants who lived in the U.S. ≤ 10
years were divorced while those who have lived in the U.S. > 10 years were 3.1%, and 8% of the
participants who lived in the U.S. ≤ 10years were widowed while those who have lived in the
U.S. > 10 years were 13.2% (X2 (4, N=254)=10.31, p=.035).
About 92% of the sample were high school or above in education, but the participants
who have lived in the U.S. > 10 years showed a higher level of education compared to those who
have lived in the U.S. ≤10 years (X2 (5, N=254)=15.62, p=.008). The participants who had lived
in the U.S. ≤ 10 years had lower household annual income than those who have lived in the U.S.
longer (X2 (4, N=254)=23.65, p=.000). Only 16.8% of new immigrants reported annual income
greater than $50,000 and 67.2% of them reported their annual income was less than $35,000.
The significant difference between the two groups was for health insurance (X2 (1,
N=254)=33.29, p=.000). About 54% of the sample had health insurance. However, 71.3% of the
participants who have lived in the U.S. > 10 year reported they had health insurance, and only
35.2% of the participants who have lived in the U.S. ≤ 10 years had health insurance.
Korean Americans who have lived in the U.S. > 10 years were more fluent in speaking
English than those who have lived in the U.S. ≤ 10 years (X2 (3, N=254)=37.27, p=.000). About
77% of the participants who have lived in the U.S. ≤ 10 years responded they speak English not
well or not at all, the other hand, 44.2% of those who have lived in the U.S. > 10 years responded.
90
TABLE 4. Demographic Differences by Length of U.S. Residence (N=254)
Characteristics
Age
50-64
≥ 65
Marital Status
Married
Living with partner
Divorce/Separated
Widowed
Never Married
Education
None
< High school
High school
Vocational/Technical/Some College
College graduate
Graduate degree
Employment Status
Working full time (≥ 35hrs a week)
Working part time (< 35hrs a week)
Retired
Unemployed
Disabled
Homemaker
Annual Income
< $20,000
$20,000-$35,000
$35,000-$50,000
$50,000-$75,000
> $75,000
Health Insurance
Yes
No
English Speaking Ability
Very well
Well
Not well
Not at all
LOS ≤ 10 yrs (%)
LOC > 10 yrs (%)
98 (78.4%)
27 (21.6%)
81 (62.8%)
48 (37.2%)
85 (68%)
11 (8.8%)
17 (13.6%)
10 (8.0%)
2 (1.6%)
98 (76%)
4 (3.1%)
7 (5.4%)
17 (13.2%)
3 (2.3%)
4 (3.2%)
13 (10.4%)
23 (18.4%)
18 (14.4%)
57 (45.6%)
10 (8%)
0 (0%)
2 (1.6%)
28 (21.7%)
17 (13.2%)
63 (48.8%)
19 (14.7%)
49 (39.2%)
33 (26.4%)
17 (13.6%)
7 (5.6%)
2 (1.6%)
16 (12.8%)
53 (41.1%)
17 (13.2%)
35 (27.1%)
6 (4.7%)
3 (2.3%)
15 (11.6%)
45 (36.0%)
39 (31.2%)
20 (16%)
14 (11.2%)
7 (5.6%)
31 (24%)
28 (21.7%)
14 (10.9%)
25 (19.4%)
31 (24%)
44 (35.2%)
81 (64.8%)
92 (71.3%)
37 (28.7%)
4 (3.2%)
25 (20%)
82 (65.6%)
14 (11.2%)
23 (17.8%)
49 (38%)
56 (43.4%)
1 (0.8%)
91
Description of Study Variables
This study involved the ten independent variables and one dependent variable. The ten
independent variables included cultural beliefs, perception of cancer screening, knowledge,
cancer fatalism, health care access, health literacy, physician’s recommendation, acculturation,
gender, and length of U.S. residence. The dependent variable is CRC screening behaviors
including fecal occult blood test (FOBT), colonoscopy, and sigmoidoscopy.
CRC Screening Behaviors
Table 5 summarized the results of CRC screening behaviors. About 90% of the
participants in this study (N= 227, 89.4%) had heard about CRC. Only 33.5% of the participants
have ever had a FOBT, and 20% who have ever had a FOBT performed in doctor’s office. The
majority (85%) among those who have had a FOBT responded that they had a FOBT as part of a
routine exam.
About 49% of the sample reported they had a colonoscopy. About 88% among those who
have had a colonoscopy reported having it as part of a routine exam as a main reason for having
had a colonoscopy. About 19% of the sample responded they have had a sigmoidoscopy in their
life. The main reason for having had a sigmoidoscopy was part of a routine exam (93.7%). The
most important reason they did/don’t have CRC screening tests was “Haven’t had any symptom”
(29.1%), “No reason/Never thought of it” (18.9%), and “Too expensive/No health insurance”
(13.8%) were followed.
92
TABLE 5. CRC Screening Behaviors among Korean Americans (N=254)
Characteristics
Heard about CRC
Yes
No
FOBT
Ever had one
Never had one
Colonoscopy
Ever had one
Never had one
Sigmoidoscopy
Ever had one
Never had one
Most important reason did/don't have these tests
Haven't had any symptom
No reason/Never thought of it
Too expensive/No insurance
Doctor didn't tell me I needed it
Didn't know I needed this type of test
Put it off/Laziness
N
(%)
227
27
89.4
10.6
85
169
33.5
66.5
124
130
48.8
51.2
48
206
18.9
81.1
74
48
35
19
18
16
29.1
18.9
13.8
7.5
7.1
6.3
There were no significant differences by gender in CRC screenings except for awareness.
More men were aware of CRC screening than women (X2 (1, N=254)=4.22, p=.040). There were
differences by gender in the reasons they did/don’t have CRC screening tests. Men responded
that the most important reasons they did/don’t have CRC screening tests were “Haven’t had any
problem” (34.8%) and “No reason/Never thought of it” (21.4%), while women reported that
“Haven’t had any problem (25.2%), “Too expensive/No health insurance”(18%), and “No
reason/Never thought of it” (17.3%). Cost and health insurance were more concerns for women
than men, but this difference was not significant (X2 (12, N=254)=12.71, p=.390).
However, there were significant differences in length of U.S. residence on all CRC
screenings even though CRC awareness was not different between the two groups. The results of
CRC screening behaviors between the two groups divided by length of U.S. residence
summarized in Table 6.
93
Korean Americans who have lived in the U.S. ≤ 10 years had lower rates of all CRC
screening tests than those who have lived in the U.S. > 10 years and these differences were
significant. Only 26% of new immigrants had ever had a FOBT, while 41% of the counterpart
had that test. This difference was significant (X2 (1, N=254)=6.84, p=.009). About 36% of new
immigrants have ever had a colonoscopy, while 61% of the counterpart had a colonoscopy, and
this difference was significant (X2 (1, N=254)=16.19, p=.000). Only 10% of new immigrant had
ever had a sigmoidoscopy, while 27% of the counterpart had this test, and it was also a
significant difference (X2 (1, N=254)=11.60, p=.001).
There were significant differences in length of U.S. residence on the main reason to have
in a colonoscopy and a sigmoidoscopy. More Korean Americans who have lived in the U.S. > 10
years responded that the main reason for having had the most recent CRC screenings was a part
of routine exam than new immigrants: colonoscopy (X2 (5, N=254)=28.54, p=.000), and
sigmoidoscopy (X2(3, N=254)=15.50, p=.001).
There were significant differences in length of U.S. residence in the reason they did/don’t
have the CRC screening tests (X2 (12, N=254)=38.09, p=.000). Korean Americans who have
lived in the U.S. > 10 years responded that “Haven’t had any problem” (21.4%) and “No
reason/Never thought of it” (19%), while those have lived in the U. S. ≤ 10 years responded
“Haven’t had any problem” (37.6%), “Too expensive/No insurance” (19.2%), and “No reason/
Never thought of it” (19.2%) for the main reason did/don’t have CRC screening tests.
94
TABLE 6. CRC Screening Behaviors by Length of U.S. Residence
Characteristics
FOBT
Ever had one
Never had one
Main reason to have a FOBT
Part of a routine exam
Because of a problem
Colonoscopy
Ever had one
Never had one
Main reason to have a colonoscopy
Part of a routine exam
Because of a problem
Sigmoidoscopy
Ever had one
Never had one
Main reason to have a sigmoidoscopy
Part of a routine exam
Because of a problem
Main reason did/don't have these tests
Haven’t had any problem
No reason/Never thought of it
Too expensive/No health insurance
LOS ≤ 10yrs
N
(%)
LOS > 10yrs
N
(%)
32
93
25.6
74.4
53
76
41.1
58.9
27
4
21.6
3.2
45
5
34.9
3.9
45
80
36
64
79
50
61.2
38.8
38
2
30.4
1.6
71
8
55
6.2
13
112
10.4
89.6
35
94
27.1
72.9
12
0
9.6
0
33
3
25.6
2.3
47
24
24
37.6
19.2
19.2
27
24
11
21.4
19
8.7
Dependent Variables
Cultural beliefs. About 74% of the sample believed that hygiene is a cause of CRC, 66.5%
were smoking, 40.2% were heredity, and 87.4% of them believed God’s will for a cause of CRC.
More women (33.3%) were likely believed hygiene is a cause of CRC than men (17.6%) and it
was a significant difference (X2 (1, N=254)=7.90, p=.005). However, there was no significant
difference of overall cultural beliefs of a cause of CRC between men and women (X2 (4,
N=254)=1.66, p=.798).
Korean Americans who have lived in the U.S. ≤ 10 years believed that less effect of
smoking and more the effect of heredity for a cause of CRC than those who have lived in the U.S.
> 10 years. These differences were significant for smoking (X2 (1, N=254)=8.83, p=.003) and
95
heredity (X2 (1, N=254)=10.75, p=.001). However, overall cultural beliefs on a cause of CRC
were not significantly different by length of U. S. residence (X2 (4, N=254)=7.50, p=.114).
Perception of cancer screening. In the perception of cancer screening, a half of the
sample (50.4%) had an annual physical exam and 20% had rectal exam. About 63% of women
had a mammogram and 56.6% of women had a Pap smear. There were no significant differences
by gender in an annual physical exam (X2 (1, N=254)=.07, p=.790), and also a rectal exam (X2 (1,
N=254)=.17, p=.679).
Significant differences were noted on an annual physical exam (X2 (1, N=254)=36.27,
p=.000) and rectal exam (X2(1, N=8.13, p=.004) by length of U.S. residence. Table 7
summarized the relationship between perception of cancer screening and length of U.S. residence.
More Korean Americans who had lived in the U.S. > 10 years reported having had an annual
physical exam and rectal exam than those who have lived in the U.S. ≤ 10 years.
The most important reason they did/do not have one of these tests was “Haven’t had any
problem (26%), and “Too expensive/No insurance” was followed (21.3%). Most men reported
“Haven’t had any problem (33.6%), while most women reported “Too expensive/No health
insurance” (28.8%). However, there was no significant difference between men and women (X2
(11, N=254)=17.81, p=.086).
There were significant differences on the most important reason did/do not have one of
these tests by length of U.S residence (X2 (11, N=254)=27.13, p=.004). Korean Americans who
have lived in the U.S. ≤10 years had more concerns of cost and health insurance than those who
have lived in the U.S. >10 years. Korean Americans who have lived in the U.S. > 10 years
reported “Haven’t had any problem (23.6%), while those who have lived in the U.S. ≤ 10 years
reported “Too expensive/No health insurance” (30.4%) and “Haven’t had any problem” (28.8%).
96
TABLE 7. Relationship between Cultural Beliefs and Perception of Cancer Screening and
Length of U.S. Residence
Characteristics
Cultural Beliefs
Smoking
Yes
No
God’s Will
Yes
No
Hygiene
Yes
No
Heredity
Yes
No
Perception of Cancer Screening
Annual Physical Examination
Yes
No
Rectal Exam
Yes
No
Mammogram
Yes
No
Pap Smear
Yes
No
Most important reason did/do not have one of
these tests:
Too expensive/No health insurance
Haven’t had any problem
Too painful/unpleasant/embarrassing
LOS ≤ 10 yrs
N
%
LOS > 10 yrs
N
%
72
53
57.6
42.4
97
32
75.1
24.9
106
16
84.6
15.2
116
13
89.9
10.1
32
93
25.6
74.4
35
90
27.1
69.8
63
62
50.4
49.6
39
90
30.2
69.8
39
86
31.2
68.8
89
40
69
31
16
109
12.8
87.2
35
94
27.1
72.9
36
29
55.4
44.6
56
22
70
27.5
38
27
58.5
41.5
44
34
55
42.5
38
36
2
30.4
28.8
1.6
16
30
43.1
12.6
23.6
_____________________________________________________________________________________________
Knowledge of CRC. Korean Americans of this sample had moderate knowledge of CRC
and screening (M=6.91, SD=2.11). There were no significant differences in knowledge of CRC
by gender (X2 (12, N=254)=6.25, p=.903). The participants who have lived in the U.S. > 10
years had more knowledge of CRC and screening than those have lived in the U.S. ≤10 years,
but this difference was not significant (X2 (12, N=254)=19.99, p=.067).
97
Cancer fatalism. Korean Americans of this sample had very low cancer fatalism
(M=2.43, SD=3.10). There was no statistical significant difference on cancer fatalism between
men and women (X2 (13, N=254)=9.74, p=.715). However, significant difference was found on
the cancer fatalism by length of U.S. residence (X2 (13, N=254)=24.28, p=.029). Korean
Americans who have lived in the U.S. ≤ 10 years had more cancer fatalism than those who have
lived in the U.S. > 10 years.
Health literacy. Korean Americans of this sample represented limited CRC health
literacy (M=4.57, SD=2.11). There were no significant differences by gender (X2 (10,
N=254)=6.59, p=.764) and by length of U.S. residence (X2 (10, N=254)=7.63, p=.665).
Health care access. About 54% of the sample reported they had health insurance. About
16% had Medicare, and Medicaid/Medi-CAL (13.4%), employer (13.4%) were followed. About
11% of the sample purchased directly from the health plan. Even though 46% of the sample
reported they were uninsured, 67% had a usual source of care and 53% were going to doctor’s
offices for health care. About 39% of the sample reported “Can’t afford/Too expensive” and 4.7%
responded “Not eligible due to working status” for the main reason they do not have any health
insurance. About 39% of the sample visited physicians one or two times in the past one year, but
21% have never visited physicians at all. Although this sample had limited health care access,
72.4% of them reported they didn’t delay or get health care when they needed and 64.6%
reported cost or lack of insurance were not reasons when they delayed or didn’t get health care.
There were no gender differences in having a health insurance (X2 (1, N=254)=.14,
p=.705), an usual source of care (X2 (1, N=254)=.95, p=.330), place for the health care (X2 (1,
N=254)=.95, p=.705), and types of health insurance (X2 (5, N=254)=8.33, p=.139). However,
more women were concerned about cost than men. More women (45.3%) responded “Can’t
98
afford/Too expensive” for the main reason they do not have health insurance than men (31.8%).
About 41% of women reported that cost or lack of health insurance were the reason for the delay
or didn’t get health care when they needed health care, while 28.3% of men reported. This
difference was significant (X2 (1, N=254)=4.50, p=.034).
Significant differences were noted on health care access by length of U.S. residence
(Table 8). Korean Americans who have lived in the U.S. ≤ 10 years had lower rates of health
insurance and usual sources of care as compared to those who have lived in the U.S. >10 years.
These differences were significant for having health insurance (X2 (1, N=254)=33.29, p=.000)
and an usual source of care (X2 (1, N=254)=15.30, p=.000) between the two groups.
The types of health insurance were also different between the two groups by length of
U.S. residence (X2 (5, N=254)=35.91, p=.000). About 13% of Korean Americans who have lived
in the U.S. ≤ 10 years had Medicaid/Medi-CA, and employer-based health insurance (10.4%),
purchased directly from the health plan (7.2%) and Medicare (6.4%) followed. About 26% of
Korean Americans who have lived in the U.S. > 10 years had Medicare, and employer (16.2%),
purchased directly from the health plan (14.7%) and Medicaid/Medi-CAL (13.9%) followed.
During the past 12 months, 66% of new immigrants have ever had no health insurance
while 35% of Korean Americans who have lived in the U.S. > 10 years have ever had no health
insurance. This difference was significant (X2 (2, N=254)=25.67, p=.000). About 50% of new
immigrants reported “Can’t afford/Too expensive” for the main reason they do not have health
insurance, while 31.8% of those who have lived in the U.S. > 10 years reported. This difference
was significant (X2 (7, N=254)=37.00, p=.000).
More new immigrants reported that they delayed or didn’t get health care when they
needed than those who have lived in the U.S. >10 years (X2 (1, N=254)=10.53, p=.001). New
99
immigrants reported cost or lack of health insurance for the reasons for delayed or didn’t get
health care when they needed while those who have lived in the U.S. > 10 years responded with
this reason. This difference was also significant (X2 (1, N=254)=16.99, p=.001).
TABLE 8. Relationship between Healthcare Access and Length of U.S. Residence (N=254)
Characteristics
LOS ≤ 10 years
N
%
Health insurance
Yes
44
No
81
Usual source of care
Yes
69
No
56
Type of health insurance
Current or former employer
13
Purchased from the health
9
plan
Medicare
8
Medicaid/Medi-CAL
16
No health insurance during the past 12 months
Yes
83
No
42
Main reason do not have any health insurance
Can’t afford/Too expensive
59
Not eligible due to working
10
status/change employer
Not eligible due to
7
citizenship immigration
status
Delay or didn’t get health care
Yes
46
No
79
Cost or lack of health insurance were reasons
Yes
60
No
65
LOS ˃ 10 years
N
%
35.2
64.8
92
37
71.3
28.7
35.2
64.8
101
28
78.3
21.7
10.4
7.2
21
19
16.2
14.7
6.4
12.8
33
18
25.5
13.9
66.4
33.6
45
83
34.8
65.2
47.2
8
41
2
31.8
1.5
5.6
0
0
36.8
63.2
24
105
18.6
81.3
48
52
30
99
23.3
76.7
Physician’s recommendation. Table 9 summarized the results of physician’s
recommendation for CRC screening. About 58% of the sample (N=254) responded that they
have personal doctors or medical providers, but only 38% of the sample received physician’s
recommendations. The main reasons they do not follow the physician’s recommendation were
100
“Haven’t had any problem” (18.1%), “No reason/Never thought of it” (10.6%), and “Too
expensive/No insurance/Cost” (7.1%).
There were no differences by gender in physician’s recommendation (X2 (1, N=254)
=.001, p=.976) but significant differences were noted by length of U.S. residence. Korean
Americans who have lived in the U.S. > 10 years had higher rates of having personal doctors or
medical providers than those who have lived in the U.S. ≤ 10 years (X2 (2, N=252)=45.94,
p=.000). Korean Americans who have lived in the U.S. > 10 years received more physician’s
recommendations for CRC screening than new immigrants who have lived in the U.S. ≤ 10 years
(X2 (1, N=234)=14.24, p=.000).
The reasons do not follow the physician’s recommendation for CRC screening were also
different between the two groups. More Korean Americans who have lived in the U.S. ≤ 10 years
responded “Too expensive/No health insurance/Cost” than those who have lived in the U.S. > 10
years. This difference was significant (X2 (7, N=254)=14.87, p=.038).
TABLE 9. Relationship between Physician’s Recommendation and Length of U.S. Residence
Characteristics
Having a personal doctor or medical providers
Yes
No
Receiving a physician's recommendation of CRC screening
Yes
No
LOS ≤ 10yrs
N
%
N
LOS > 10yrs
%
47
77
37.6
61.6
101
26
79.5
20.5
31
78
28.4
71.6
66
59
52.8
47.2
HBM scale. Korean Americans of this study showed low perceived susceptibility
(M=7.78, SD=3.09) and low perceived seriousness (M=15.3, SD=5.79) for CRC with moderate
perceived barriers (M=38.2, SD=11.14) for CRC screenings even though they had high perceived
benefits (M=20.5, SD=4.77) of CRC screenings.
101
There were no significant differences by gender in perceived susceptibility, seriousness,
benefits, and barriers for CRC and screening. However, there were significant differences in
perceived barriers (X2 (118, N=252)=147.32, p=.035) by length of U.S. residence. Korean
Americans who have lived in the U.S. ≤ 10 years had higher rates of perceived barriers for CRC
and screening than those who have lived in the U.S. > 10 years. Table 10 summarized the results
of the HBM scale for CRC and screening by length of U. S. residence.
TABLE 10. HBM Scale for CRC and Screening among Korean Americans (N=252)
Characteristics
Susceptibility
Seriousness
Benefits
Barriers
LOS ≤ 10yrs (N=125)
Mean (SD)
8.45 (3.14)
16.68 (5.45)
20.96 (4.08)
41.86 (10.52)
LOS > 10yrs (N=127)
Mean (SD)
7.12 (2.91)
13.89 (5.80)
20.12 (5.35)
34.77 (10.64)
Acculturation. Korean Americans of this study showed moderate acculturation
(M=41.02, SD=13.60) to the western culture. There were no significant differences in Korean,
Asian, and western culture between men and women and between the two groups divided by
length of U.S. residence.
Correlations between CRC Screening Behaviors and Independent Variables
Table 11 summarized the results of correlation between CRC screening behaviors and the
independent variables (cultural beliefs, perceptions of cancer screenings, CRC knowledge,
cancer fatalism, CRC health literacy, health care access, physician’s recommendation,
acculturation, gender, and length of U.S. residence). All three CRC screenings were positively
associated with each other. All three CRC screening behaviors were positively associated with
length of U S. residence, perceptions of cancer screening, CRC knowledge, health insurance,
physician’s recommendations, and perceived barriers. At least two of three CRC screening
102
behaviors were related to cancer fatalism, having a usual source of care, having a personal doctor
or medical providers, and acculturation to western culture.
Having a FOBT was associated with length of U.S. residence (r=.16, p=009), perception
of cancer screening (men: r=.30, p=.000; women: r=.25, p=.000), CRC knowledge (r=.20,
p=.002), cancer fatalism (r= -.13, p=.038), health insurance (r=.21, p=.001), having had a
personal doctor or medical providers (r= .15, p=.016), physician’s recommendation (r=.21,
p=.001), perceived barrier (r=-.25, p=.000), and acculturation (r=.18, p=.004).
Having a colonoscopy was significantly associated with length of U.S. residence (r=.25,
p=.000), perception of cancer screening (men: r=.35, p=.000; women: r=.19, p=.002), CRC
knowledge (r=.14, p=.027), usual source of care (r=.17, p=.007), health insurance (r=.26,
p=.000), physician’s recommendation (r=.38, p=.000), and perceived barriers (r= -.34, p=.000).
Having a sigmoidoscopy was significantly associated with length of U.S. residence
(r=.21, p=.001), perception of cancer screening (men: r=.20, p=.001; women: r=.18, p=.004),
CRC knowledge (r=.25, p=.000), cancer fatalism (r= -.16, p=.014), CRC literacy (r=.14, p=.026),
usual source of care (r=.13, p=.046), health insurance (r=.13, p=.043), physician’s
recommendation (r=.27, p=.000), and perceived barriers (r= -.24, p=.000).
103
TABLE 11. Correlations Matrix between CRC Screening Behaviors and Independent Variables
1
2
1
.259***
1. FOBT
1
2. Colonoscopy
3. Sigmoidoscopy
4. Sex
5. Length of US
residence
6. Cultural Beliefs
7. Perception_M
8. Perception_F
9. CCKQ
10. Fatalism
11. ACCL
12. Usual source of
care
13. Health Insurance
14. Physician's
recommendation
15. Acculturation
** p < 0.01 (2-tailed).
* p < 0.05 level (2-tailed).
5
6
7
8
9
10
11
12
13
14
15
.318**
3
.098
4
.164**
.088
.295**
.248**
.197**
-.131*
.064
.091
.209**
.206**
.182**
.394**
-.013
.252**
.006
.346**
.192**
.139*
-.084
.003
.168**
.262**
.376**
.113
1
.007
.214**
.125*
.199**
.182**
.250**
-.155*
.140*
.126*
.127*
.272**
.153*
1
.085
.079
-.024
.585**
.071
-.055
.026
.061
-.024
.002
-.141*
1
.025
.340**
.204**
.126*
-.230**
.107
.245**
.362**
.247**
.344**
1
.015
.131*
.235**
-.097
.107
.084
-.008
.050
.088
1
.418**
.208**
-.196**
.144*
.352**
.507**
.362**
.283**
1
.142*
-.138*
.130*
.194**
.221**
.239**
.069
1
-.367**
.453**
.133*
.136*
.212**
.161*
1
-.149*
-.240**
-.100
-.047
-.179**
1
.167**
.074
.208**
.171**
1
.318**
.311**
.134*
1
.414**
.193**
1
.164*
1
Findings Related to Research Questions
Research Question One
What are the predictors of CRC screening behaviors among Korean Americans?
The first research question was addressed by correlation analysis. Table 11 lists the
results of correlation analysis between CRC screening behaviors and the independent variables.
The significant predictors of CRC screening (FOBT, colonoscopy, and sigmoidoscopy) were the
length of U.S. residence, perception of cancer screening, CRC knowledge, having an usual
source of care, health insurance, having personal doctors/medical providers, physician’s
recommendation, and acculturation.
Length of U.S. residence, perception of cancer screening, and the physician’s
recommendation were strongly positively associated with having had all three CRC screenings
(FOBT, colonoscopy, and sigmoidoscopy). CRC knowledge and acculturation were moderately
associated with having had all CRC screenings. Having had a personal doctor or medical
providers was positively associated with colonoscopy and sigmoidoscopy, and usual source of
104
care was positively related to FOBT and colonoscopy. Perception of cancer screening was the
strongest predictor for a FOBT, and the physician’s recommendation was the strongest predictor
for colonoscopy and sigmoidoscopy.
Research Question Two
What are the barriers to engaging in CRC screening behaviors among Korean Americans?
The correlation analysis was used to determine the barriers of CRC screening behaviors
(Table 11). The significant barriers for all CRC screening behaviors were perceived barriers and
health insurance. Perceived barrier was negatively associated with having had all CRC screening,
and it was the strongest barrier to having CRC screening. Cancer fatalism was a moderate barrier
for having had FOBT and sigmoidoscopy.
Research Question Three
Which predictor or barrier has the greatest influence on CRC screening behaviors?
Logistic regression analysis with stepwise methods was used to determine the greatest
predictor or barrier to influence on CRC screenings. Table 12 summarized the result for a FOBT.
In the final model, perceptions to cancer screening was determined as the greatest predictor to a
FOBT among length of U.S. residence, perception of cancer screening, CRC knowledge, cancer
fatalism, health insurance, physician’s recommendation, perceived barriers, and acculturation.
Korean Americans who had positive perceptions of cancer screening (annual physical exam and
periodic cancer screening) had more than four times greater odds of ever having had a FOBT
(OR= 4.008, 95% CI 2.058, 7.807) than those who had negative perceptions of cancer screening.
105
TABLE 12. Logistic Regression Analysis: Predictor of Ever Having Had a FOBT
Variable
Perception of cancer
screening
Constant
B
1.388
Wald
16.661
Sig.
.000
Exp(B)
4.008
-1.001
36.605
.000
.368
95% C.I. for EXP(B)
Lower
Upper
2.058
7.807
Length of U.S. residence, perception of cancer screening, CRC knowledge, having a
usual source of care, health insurance, physician’s recommendation, and perceived barriers were
associated with ever having had a colonoscopy. The final logistic regression model included the
physician’s recommendation as a strong predictor (Table 13). Korean Americans who had the
physician’s recommendations for a colonoscopy were almost five times greater odds of having
had a colonoscopy (OR= 4.992, 95% CI 2.821, 8.834) than those who did not receive a
physician’s recommendation.
TABLE 13. Logistic Regression Analysis: Predictor of Ever Having Had a Colonoscopy
Variable
Physician's
recommendations
Constant
B
1.608
Wald
30.479
Sig.
.000
Exp(B)
4.992
-.617
11.888
.001
.539
95% C.I. for EXP(B)
Lower
Upper
2.821
8.834
Length of U.S. residence, perception of cancer screening, CRC knowledge, cancer
fatalism, CRC literacy, having had a usual source of care, health insurance, physician’s
recommendation, and perceived barriers were associated with ever having had a sigmoidoscopy.
The final model included the physician’s recommendations as a strong predictor for ever having
had a sigmoidoscopy (Table 14). Korean Americans who had had the physician’s
recommendation were more than four times greater odds of ever having had a sigmoidoscopy
than those didn’t have the physician’s recommendation (OR=4.190, 95% CI 2.083, 8.430).
106
TABLE 14. Logistic Regression Analysis: Predictors of Ever Having Had a Sigmoidoscopy
Variable
Physician's
recommendation
Constant
B
1.433
Wald
16.137
Sig.
.000
Exp(B)
4.190
-2.173
59.358
.000
.114
95% C.I. for EXP(B)
Lower
Upper
2.083
8.430
Research Question Four
What are the differences in the predictors and barriers to CRC screening behaviors
between Korean American men and women?
There were no significant differences between Korean American men and women in the
predictors and barriers to all three CRC screenings and CRC screening behaviors this study.
Table 15 summarized the descriptive data of the differences of CRC screening behaviors by
gender.
TABLE 15. The Differences of CRC Screening Behaviors and Variables by Gender
Variables
FOBT
Colonoscopy
Sigmoidoscopy
Length of US residence
Cultural Beliefs
Perception_Male
Perception_Female
Knowledge
Health Literacy
Fatalism
Usual Source of Care
Health Insurance
Physician’s Recommendation
Acculturation
Susceptibility
Seriousness
Benefits
Barriers
Mean
0.28
0.50
0.19
1.46
2.13
0.73
0.15
6.74
4.51
2.62
0.64
0.55
0.41
43.15
7.99
15.13
20.45
38.74
Men (N=112)
SD
SE Mean
0.45
0.50
0.39
0.50
0.81
0.77
0.96
2.16
2.22
3.20
0.48
0.50
0.49
12.81
3.22
5.16
4.63
11.09
0.04
0.05
0.04
0.05
0.08
0.07
0.09
0.20
0.21
0.30
0.05
0.05
0.05
1.21
0.30
0.49
0.44
1.05
Mean
Women (N=140)
SD
SE Mean
0.38
0.48
0.19
1.55
2.26
0.69
1.91
7.04
4.62
2.28
0.70
0.52
0.42
39.30
7.61
15.39
20.61
37.93
0.49
0.50
0.39
0.50
0.83
0.77
1.39
2.07
2.04
3.02
0.46
0.50
0.49
14.02
2.98
6.26
4.90
11.22
0.04
0.04
0.03
0.04
0.07
0.06
0.12
0.17
0.17
0.25
0.04
0.04
0.04
1.19
0.25
0.53
0.41
0.95
107
Research Question Five
What are the differences in the predictors and barriers to CRC screening behaviors
between Korean Americans who have lived in the U.S. ≤ 10 years and those who have lived in
the U.S. > 10 years?
Table 16 summarized the descriptive data of CRC screening behaviors by length of U.S.
residence. Significant differences were found in all three CRC screening behaviors and most of
variables between the two groups by length of U.S. residence: perception of cancer screenings,
cancer fatalism, usual sources of care, health insurance, physician’s recommendations, and
perceived barriers (p < .05). However, cultural beliefs, CRC knowledge, CRC health literacy,
perceived susceptibility, perceived seriousness, perceived benefits, and acculturation didn’t have
any differences between the two groups (p >.05).
TABLE 16. The Differences of CRC Screening Behaviors by Length of U.S. Residence
Variables
FOBT
Colonoscopy
Sigmoidoscopy
Gender
Cultural Beliefs
Perception_Male
Perception_Female
Knowledge
Health Literacy
Fatalism
Usual Source of Care
Health Insurance
Physician’s Recommendation
Acculturation
Susceptibility
Seriousness
Benefits
Barriers
LOS ≤ 10 years (N=125)
Mean
SD SE Mean
0.26
0.36
0.10
1.51
2.18
0.44
0.82
6.64
4.34
3.15
0.55
0.35
0.28
36.34
8.45
16.68
20.97
41.87
0.44
0.48
0.31
0.50
0.89
0.68
1.25
2.26
2.00
3.65
0.50
0.48
0.45
10.71
3.14
5.45
4.08
10.53
0.04
0.04
0.03
0.04
0.08
0.06
0.11
0.20
0.18
0.33
0.04
0.04
0.04
0.96
0.28
0.49
0.36
0.94
LOS > 10 years (N=127)
Mean
SD SE Mean
0.41
0.61
0.27
1.60
2.22
0.96
1.43
7.17
4.80
1.73
0.78
0.71
0.53
45.67
7.11
13.89
20.12
34.77
0.49
0.49
0.45
0.49
0.74
0.76
1.65
1.94
2.21
2.27
0.41
0.45
0.50
14.57
2.91
5.80
5.35
10.64
0.04
0.04
0.04
0.04
0.07
0.07
0.15
0.17
0.19
0.20
0.04
0.04
0.04
1.30
0.26
0.51
0.47
0.94
108
Table 17 lists the differences of predictors and barriers in CRC screening behaviors
between the two groups divided by length of U.S. residence. Both groups had the same barriers
(perceived barriers and health insurance) for having CRC screening, but the predictors were
different between the two groups except for CRC knowledge and the physician’s
recommendation.
TABLE 17. Predictors and Barriers between the Two Groups Divided by Length of U.S.
Residence
LOS > 10 years
LOS
Predictors
Barriers
Perception of cancer screening
Physician’s recommendation
CRC Knowledge
Having a doctor/medical provider
Perceived barriers
Health insurance
Physician’s recommendation
CRC Knowledge
Perceived barriers
Health insurance
Korean Americans who have lived in the U.S. ≤ 10 years. The perception of cancer
screening (annual physical exam and rectal exam), physician’s recommendation, CRC
knowledge, and having a doctor/medical provider were the important predictors for CRC
screening behaviors in this group. Logistic regression analyses were illustrated in Table 18, 19,
and 20 for CRC screening behaviors among Korean Americans who have lived in the U.S. ≤ 10
years.
New immigrants were more than 3.5 times greater odds of ever having had a FOBT than
those who didn’t have had positive perceptions of cancer screening (OR 3.524, 95% CI 1.866,
6.654). New immigrants were more than four times greater odds of ever having had a
colonoscopy than those who didn’t receive physician’s recommendations (OR 4.348, 95% CI
1.800, 10.505), and were more than 1.7 times greater odds of ever having had a sigmoidoscopy
than those who didn’t have CRC knowledge (OR 1.705, 95% CI 1.180-2.462).
109
TABLE 18. Logistic Regression: Predictors of Ever Having Had a FOBT of LOS ≤ 10 Years
Variable
Perception of Cancer Screening
Constant
95% C.I EXP(B)
B
Wald Sig. Exp(B) Lower
Upper
1.259 15.075 .000
3.524
1.866
6.654
-1.783 29.934 .000
.168
Group = LOS < 10yrs
TABLE 19. Logistic Regression: Predictors of Ever Having Had a Colonoscopy of LOS ≤ 10
Years
B
Wald
Step 1a Physician’s Recommendation
1.470 10.663
Constant
-.872 12.327
Step 2b Perception
.715 5.026
Physician’s Recommendations 1.138 5.661
Constant
-1.140 16.024
Sig.
.001
.000
.025
.017
.000
Exp(B)
95% C.I. for EXP(B)
Lower
Upper
4.348
.418
2.043
3.121
.320
1.800
10.505
1.094
1.222
3.816
7.968
a. Variable(s) entered on step 1: Physician’s Recommendations
b. Variable(s) entered on step 2: Perception of Cancer Screening
c. Group = LOS ≤ 10yrs
TABLE 20. Logistic Regression: Predictor of Ever Having Had a Sigmoidoscopy of LOS ≤ 10
Years
CCKQ
Constant
95% C.I.for EXP(B)
B
Wald Sig. Exp(B)
Lower
Upper
.533 8.080 .004
1.705
1.180
2.462
-6.080 15.130 .000
.002
a. Variable(s) entered on step 1: CCKQ.
b. Group = LOS ≤ 10yrs
Korean Americans who have lived in the U.S. >10 years. The physician’s
recommendation was the most important predictor for all CRC screening among Korean
Americans who have lived in the U.S. > 10years. Logistic regression analyses list for the most
important predictor of CRC screenings in this group in Table 21, 22, and 23.
Korean Americans who have lived in the U.S. > 10 years were more than 2.7 times
greater odds of ever having had a FOBT than those who didn’t receive a physician’s
recommendation (OR 2.771, 95% CI 1.306, 5.880), were more than 4.5 times greater odds of
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ever having had a colonoscopy (OR 4.533, 95% CI 2.090, 9.833), and more than 3.9 times
greater odds of ever having had a sigmoidoscopy than those who didn’t receive physician’s
recommendations in this group.
TABLE 21. Logistic Regression: Predictor of Ever Having Had a FOBT of LOS ≥10 Years
Physician’s Recommendations
Constant
B
1.019
-.989
95% C.I. for EXP(B)
Wald Sig.
Exp(B) Lower
Upper
7.054 .008
2.771
1.306
5.880
11.397 .001
.372
a. Variable(s) entered on step 1: Physician’s Recommendations
b. Group = LOS > 10yrs
TABLE 22. Logistic Regression: Predictor of Ever Having Had a Colonoscopy of LOS ≥10 Years
95% C.I. for EXP(B)
Step 1
a
Step 2b
Physician’s Recommendations
Constant
Physician’s Recommendations
Perceived Barriers
Constant
B
Wald
1.511
14.637
-.307
1.362
1.214
8.485
-.049
5.835
1.583
3.693
Sig.
Exp(B) Lower
.000
4.533
2.090
.243
.735
.004
3.367
1.488
.016
.952
.915
.055
4.868
Upper
9.833
7.623
.991
a. Variable(s) entered on step 1: Physician’s Recommendations
b. Variable(s) entered on step 2: Perceived Barriers.
c. Group = LOS > 10yrs
TABLE 23. Logistic Regression: Predictor of Ever Having Had a Sigmoidoscopy of LOS ≥ 10
Years
Step 1a
Step 2b
Physician’s Recommendations
Constant
ACCL
Physician’s Recommendations
Constant
B
Wald Sig.
1.382 9.117 .003
-1.852 23.728 .000
.246 4.597 .032
1.178 6.242 .012
-3.015 18.741 .000
95% C.I. for EXP(B)
Exp(B)
Lower
Upper
3.984
1.624
9.774
.157
1.279
1.021
1.602
3.246
1.289
8.177
.049
a. Variable(s) entered on step 1: Physician’s Recommendations
b. Variable(s) entered on step 2: ACCL.
c. Group = LOS > 10yrs
Summary
In this study, Korean Americans had lower rates of CRC screening behaviors compared
to the general U.S. population. Only 33.5% of the sample had ever had a FOBT, 49% had ever
had a colonoscopy, and 19% reported they had ever had a sigmoidoscopy in their lifetime.
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Korean Americans in this study had low rates of perception of cancer screening (annual physical
exam, rectal exam, mammography, and Pap smear), moderate CRC knowledge, low cancer
fatalism, limited CRC literacy, lack of health care access, and low rate of receiving the
physician’s recommendation of CRC screenings.
The greatest predictors influencing CRC screening behaviors were perception of cancer
screening (annual physical exam and periodic cancer screening) for a FOBT, physician’s
recommendation for a colonoscopy and sigmoidoscopy. The greatest barrier influencing CRC
screening behaviors were perceived barriers and lack of health insurance.
There were no significant differences by gender in CRC screening behaviors and for the
cultural beliefs, perception of cancer screening, cancer fatalism, CRC knowledge, CRC health
literacy, health care access, the physician’s recommendation, acculturation, and the perceived
health beliefs. However, significant differences in length of U.S. residence were found in all
CRC screenings, perception of cancer screening, cancer fatalism, health care access, physician’s
recommendation, and perceived barriers to CRC and screenings. New immigrants who have
lived in the U.S. ≤ 10 years had lower rates of all three CRC screening, lower perception of
cancer screening, higher uninsured, less receiving physician’s recommendation, and higher
perceived barriers compared to those who have lived in the U.S. > 10 years.
For new Korean immigrants, the greatest predictor for a FOBT was perception of cancer
screening, a physician’s recommendation for a colonoscopy, and CRC knowledge for a
sigmoidoscopy. For Korean Americans who have lived in the U.S. > 10 years, a physician’s
recommendation was the most important predictor for all three CRC screenings.
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CHAPTER V: DISCUSSION
This study explored CRC screening behaviors among Korean Americans, and identified
the predictors and barriers influencing CRC screening behaviors from possible factors: cultural
beliefs, perception of cancer screening, knowledge of CRC and screening, cancer fatalism, health
care access, health literacy, physician’s recommendation, acculturation, gender, and length of
U.S. residence. A literature review was guided by the HBM and this theory was tested among
Korean Americans in this study. Data were collected from 254 Korean Americans who are age
50 and older in Los Angeles, California. This chapter discusses: (1) sample characteristics , (2)
CRC screening behaviors, (3) interpretation of the findings for research questions, (4)
implications of the research findings for theory, research, and practice, (5) strengths and
limitations, (6) suggestions for the further study, and (6) conclusion.
Discussion of Sample Characteristics
There are many differences in the characteristics of the samples of this study compared to
previous Korean American cancer screening studies. One of the strengths of this study is that
there were sufficient men in this study to make meaningful comparisons between genders. More
women participated than men (141 vs. 113), however, more men participated in this study to
investigate the gender differences of CRC screening behaviors compared to other Korean
American CRC screening studies (Jo, Maxwell, Wong & Bastani, 2008; Ma et al., 2009). In Jo et
al.’s (2008) CRC screening study, Korean women were more predominated (68%) than men
(32%) (Jo, Maxwell, Wong & Bastani, 2008). There was no study to compare gender differences
of CRC screening behaviors in previous Korean American cancer screening studies; therefore it
was important to discover that there were no gender differences in CRC screening behaviors
among Korean Americans. Although the incidence and prevalence of CRC have been increased
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in Korean American men (ACS, 2010; CCR, 2010), there was limited knowledge of Korean
men’s cancer screening behaviors. This study increased knowledge of Korean American men’s
cancer screening behaviors.
The average length of U.S. residence in this study was about 18 years and it was similar
to previous Korean American cancer screening studies (Ma, Shive, Wang & Tan, 2009; Maxwell,
Crespi, Antonio & Lu, 2010). However, one strength of this study was the large numbers of new
immigrants included in this study. This was particularly important as it was discovered that these
new immigrants were different from those who had lived in the U.S. longer.
This study collected and analyzed CRC screening behaviors from the two groups divided
by length of U.S. residence. As there was no study to investigate the differences of predictors and
barriers of CRC screening behaviors between new Korean immigrants and those who have lived
longer in the U.S; this study adds new knowledge to the literature. Korean Americans who have a
shorter immigration history than other ethnic groups and their average length of U.S. residence
was about 20 years. Therefore, Korean Americans are considered as new immigrants. However,
many meaningful differences were found in demographic characteristics influencing CRC
screening behaviors between the new immigrants and those who have lived longer in the U S. in
this study.
The different demographic characteristics were found between new immigrants and those
who have lived in the U.S. > 10 years for marital status, education, employment, household
annual income, health insurance, and English speaking ability. The new immigrants had less
education and household income, and were less able to speak English than those who have lived
in the U.S. longer.
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The greatest difference was found for health insurance. About a half of samples in this
study were uninsured. This result was much higher than the uninsured rate of the 2010 National
Health Interview Survey (NHIS) (Klabunde et al., 2012) and previous Korean American research
findings (Barnes, Adams & Powell-Griner, 2010; Jo, Maxwell, Wong & Bastani, 2008; Juon,
Kim, Shankar & Han, 2004; Ma et al., 2009). According to the 2010 NHIS, only 20% of the
NHIS participants were uninsured (Klabunde et al., 2012).
New immigrants had much higher uninsured rates compared to those who have lived in
the U.S. longer in this study. Longer years of U.S. residence are significantly associated with
having health insurance in this population. This is not surprising because new immigrants may
have not lived in the U.S. long enough to qualify for health insurance as those who immigrated
more years ago.
The main type of health insurance was the public insurance in this study. As found in
Song et al.’s (2010) study, most Korean Americans in this study stated that the insurance is too
expensive to obtain. Another important reason of uninsured or underinsured of Korean
Americans may be considered that most Korean Americans are self-employed or employed in
small businesses that do not provide the health insurance. Korean Americans have been the
highest proportion of self-owned business among Asian Americans (Lee et al., 2009), and selfemployed immigrants in the U.S. as much more likely to be uninsured than those with other
types of employment (Ryu, Young & Park, 2001).
However, 72.4% of the sample in this study reported that they didn’t delay for or get
health care and 64.6% reported that cost and/or lack of insurance were not reasons when they
delayed or didn’t get health care. Although lack of or limited health care access was the barriers
to obtaining CRC screening in this study, costs and lack of health insurance were not the primary
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reasons for not having had CRC screenings among Korean Americans. Most of previous Korean
American cancer screening studies addressed the lack of health care access was the strongest
barrier for cancer screening in Korean Americans (Maxwell, Crespi, Antonio & Lu, 2010; Song
et al., 2010), and only a few studies reported that cost or health insurance was not the major
barrier for not having had a cancer screening (Juon, Choi, Klassen & Roter, 2006; Lee, Fogg &
Sadler, 2006; Maxwell & Crespi, 2009). The results of this study were inconsistent with the
majority of previous studies, but supported the findings of Juon et al. (2006), Lee et al. (2006),
and Maxwell et al. (2009).
Although more than half of the sample reported an annual household income under
$35,000, 15% of the sample also reported their income was more than $75,000. The sample of
this study had higher income levels than were reported in other similar studies (Jo, Maxwell,
Wong & Bastani, 2008; Ma et al., 2009; Sohn & Harada, 2004) in that there were more Korean
Americans reporting income levels over $75,000. One explanation for this finding is that the data
were collected from several different sources: churches, grocery stores, shopping centers, spas,
community health seminars, and community organizations throughout the Los Angeles area
instead of organizations or groups which may have greater numbers of low income Korean
Americans.
This study sample had relatively high educational levels. The majority of the sample had
at least a college education or were college graduates and above, which was different than
previous research (Jo, Maxwell, Wong & Bastani, 2008; Juon, Choi, Klassen & Roter, 2006; Ma
et al., 2009). However, the level of education did not indicate the ability to speak English in that
about 60% reported they were able to speak English not well or not at all. Another interesting
finding was that ability to speak English was not related to length of residence. No matter how
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long Korean Americans have lived in the U.S., many have limited English speaking ability.
Regardless of education level or length of U S. residence, the lack of ability to speak English was
consistent with previous research (Han et al., 2011; Lee et al., 2009; Lee, 2006). One possible
explanation for this might be that Korean is mostly spoken in the home, many older Koreans
comfortably exist in neighborhoods where English is not required, shop at Korean establishments,
and in general participate in a Korean society within the U.S.
Discussion of CRC Screening Behaviors
The result of this study was consistent result with previous studies that have reported low
CRC screening utilization among Korean Americans (ACS, 2010; CCR, 2010; CHIS, 2005; Jo,
Maxwell, Wong & Bastani, 2008; Juon, Han, Shin, Kim & Kim, 2003; Ma, Shive, Wang & Tan,
2009; Maxwell & Crespi, 2009). The rate of CRC screening of this study was significantly lower
than the Healthy People 2020 target of 70.5%. However, the results of this study show an
improvement in rates from previous research (CHIS, 2005). For example, the rate of having a
FOBT was 33.5% in this study while that of the 2005 CHIS was 4% (CHIS, 2005).
Although men had more awareness of CRC than women, their CRC screening behaviors
were not different from women. Consistent with Molina-Barcelo et al.’s study (2011), gender
appears to not influence CRC screening behavior, but perhaps other factors are more important
such as length of U.S. residence.
Length of U. S. residence was an important factor in CRC screening behaviors: FOBT,
colonoscopy, and sigmoidoscopy in this study. New immigrants who have lived in the U.S. ≤ 10
years had lower rates of all CRC screening tests than those who have lived in the U.S. > 10 years.
Cost and health insurance were greater barriers to obtain CRC screening for new immigrants
than those who have lived in the U.S. longer. New immigrants had more structural barriers to
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obtaining CRC screenings than those who have lived in the U.S. longer.
Interpretation of the Findings for Research Questions
Research Question One
What are the predictors of CRC screening behaviors among Korean Americans?
Although there were a number of predictors of CRC screenings, the three most important
were length of U.S. residence, perception of cancer screening and the physician’s
recommendation. These three predictors were strongly positively associated with having had all
three CRC screenings (FOBT, colonoscopy, and sigmoidoscopy). Korean Americans who have
lived in the U.S. longer, had regular annual checkups for a physical exam or other cancer
screening, and received the physician’s recommendation were more likely having had FOBT,
colonoscopy, and sigmoidoscopy in this sample. These three predictors discussed in more detail
in research question three and five.
The importance of length of U.S. residence has been supported in previous research
documenting that new immigrants were the one of the highest risk groups (Ferrer et al., 2012;
Klabunde et al., 2012; Pons-Vigues et al., 2012). As the results of this study, many Korean
American cancer screening studies also reported perception of cancer screening (annual
checkups and periodic cancer screening) was a strong factor for cancer screening (Lee, Fogg &
Sadler, 2006; Lee, Fogg & Menon, 2008; Maxwell, Bastani & Warda, 2000).
A physician’s recommendation has been identified as one of the most important
predictors for CRC screening behaviors across populations (Sarfaty & Wender, 2007; Smith,
Cokkinides, Brooks, Saslow & Brawley, 2010; Ueland, Hornung & Greenwald, 2006). Yet, the
number of Korean Americans who receive a physician’s recommendation for CRC screening
remains low, 38% of the sample in this study. For those who received such a recommendation in
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this study, a physician’s recommendation was one of the strongest predictors influencing CRC
screening. However, there is limited knowledge of the role of a physician’s recommendation for
cancer screening in Korean Americans. Therefore, this suggests that further research needs to
address the health care disparities in physician recommendations as one method to improve
screening rates.
With these three predictors, CRC knowledge was moderately associated with having had
all CRC screening in this study. This result was inconsistent with other Korean American studies
(Lee, Fogg & Menon, 2008; Lee, Kim & Han, 2009; Ma, Shive, Wang & Tan, 2009) which had
reported Korean Americans had a lack of information and knowledge of CRC and screening.
Although studies have been reported that knowledge of cancer screening and screening
guidelines was the strongest predictor for cancer screening in Korean Americans, the effect of
knowledge of CRC screening was moderate in this study.
Although the awareness of CRC and screening tests was increased compared to the 2005
CHIS, the rates of CRC screening in Korean Americans were not much improved. It means that
the high awareness and moderate level of knowledge of CRC and screening were not strongly
associated with CRC screenings in this population even though knowledge was moderately
associated with CRC screening. However, this finding supports the result of Weinberg (2009)’s
study. Weinberg and colleagues (2009) found knowledge was not an adequate stimulus to CRC
screening adherence. Despite greater knowledge of CRC and screening guidelines, most
participants underestimated their personal risk and showed no intention to take CRC screening
(Weinberg et al., 2009).
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Research Question Two
What are the barriers to engaging in CRC screening behaviors among Korean Americans?
The barriers to engaging in CRC screening among Korean Americans were perceived
barriers, health care access, and cancer fatalism. Perceived barriers and health care access were
strongly associated with having had all CRC screening and cancer fatalism was moderate
barriers to having had a FOBT and sigmoidoscopy.
New immigrants had higher perceived barriers and lower rates of all CRC screening than
those who have lived in the U.S. longer. Although perceived benefits were not different between
the two groups by length of U.S. residence, new immigrants experience higher perceived barriers
for CRC screening and had lower CRC screening rates than those who have lived in the U.S.
longer. It may be explained by CRC screening requires physician’s referral, high cost, and
limited government programs. Therefore, even though new immigrants have perceived benefits
of CRC screening, perceived barriers can be the obstacle to adhere CRC screening because they
have more structural barriers than those who have lived in the U.S. longer.
Health care access was one of the strongest barriers to having CRC screening in this
population and significant differences were found by length of U.S. residence. About half of the
sample was uninsured in this study. This finding is consistent with other studies that have
reported Korean Americans were the least likely to have health insurance and their insured rates
were much lower than other ethnic groups in the U.S. (Barnes, Adams & Powell-Griner, 2010;
Jo, Maxwell, Wong & Bastani, 2008; Kandula, Wen, Jacobs & Lauderdale, 2006).
More Korean Americans who have lived in the U.S. longer had Medicare and
employment based insurance while more new immigrants were uninsured and rely on public
health insurance in this study. More new immigrants reported that they experienced delayed or
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didn’t get health care when they needed and the reasons were cost or lack of health insurance
than those who have lived in the U.S. longer.
Health care access was one of the strongest barriers for having CRC screening among
Korean Americans in this study, it is the consistent result with many Korean American cancer
screening studies (Jo, Maxwell, Crespi, Antonio & Lu, 2010; Kagawa-Singer, Dadia, Yu &
Surbone, 2010; Lee, Fogg & Menon, 2008). However, about three-fourth of the sample reported
they didn’t delay health care when they needed and more than half of the sample responded cost
or health care access were not main reasons when they delay or didn’t get health care in this
study. Only a few studies have addressed that costs and health insurance may not be primary
reasons for not having had cancer screenings among Korean Americans (Juon, Choi, Klassen &
Roter, 2006; Lee, Fogg & Sadler, 2006; Maxwell & Crespi, 2009).
Cancer fatalism was considered a psychological barrier to influence an individual’s
decision for cancer screening and treatment, however, the impact of cancer fatalism of cancer
screening had rarely been studied in Korean Americans. Although cancer fatalism was very low
in this sample, it was a moderate barrier to having CRC screenings, especially for new
immigrants. New immigrants had higher cancer fatalism than those who have lived in the U.S.
longer, and it influenced on their CRC screening behavior. It can be explained that new
immigrants were less educated, had lower income and less knowledge for CRC screenings than
those who have lived in the U.S. longer. This finding supports Lee et al.’s (2000) study, in which
knowledge deficits of cancer disease and screening accelerated cancer fatalism.
Many factors may influence cancer fatalism. From this study, knowledge deficit for CRC
screening, low level of education, and low household income affected cancer fatalism with
structural barriers, such as shorter length of U.S. residence, limited English speaking ability, and
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low level of acculturation. Although Korean Americans in this study showed low cancer fatalism,
it was a moderate psychosocial barrier for their cancer screening practice.
Research Question Three
Which predictor or barrier has the greatest influence on CRC screening behaviors?
Perception of cancer screening was the strongest predictor for a FOBT, and the
physician’s recommendation was the strongest predictor for ever having had a colonoscopy and a
sigmoidoscopy.
Korean Americans who had positive perceptions of cancer screening (annual physical
exam and periodic cancer screening) had more than four times greater odds of ever having had a
FOBT (OR= 4.008, 95% CI 2.058, 7.807) than those who had negative perceptions of cancer
screening. Participants who have ever had a FOBT, colonoscopy, or sigmoidoscopy responded
that these screenings were part of a routine exam as a main reason for having had a CRC
screening. Having a periodic health checkup was the most important predictor of CRC screening
in this study. This finding is consistent with other Korean American cancer screening studies
(Ma et al., 2009; Lee, Fogg & Menon, 2008; Smith et al., 2010). Regular checkup reflects an
individual’s perception of preventive health and provides an opportunity to discuss preventive
examination such as cancer screening.
In this study, the main reason not having CRC screenings was that they do not have
symptoms. One-third of the sample in this study believed that CRC screening is unnecessary
because they do not have symptoms of CRC. This finding is consistent with other Korean
Americans studies (Kagawa-Singer, Dadia, Yu & Surbone, 2010; Ma et al., 2009; Maxwell,
Crespi, Antonio & Lu, 2010). Despite the benefits of cancer screening tests, many Korean
Americans are less familiar with the concept of preventive health and they do not view
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preventive health as a priority, especially for new immigrants. Therefore, they have neither been
screened nor are screened regularly. About a half of this sample was unfamiliar with the concept
of routine screening to detect health problems before the onset of symptoms of disease in this
study. Therefore, perception of cancer screening (annual checkups and other cancer screening)
was the strongest predictor for CRC screening and Korean Americans who have had routine
checkups and periodic cancer screening were more likely to have CRC screening, especially a
FOBT, than those who have not had them.
Across populations, the physician’s recommendation is the most important predictor for
having CRC screening (Jo, Maxwell, Rick, Cha & Bastani, 2008; Kagawa-Singer, Dadia, Yu &
Surbone, 2010; Sarfaty & Wender, 2007; Smith et al., 2010). In this study, Korean Americans
who had had a physician’s recommendation for a colonoscopy were almost five times more
likely to having had a colonoscopy, and for a sigmoidoscopy were more than three times greater
having had a sigmoidoscopy compared to those who did not receive a physician’s
recommendation.
Although 58% of the sample had a personal doctor or medical provider, relatively few
received CRC screening recommendations. The rate of receiving a physician’s recommendation
for CRC screening (38%) was improved from the 2005 CHIS (11%). However it is still unclear
why Korean Americans receive lower physician’s recommendation for CRC screening than other
ethnic groups.
As Sarfaty and Wender (2007) addressed, minority patients were less likely to receive
information and recommendation for preventive care including CRC screening from physicians
than non-Hispanic white patients. Korean Americans receive less physicians’ recommendation of
cancer screening compared to the general populations in the U.S. (Kagawa-Singer, Dadia, Yu &
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Surbone, 2010; Maxwell, Crespi, Antonio & Lu, 2010). Korean physicians are also less likely to
recommend cancer screening to Korean American patients (Jo, Maxwell, Rick, Cha & Bastani,
2009; Lew et al., 2003). However, Korean American patients prefer to go a physician of the
same ethnicity because of language and cultural barriers. If Korean American physicians are
reluctant to recommend CRC screening to Korean American patients, different strategies will be
needed for Korean American physicians to increase the recommendation for CRC screening in
Korean patients rather than patient’s side approaches.
Research Question Four
What are the differences in the predictors and barriers to CRC screening behaviors
between Korean American men and women?
There were no differences in CRC screening behaviors between men and women in this
study. Unlike research in other ethnic groups (Bass et al., 2011; Molina-Barcelo et al., 2011),
Korean American men in this study were not different in seeking medical attention, knowledge
of the disease and screening, and CRC screening practice from women. Even though a gender
difference was not found, it is an important finding that there were no gender differences in CRC
screening behaviors among Korean Americans because this information is new.
Research Question Five
What are the differences in the predictors and barriers to CRC screening behaviors
between Korean Americans who have lived in the U. S. ≤ 10 years and those who have lived in
the U. S. > 10 years?
Length of U.S. residence was the most influencing factor for CRC screening behaviors
among Korean Americans in this study. Many differences were found between the two groups
divided by length of U.S. residence in all three CRC screenings, perception of cancer screenings,
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cancer fatalism, the usual sources of care, healthcare access, physician’s recommendations,
acculturation, perceived susceptibility, perceived seriousness, and perceived barriers.
These differences between the two groups provided unambiguous answers for previous
inconsistent results of Korean American cancer screening studies. For example, many studies
reported that health care access was the most important barrier and predictor for Korean
Americans (Jo et al., 2010; Kagawa-Singer, Dadia, Yu & Surbone, 2010; Smith et al., 2010), but
some (Juon, Choi, Klassen & Roter, 2006; Lee, Fogg & Sadler, 2006; Maxwell & Crespi, 2009)
reported health care access was not the barrier for this group. This current study found that health
care access was not the barrier to obtain CRC screening for Korean Americans who have lived in
the U.S. longer, but it was only the barrier for new immigrants. Most previous Korean American
cancer screening studies didn’t divide groups by length of U.S. residence because Korean
Americans have a short immigration history and were assumed to have similar demographic
characteristics and cancer screening behaviors regardless of length of U.S. residence. However,
new immigrants had different demographic characteristics and structural barriers from those who
have lived in the U.S. longer, and these differences affected their CRC screening behaviors in
this study.
As studies had addressed (Pons-Vigues et al., 2012; Remennick, 2003), immigrant’s
marginal status and social determinants of health care disparities affect CRC screening behaviors
in this study. As the participants of Remenneck’s study (2003), Korean Americans were well
educated, knowledgeable to CRC and screenings, and have high perceived benefits of CRC
screening. Even though perceived benefits of CRC screening was not different between the two
groups divided by length of U.S. residence, new immigrants had higher perceived barriers and
lower rates of CRC screenings than those who have lived in the U.S. longer. Perceived benefits
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did not translate into CRC screening practice for new immigrants. Therefore, this finding
suggests that different approaches and strategies are required for new immigrants and those who
have lived in the U.S. longer to increase the rates of CRC screenings.
Implications of the Study
The current study described the CRC screening behaviors among Korean Americans and
identified the predictors and barriers for their CRC screening practices. This study examined how
CRC screening behaviors of Korean Americans are different between the two groups divided by
gender and length of U.S. residence. This study also tested the HBM for its usefulness for CRC
screening behaviors of Korean Americans. The implications of the research findings in this study
are discussed as follows from the perspective of theory, practice, and research.
Implications for Theory
The HBM successfully explained CRC screening behaviors for Korean Americans in this
study. The findings of this study extended the usefulness of the HBM. Originally the HBM was
developed for breast cancer screening. This study utilized the modified HBM scale for CRC
screening and added culturally tailored items for immigrants. It extended the usefulness of HBM
to CRC screening and increased utilization of the HBM in a different ethnic group.
From the findings of the study, perceived barriers were the greatest obstacles for Korean
Americans, especially new immigrants, to adhere CRC screenings even though they have high
perceived benefits for CRC screenings. Although the HBM has been rarely used in the Korean
American studies to examine their health behaviors, it was an appropriate theory for the current
study. The HBM was applied from the literature reviews to implement of this descriptive study
to obtain in-depth knowledge of CRC screening behaviors of Korean Americans. It increases a
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possibility of applying the HBM to other minority groups and immigrants, and other health
behaviors.
The findings of this study also support the social determinants of health disparity model.
The social determinants of health of Korean American influenced CRC incidence and screening
prevalence disparities. As the predominately first-generation of immigrants, many Korean
Americans are in the social determinants of health disparities with structural barriers and these
influenced their CRC screening behaviors. Korean Americans received lower quality of cancer
care than the general U.S. population and it contributes to poorer health outcomes and health
disparities.
Implications for Practice
The findings of this study increased knowledge of unique Korean American’s CRC
screening behaviors. Korean Americans have a shorter immigration history compared to other
ethnic groups, and they have unique health beliefs and health behaviors, such as perceptions of
preventive care. The findings help healthcare providers to understand Korean Americans and
their unique health beliefs and health behaviors in practice.
The findings increased cultural competency with discovering new knowledge of CRC
screening behaviors among Korean Americans. The participants of this study reported the main
reason do not have an annual physical exam and CRC screening, and do not follow the
physician’s recommendations for CRC screenings was no symptoms. Korean Americans believe
that they are healthy if they do not have any physical symptoms of disease. Therefore, they
believe they do not need annual checkups and periodic cancer screenings. These beliefs and
behaviors may be considered noncompliant for health care providers in practice. When health
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care providers have an understanding of health beliefs and behaviors of Korean Americans,
healthcare providers can approach differently to Korean patients to increase the health outcomes.
The findings of this study reinforced the role of physician’s recommendation for CRC
screenings. The findings of this study provided the rationale to develop strategies to improve the
adherence of CRC screenings in Korean Americans. The perception of cancer screening (annual
physical exam and periodic cancer screenings) and physician’s recommendations were the most
important predictors for CRC screening behaviors in Korean Americans. Therefore, systemic
approaches to increase the physician’s recommendations for CRC screenings and annual
checkups will be appropriate for Korean Americans, for example, education for physicians and
media campaigns at the community level. Most Korean Americans prefer to go to same ethnic
physicians and health care providers for language and cultural barriers. To increase the issues of
mutual interest in the role of physician’s recommendation for CRC screenings among Korean
American physicians, educating physicians for the importance of CRC screenings and
physician’s recommendations through the association of Korean American physicians can be a
strategy. The community education can be a strategy to improve the adherence of CRC
screenings. Most Korean American communities in the U.S. have local ethnic newspaper and/or
radio, TV broadcasting. Korean Americans obtain local and national news and information from
this media. The media can be the excellent resource to educate community residents about the
importance of annual checkups and CRC screenings.
Implications for Further Research
From the findings of this study, several studies can be suggested for further research to
improve the adherence of CRC screenings among Korean Americans. Although the physician’s
recommendation for CRC screenings was the greatest predictor for Korean Americans, Korean
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Americans received low physician’s recommendation for CRC screenings. However, there are
few studies to investigate the role of physician’s recommendation for CRC screening in Korean
Americans and how to increase recommendations by physicians who treat Korean Americans.
There are four possible research studies regarding the physician’s recommendations for
CRC screenings for further investigation. First, a study needs to be conducted to clarify the
actual number of referrals for cancer screening by Korean American physicians compared to
non-Korean physicians. Second, a study needs to investigate why Korean physicians do not
recommend cancer screenings to their patients if they have less recommended cancer screenings
than non-Korean physicians. Third, a study needs to clarify whether Korean physicians have less
recommended cancer screenings for general patients or only Korean Americans patients. Fourth,
the effectiveness of the educational seminar for Korean physicians and for community residents
by media at the community level can be studied. The educational seminar for Korean physicians
can increase the mutual interest of Korean physicians for the Korean American community and
help to develop the strategies to increase the adherence of CRC screenings at their individual
practice and the community level. To investigate the effectiveness of the educational seminar for
Korean physicians, the rates of referral for colorectal surgeons and CRC screenings can be
compared before and after the educational seminar.
The community programs based on the community based participatory research model
may be considered to improve the adherence of CRC screenings among Korean Americans. The
media will take an important role to raise awareness of emerging CRC incidence and prevalence
among Korean Americans in the Korean American community. As community partners, many
Korean American community organizations can have an issue of mutual interests for CRC
screening and an importance of annual checkups to increase the adherence of CRC screenings.
129
Korean American family practice physicians and colorectal surgeons can make a network for this
community program and provide CRC screenings for low income families with discount price if
they can offer. This community program will have many benefits for Korean community, such as
increase mutual interests of Korean Americans residents and the community as well, and can be
a good model for other community problems to solve together as a one unit.
Strengths of the Study
Instruments
The study had several strengths. First, this study utilized culturally and linguistically
equivalent instruments. Many scales have never been used in Korean Americans and never
translated into Korean. The 2009 CHIS, PFI, CCKQ, ACCL, and Jacob’s HBM scale for CRC
were translated into Korean under original author’s permission.
Originally the CHIS has been used for the telephone survey, the 2009 adult CHIS
questionnaire was translated into Korean for this study to measure CRC screening behaviors and
many related factors. The Powe Fatalism Inventory (PFI) was used to measure cancer fatalism.
Although cancer fatalism can be considered a psychological barrier for cancer screenings, cancer
fatalism has never been measured with instruments before in Korean Americans.
Both the CCKQ and ACCL were measured knowledge and literacy of CRC and
screenings specifically. Especially, utilization of the ACCL was the first trial to measure diseasespecific health literacy in Korean Americans CRC screening study. The health literacy scales
have commonly used in the literature limit to measure health literacy because health literacy is
not only reading the letters or sentences, but understanding what they read and transferring
knowledge to their decision making. Although limited English speaking ability has been the
barrier for Korean Americans, most Korean Americans can read English letters and sentences
130
with their high level of education in their county. However, it does not mean that they understand
what they read, and utilize this information for their decision making of CRC screening.
Therefore, the disease-specific health literacy scale was more effective tool to measure their
health literacy rather than measuring just reading letters and sentences.
The Jacob’s HBM scale for CRC is the modified the Champion’s HBM scale. This study
extended its utility with translation. The AAMAS was used to measure the level of acculturation
in this study. Most Korean American cancer screening studies used a proxy to measure the level
of acculturation, such as language skills and length of U.S. residence. However, language skills
and length of U.S. residence are inadequate to measure the level of acculturation. Although the
average length of U.S. residence of Korean Americans was about 20 years, their English
speaking ability was still poor. When highly educated new immigrants can speak English well, it
is hard to say they are well acculturated to the host country. Therefore, English speaking ability
has less association with length of U.S. residence, and the proxy were inadequate to measure the
level of acculturation. This study used the AAMAS to measure multidimensional acculturation
level and it was appropriate in this study.
Recruitment
Korean Americans are hard to reach population, and most studies collected data from
small groups from churches or other organizations. This study recruited 254 Korean Americans
give the study adequate power. To increase generalizability, data collected from various places
across the Los Angeles area. Three churches were selected from north, central (Korean town),
and south of Los Angeles. These three areas have different socio-demographic background, such
as household income and education level. Four Korean grocery stores, two Korean shopping
centers, two Korean spas, two community health seminars, two community organizations
131
working for new immigrants, and one cultural center were the places for data collection. This
study minimized sampling bias and improved generalizability with these approaches.
Two-Group Analysis
This study divided and analyzed the two groups by gender to identify differences of CRC
screening behaviors between the two groups. This was the first study to compare gender
differences in Korean American CRC screening. Although there was no difference between men
and women, it provided important information in the literature about CRC screening practices of
this population.
The other approach was comparing CRC screening behaviors of the two groups divided
by length of U.S. residence. Many significant differences were found between the two groups.
These findings clarify some of the inconsistent results from other previous studies and
undiscovered important knowledge was obtained by this approach in this population. The
findings of this study provide the rationale for the necessity of different strategies to increase the
rates of CRC screening in this population.
Limitations of the Study
Data Collection Method
Questionnaires were utilized to collect data with self-report method. Even though
confidentiality was promised before participation and privacy was kept while filling up the
questionnaires, some participants may answer dishonestly for their CRC screening behaviors and
some uncomfortable questions, such as education level, household income, or CRC screening
behaviors. They may answer in the socially desirable way. An inconsistent answer was clarified
by the researcher with checking missing data right after participants completed questionnaires.
132
Social desirability response bias can be a limitation of self-report which may threaten the
external validity of this study.
This study used a cross-sectional design, which limits the ability to make strong causal
conclusions. It is difficult to verify the sequence of the variables because data collected one time.
Longitudinal research may be considered to improve the validity and an issue of causality; and
will be used in further research.
Instruments
This study used the 2009 CHIS questionnaires to measure CRC screening behaviors,
health care access, and the physician’s recommendation. Even though the CHIS have been used
biannually to measure Californian’s health behaviors, the validity and reliability information
couldn’t obtain. The researcher contacted the University of California Los Angeles, Center for
Health Policy Research, which the CHIS was developed, to get validity and reliability
information and a permission to use of the questionnaires. But the validity and reliability of the
questionnaire were not obtained. Although the validity and reliability of the questionnaires are
important to get valid and reliable data, this study has limitation from this main questionnaire.
The concept of cultural beliefs was unclear in this study. Cultural beliefs were measured
beliefs for the cause of cancer in this study. However, because of culture and cultural beliefs
were broad concepts, the concept of cultural beliefs should be clearly defined and tested the
content validity for this study.
Conclusion
This chapter discussed: (1) sample characteristics, (2) CRC screening behaviors, (3)
interpretation of the findings for research questions, (4) implications of the research findings for
theory, research, and practice, and (5) strengths and limitations. The rates of all CRC screenings
133
were significantly lower than the Healthy People 2020 target of 70.5% and the 2010 NHIS. The
greatest influencing predictors and barriers were perception of cancer screening for a FOBT and
the physician’s recommendations for a colonoscopy and sigmoidoscopy. There were no gender
differences in CRC screenings. Length of U.S. residence was not the most important predictor
for CRC screening among Korean Americans in this study. The two groups divided by length of
U.S. residence had many differences in all CRC screening, perception of cancer screenings,
cancer fatalism, the usual sources of care, healthcare access, physician’s recommendations,
perceived barriers with demographic characteristics. The findings of this study increased
knowledge of unique health beliefs and CRC screening behaviors among Korean Americans, and
provided the rationale to develop the strategies to improve the adherence of CRC screenings. The
HBM was an appropriate theoretical framework for this current study and proved its usefulness.
The findings also suggested recommendations for further research.
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APPENDIX A: HUMAN SUBJECTS REVIEW AND APPROVAL
135
136
APPENDIX B: REVISED HUMAN SUBJECTS APPROVAL
137
138
APPENDIX C: DISCLOSURE (ENGLISH)
139
140
APPENDIX D: DISCLOSURE (KOREAN)
141
142
143
APPENDIX E: REVISED DISCLOSURE (ENGLISH)
144
145
APPENDIX F: REVISED DISCLOSURE (KOREAN)
146
147
148
APPENDIX G: INSTRUMENT (ENGLISH)
149
Date: ____________
Subject ID: _______
Colorectal Cancer Screening Behaviors among Korean Americans
Moonju Ko, RN, MSN
University of Arizona College of Nursing
150
A. Demographic Information
A1
What is your gender?
 01 Male
A2
What is your current age and year of birth?
Age _________
A3
 02 Female
Year _________
What is your current marital status?
 01 Married
 02 Living with partner
 03 Divorced/Separated
 04 Widowed
 05 Never married
 99 Other (_____________)
A4
What is the highest level of education you have completed?
 01 None
 02 Less than high school
 03 High school
 04 Vocational/Technical school/Some college
 05 College graduate
 06 Graduate degree
A5
What is your current employment status?
 01 Working full time (35 hrs or more a week)
 02 Working part time (less than 35 hrs a week)
 03 Retired
 04 Unemployed
 05 Disabled
 06 Homemaker
 99 Other (_______________________)
A6
What is your best estimate of your household’s total income from all sources before filing for
taxes?
01 Less than $20,000
02 $20,001 - $35,000
03 $35,001 - $50,000
04 $50,001 - $75,000
05 Greater than $75,000
A7
How many people living in your household are supported by the total household income,
including yourself?
___________ Number of people
151
A8
Do you have a health insurance?
01 Yes 02 No
A9
How well do you speak English?
 01 Very well
02 Well
03 Not well
04 Not at all
A10
How many years have you lived in the United States?
(For less than a year, enter 1 year)
__________ Number of years
152
B. Cultural Beliefs: Cause of CRC
Would you please check the appropriate answers below corresponding to your beliefs?
B1
Active or passive smoking causes colorectal cancer.
01 Yes 02 No
B2
God’s will cause colorectal cancer.
01 Yes 02 No
B3
Poor hygiene causes colorectal cancer.
01 Yes 02 No
B4
Heredity causes colorectal cancer.
01 Yes 02 No
153
C. Perception of Cancer Screening
C1
C2
Do you get an annual:
a. Physical examination?
 01 Yes
 02 No
b. Rectal Examination
 01 Yes
 02 No
c. Mammogram
 01 Yes
 02 No
03 N/A
d. Pap Smear
 01 Yes
 02 No
03 N/A
What is the ONE most important reason why you have (never/not had) one of these exams?
 01 No reason /Never thought of it
 02 Didn’t know I needed this type of test
 03 Doctor didn’t tell me I needed it
 04 Haven’t had any problems
 05 Put it off / Laziness
06 Too expensive /No insurance / Cost
07 Too painful, unpleasant, or embarrassing
 08 Had another type of colorectal exam
 09 Don’t have a doctor
 99 Other (_________________________)
154
D. Colorectal Cancer Knowledge Questionnaire (CCKQ)
Tell me if you think these questions are true, false, or don’t know.
Do you think or believe that:
1. Men get cancer of the bowel more often than women.
2. Bowel cancer is always a deadly disease.
3. To check for blood in your bowel movement, you need to have a
bowel movement blood test.
4. You think you would always have pain if you had cancer of the
bowel.
5. You think your chances of getting cancer of the bowel are greater if
you have a family member who had cancer of the bowel.
6. Blood in your bowel movement means you have cancer for sure.
7. You need to check your bowel movement for blood even if your
bowel habits are normal.
8. You think testing bowel movements for hidden blood would be very
painful.
9. Almost all the people who get bowel cancer are 50 years old or older.
10. Most people who get cancer of the bowel could be saved if it were
found and treated at an early stage.
11. A diet with a lot of roughage, like fruits, vegetables, and grains, may
reduce your chances of getting cancer of the bowel.
12. You should have your bowel movement tested for hidden blood every
year if you are 50 years or older.
True
False
Don’t
Know
155
E. Colorectal Cancer Screening Behaviors
Please read the following statements and write or mark the response most appropriate for you.
E1
Have you ever heard of colorectal cancer?
01 Yes
E2
02 No
A stool or fecal occult blood test is done at home to check for colon or rectal cancer. You send
your stool sample to the doctor’s office or lab for testing. Have you ever done a stool or fecal
occult blood test?
 01 Yes
( 01-1 Home
 01-2 Doctor’s office)
 02 No
E3
When did you do your most recent fecal blood test using a home kit to check for colon or rectal
cancer?
01 Never had a fecal blood test (Skip next question and go to E5)
02 A year ago or less
03 More than 1 year ago up to 2 years ago
04 More than 2 years ago up to 5 years ago
05 More than 5 years ago
E4
What was the main reason you had your most recent stool blood test using a home kit?
01 Part of a routine exam
02 Because of a problem
03 Some other reason (_____________________)
A sigmoidoscopy and a colonoscopy are both tests that examine the bowel by inserting a tube in the
rectum. The difference is that during a sigmoidoscopy, you are awake and can drive yourself home after
the test; however, during a colonoscopy, you may feel sleepy and you need someone to drive you home.
E5
Have you ever had a colonoscopy?
 01 Yes
 02 No
156
E6
When did you have your most recent colonoscopy to check for colon cancer?
01 Never had a colonoscopy (Skip next question and go to E8)
 02 A year ago or less
 03 More than 1 up to 5 years ago
 04 More than 5 up to 10 years ago
 05 More than 10 years ago
E7
What was the main reason you had your most recent colonoscopy?
 01 Part of a routine exam
 02 Because of a problem,
 03 Some other reason (_____________________)
E8
Have you ever had a sigmoidoscopy?
 01 Yes
E9
 02 No
When did you have your most recent sigmoidoscopy to check for colon or rectal cancer?
01 Never had a sigmoidoscopy
 02 A year ago or less
 03 More than 1 up to 5 years ago
 04 More than 5 up to 10 years ago
 05 More than 10 years ago
E10
What was the main reason you did your most recent sigmoidoscopy?
01 Part of a routine exam
02 Because of a problem
03 Some other reason (_____________________)
157
E11
What is the ONE most important reason why you have (never had/not had) one of these exams
recently?
01 No reason /Never thought of it
02 Didn’t know I needed this type of test
03 Doctor didn’t tell me I needed it
04 Haven’t had any problems
05 Put it off / Laziness
06 Too expensive / No insurance
07 Too painful, unpleasant, or embarrassing
08 Had another type of colorectal exam (______________________)
09 Don’t have a doctor
 99 Other (_________________________)
158
F. Powe Fatalism Inventory (PFI)
Please answer the following questions.
1. I think if someone is meant to have bowel cancer, it doesn't matter what
kinds of food they eat, they will get bowel cancer anyway.
YES
NO
2. I think if someone has bowel cancer, it is already too late to get treated
for it.
YES
NO
3. I think someone can eat fatty foods all their life, and if they are not
meant to get bowel cancer, they won't get it.
YES
NO
4. I think if someone is meant to get bowel cancer, they will get it no matter
what they do.
YES
NO
5. I think if someone gets bowel cancer, it was meant to be.
YES
NO
6. I think if someone gets bowel cancer, their time to die is soon.
YES
NO
7. I think if someone gets bowel cancer, that's the way they were meant to
die.
YES
NO
8. I think getting checked for bowel cancer makes people scared that they
may really have bowel cancer.
YES
NO
9. I think if someone is meant to have bowel cancer, they will have bowel
cancer.
YES
NO
10. I think some people don't want to know if they have bowel cancer
because they don't want to know they may be dying from it.
YES
NO
11. I think if someone gets bowel cancer, it doesn't matter whether they find
it early or late, they will still die from it.
YES
NO
12. I think if someone has bowel cancer and gets treatment for it, they will
probably still die from the bowel cancer.
YES
NO
13. I think if someone was meant to have bowel cancer, it doesn't matter
what doctors and nurses tell them to do, they will get bowel cancer
anyway.
YES
NO
14. I think if someone is meant to have bowel cancer, it doesn't matter if they
eat healthy foods, they will still get bowel cancer.
YES
NO
15. I think bowel cancer will kill you no matter when it is found and how it
is treated.
YES
NO
159
G. Health Care Access
Please read each statement and mark the response most appropriate for you.
G1
Is there a place that you usually go to when you are sick or need advice about health?
01 Yes
G2
02 No
What kind of place do you go to most often for health care?
 01Doctor’s office / Other HMO
 02 Clinic/Health Center/Hospital Clinic
 03 Emergency Room
 04 Some other place (Specify:__________________)
 05 No one place
G3
What type of health insurance do you have?
01 Don’t have health insurance
02 Through current or former employer/union
03 Through school, profession association, trade group, or other organization
04 Purchased directly from health plan
05 Medicare
06 Medicaid/Medi-CAL (Medi-CAL is a plan for low-income children and their families,
pregnant women, and disabled or elderly people.)
07 Healthy Families (State program that pay for health insurance for children up to age 19)
08 Champus/Champ-VA/Tricare, VA, or some other military health care
09 Healthy Kids (Low-or no-cost health insurance for children ages 0-5 in L.A. County who
are not eligible for Medi-Cal or Healthy Families)
99 Other (__________________)
G4
During the past 12 months, was there any time when you had no health insurance at all?
01 Yes
02 No
160
G5
What is the ONE MAIN reason why you do not have any health insurance?
01 Can’t afford /Too expensive
02 Not eligible due to working status/changed employer/lost jobs
03 Not eligible due to health or other problems
04 Not eligible due to citizenship/immigration status
05 Family situations changed
06 Don’t believe in insurance
07 Switched insurance companies, delayed between
08 Can get health care for free /Pay for own care
99 Other (________________)
G6
During the past 12 months, did you visit a hospital emergency room for your own health?
01 Yes
G7
02 No
During the past 12 months, how many times have you seen a medical doctor?
____________Times
G8
About how long has it been since you last saw a doctor about your own health?
01 One year ago or less
02 More than 1 up to 2 years ago
03 More than 2 up to 5 years ago
04 More than 5 years ago
05 Never
G9
During the past 12 months, did you delay or not get any other medical care you felt you needed
such as seeing a doctor, a specialist, or other health professional?
 01 Yes
G10
02 No
Was cost or lack of insurance a reason why you delay or did not get health care you felt you
needed?
01 Yes
02 No
161
H. Assessment of Colon Cancer Literacy (ACCL)
Please mark the following statements as true or false or unsure.
True False Unsure
1. In the United States, colon cancer is the 3rd most common cancer in
men and women.
2. Colon cancer is caused only by generics, not by the environment.
3. All colon polyps are cancerous.
4. All colon cancer is potentially invasive.
5. Malignant means cancer has already spread.
6. Colon cancer that has spread to the lymph nodes is called metastatic.
7. During colon cancer surgery, lymph nodes are also removed.
8. All stomas (bags) are permanent.
9. Chemotherapy is used to treat colon cancer that has spread.
10. Radiation therapy is usually used to treat colon cancer.
162
I. Physician’s Recommendation
Please read each statement and mark the response most appropriate for you.
I1
Do you have personal doctor or medical provider who is your main provider?
01 Yes
I2
02 No
In the past 5 years, has a doctor recommended that you have a sigmoidoscopy, colonoscopy or
fecal blood test?
01 Yes
02 No
 03 Did not go to a doctor in past 5 years
I3
What is the ONE main reason you do not follow your doctor’s recommendation for cancer
screening?
 01 No reason/Never thought of it
 02 Didn’t know I needed this type of test
 03 Haven’t had any problems
 04 Put it off/Laziness
 05 Too expensive/No insurance/Cost
 06 Too painful, unpleasant, or embarrassing
 99 Other (_________________________)
163
J. Champion’s Health Belief Model Scales
Please check the appropriate answers below corresponding to your thoughts about colon or rectal
cancer.
1. Strongly agree 2. Agree
3. Somewhat agree
4. Disagree
5. Strongly disagree
Susceptibility
J1. It is extremely likely I will get colon cancer in the future.
1 2 3 4 5
J2. I feel I will get colon in the future.
1 2 3 4 5
J3. There is a good possibility I will get colon cancer in the next 10 years.
1 2 3 4 5
J4. My chances of getting colon cancer are great.
1 2 3 4 5
J5. I am more likely than the average person to get colon cancer.
1 2 3 4 5
Seriousness
J6. The thought of colon cancer scares me.
1 2 3 4 5
J7. When I think about colon cancer, my heart beats faster.
1 2 3 4 5
J8. I am afraid to think about colon cancer.
1 2 3 4 5
J9. Problems I would experience with colon cancer would last a long time.
1 2 3 4 5
J10. Colon cancer would threaten a relationship with my partner.
1 2 3 4 5
J11. If I had colon cancer, my whole life would change.
1 2 3 4 5
J12. If I developed colon cancer, I would not live longer than 5 years.
1 2 3 4 5
Benefits
J13. If I had regular check-ups to detect colon cancer, I would feel good.
1 2 3 4 5
J14. If I had regular check-ups to detect colon cancer, I wouldn’t worry as much
about colon or rectal cancer.
1 2 3 4 5
J15. Having regular check-ups to detect colon cancer will allow me to find
cancer early.
1 2 3 4 5
J16. If I have regular check-ups to detect colon cancer, I will decrease my chance
of dying from colon cancer.
1 2 3 4 5
J17. If I have regular check-ups to detect colon cancer, I will decrease my chances
of requiring radical or disfiguring surgery if colon cancer occurs.
1 2 3 4 5
J18. If I have regular check-ups to detect colon cancer, it will help me to
detect something that may be cancer early.
1 2 3 4 5
164
1. Strongly agree 2. Agree
3. Somewhat agree
4. Disagree
5. Strongly disagree
Barriers
J19. I feel uncomfortable talking about colon cancer.
1 2 3 4 5
J20. Having regular check-ups to detect colon cancer will make me worry
about colon cancer.
1 2 3 4 5
J21. I am afraid to have a colon cancer screening because I might find
out something is wrong.
1 2 3 4 5
J22. Regular check-ups to detect colon cancer will be embarrassing to me.
1 2 3 4 5
J23. Regular check-ups to detect colon cancer will take too much time.
1 2 3 4 5
J24. Regular check-ups to detect colon cancer will be unpleasant.
1 2 3 4 5
J25. Having regular check-ups to detect colon cancer will cost too much
money.
1 2 3 4 5
J26. I am afraid to have a colon cancer screening because I don’t really
understand what will be done.
1 2 3 4 5
J27. I don’t know how to go about getting a colon cancer screening.
1 2 3 4 5
J28. Having a colon cancer screening is too painful.
1 2 3 4 5
J29. I cannot remember to schedule a colon cancer screening.
1 2 3 4 5
J30. I have other problems more important than getting colon cancer
screening.
J31. I am too old to need a routine colon cancer screening.
1 2 3 4 5
1 2 3 4 5
J32. My doctor rarely recommended me for a routine colon cancer
screening.
1 2 3 4 5
J33. It is too difficult to arrange transportation to get a routine colon
cancer screening.
1 2 3 4 5
J34. I have no insurance to pay a colon cancer screening.
1 2 3 4 5
J35. My English is not good enough to get a colon cancer screening.
1 2 3 4 5
165
K. Acculturation
Please circle the number that best represents your view on each item. Please note that reference to
“Asian” hereafter refers to Asians in America and not Asia.
Not very well
1
2
3
Somewhat
4
5
Very well
6
K1. How well do you speak the language of -a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
English?
1
2
3
4
5
6
K2. How well do you understand the language of -a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
English?
1
2
3
4
5
6
K3. How well do you read and write in the language of -a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
English?
1
2
3
4
5
6
K4. How often do you listen to music or look at movies and magazines from
a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K5. How much do you like the food of a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K6. How often do you eat the food of a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
166
Not very well
1
2
3
Somewhat
4
5
Very well
6
K7. How knowledgeable are you about the history of a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K8. How knowledgeable are you about the culture and traditions of a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K9. How much do you practice the traditions and keep the holidays of a.
your own Asian ethnic culture?
1
2
3
4
5
6
b.
other Asian cultures?
1
2
3
4
5
6
c.
the White mainstream culture?
1
2
3
4
5
6
K10. How much do you identify with a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K11. How much do you feel you have in common with people from a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K12. How much do you interact and associate with people from a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
K13. How much would you like to interact and associate with people from a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
167
Not very well
1
2
3
Somewhat
4
5
Very well
6
K14. How proud are you to be part of a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
*K15. How negative do you feel about people from a.
your own Asian ethnic group?
1
2
3
4
5
6
b.
other Asian groups?
1
2
3
4
5
6
c.
the White mainstream groups?
1
2
3
4
5
6
*Reverse worded item.
168
APPENDIX H: INSTRUMENT (KOREAN)
169
날짜: ____________
대상자 ID: ________
미주 한인들의 대장암 검사 행위
고 문주, RN, MSN
아리조나 대학교 간호 대학
170
A. Demographic Information
A1
당신의 성별은 무엇입니까?
 01 남성
A2
현재 나이와 출생연도가 어떻게 되십니까?
나이 _________
A3
 02 여성
년도 __________
당신의 결혼상태는 어디에 해당되십니까?
 01 기혼
 02 동거
 03 이혼/별거
 04 사별
 05 결혼한 적 없슴
 99 기타 (_____________)
A4
최종 정규교육은 어디까지 마치셨습니까?
 01 무학
 02 고등학교 졸업 이하
 03 고등학교 졸업
 04 직업학교/기술학교/대학중퇴
 05 대학졸업
 06 대학원 졸업
A5
당신의 현재 근로 조건은 어떠십니까?
 01 정규직 (주 35 시간 이상)
 02 파트 타임 (주 35 시간 이하)
 03 은퇴
 04 무직
 05 장애상태
 06 주부
 99 기타 (_______________________)
A6
세금 공제 전 가정의 총 수입은 대략 얼마입니까?
01 2 만불 이하
02 2 만 – 3 만 5 천불
03 3 만 5 천 - 5 만불
04 5 만 – 7 만 5 천불
171
05 7 만 5 천불 이상
A7
본인을 포함하여 가정 총수입으로 생활하는 함께 사는 가족은 몇 명입니까?
___________ 명
A8
의료 보험이 있으십니까?
01 예
A9
02 아니오
영어 회화 능력은 어떠십니까?
 01 매우 좋음
02 좋음
03 잘 못 함
04 전혀 못 함
A10
미국에 거주하신 지는 얼마나 되었습니까? (1 년 미만은 1 년으로 기입해 주십시오)
__________ 년
172
B. Cultural Beliefs: Cause of CRC
아래의 질문에 본인의 믿음과 부합하는 답에 표시해 주십시오
B1
직접, 간접 흡연은 대장직장암을 초래한다.
01 예
B2
대장 직장암에 걸리는 것은 하늘의 뜻이다.
01 예
B3
02 아니오
청결하지 않으면 대장직장암이 발생할 가능성이 높다.
01 예
B4
02 아니오
02 아니오
대장직장암은 유전된다.
01 예
02 아니오
173
C. Perception of Cancer Screening
C1
당신은 매 년 아래의 검사를 하십니까?
e. 정기 신체검사
 01 예
 02 아니오
f.
 01 예
 02 아니오
직장 검사
g. 매모그램 (유방 엑스레이)  01 예
h. 자궁암 검사
C2
 01 예
 02 아니오 03 해당 사항 없슴
 02 아니오 03 해당 사항 없슴
위의 검사 중에 하나를 한적이 없거나 하지 않은 가장 중요한 이유는 무엇입니까?
 01 이유 없슴 / 생각해 본 적 없슴
 02 이런 검사가 필요했는지 몰랐다.
 03 의사가 이런 검사가 필요하다고 말하지 않았다.
 04 아무 증상/문제가 없었다.
 05 미루어 왔다/게으름
06 너무 비싸다/의료 보험 없슴/비용
07 검사가 너무 아프고, 불쾌하거나 당황스럽다.
 08 다른 종류의 대장직장암 검사를 했다.
 09 주치의가 없다.
 99 기타 (_________________________)
174
D. Colorectal Cancer Knowledge Questionnaire (CCKQ)
다음의 질문들이 맞는지 틀리는지 또는 잘 모르겠는지 답해 주십시오.
당신이 생각하기에 또는 믿기에:
1. 남성들이 여성들 보다 대장암에 더 많이 걸린다.
2. 대장암은 언제나 치명적인 질병이다.
3. 대변에 피가 섞여 나오는지를 확인하기 위해서는 대변 잠혈 검사 (대변에
피가 섞여 있는지 보는 검사)가 필요하다.
4. 대장암이 있으면 항상 통증이 있을 것이라 생각한다.
5. 가족 중에 대장암에 걸린 사람이 있으면 대장암에 걸릴 가능성이 더
높다고 생각한다.
6. 대변에 피가 섞여 나오는 것은 대장암이 확실하다는 것을 의미한다.
7. 배변 습관이 정상이라 할지라도 대변에 피가 섞여 나오는지 검사할
필요가 있다.
8. 대변 잠혈 검사 (대변에 피가 섞여 있는지 보는 검사)는 매우 아플 것이라
생각한다.
9. 대장암에 걸리는 거의 대부분의 사람들은 50 세 이상이다.
10. 초기에 대장암을 발견하고 치료하면 대부분의 사람들이 생명을 구할 수
있다.
11. 과일, 야채와 곡류 같은 섬유질이 많은 식생활은 대장암에 걸릴 가능성을
줄일 수 있다.
12. 50 세 이상이라면 대변 잠혈 검사 (대변에 피가 섞여 있는지 보는 검사)를
매 년 받아야 한다.
맞다
틀리다
모르겠다
175
E. Colorectal Cancer Screening Behaviors
다음 각 문항을 읽고 당신에게 가장 적합하게 해당되는 곳에 답을 쓰거나 표시해 주십시오.
E1
대장직장암에 대해 들어 본 적 있습니까?
01 예
E2
02 아니오
대변 잠혈 검사 (대변에 피가 섞여 나오는지 보는 검사) 는 대장암 또는 직장암을 알아 내기 위해서
집에서 하는 검사입니다. 집에서 채취한 대변 샘플을 의사 오피스 또는 검사실에 보냅니다.
대변 잠혈 검사를 해 보신 적이 있으십니까?
 01 예
( 01-1 집  01-2 의사 오피스)
 02 아니오
E3
대장 직장암을 확인하기 위해 가장 최근에 가정에서 대변 잠혈 검사를 하신 것이 언제입니까?
01 한번도 해 본 적 없슴 (다음 문제는 생략하시고 E5 로 가십시오)
02 일년 이내
03 1 년 이상 2 년 이내
04 2 년 이상 5 년 이내
05 5 년 이상
E4
가정서 가장 최근에 대변 잠혈 검사를 한 주된 이유는 무엇입니까?
01 정기 검진의 한 부분
02 증상이 있기 때문에
99 다른 이유 (_____________________)
결장 내시경 검사 와 대장 내시경 검사는 모두 항문으로 튜브를 넣어서 장을 검사하는 테스트입니다.
두 검사의 차이는 결장 내시경 검사는 검사 중 의식이 있으며 검사 후 운전을 하여 집에 돌아 갈 수 있지만,
대장 내시경 검사는 검사 중 마취로 잠을 잘 수 있고 검사 후 누군가 운전을 해 줄 사람이 필요합니다.
E5
대장 내시경 검사를 해 본 적이 있으십니까?
 01 예
E6
 02 아니오
가장 최근에 대장암 검사를 위하여 대장 내시경 검사를 하신 게 언제입니까?
01 한번도 해 본 적 없슴(다음 문제는 생략하시고 E8 로 가십시오)
 02 일 년 이내
 03 1 년 이상 5 년 이내
 04 5 년 이상 10 년 이내
 05 10 년 이상
176
E7
가장 최근에 대장 내시경 검사를 한 주된 이유는 무엇입니까?
 01 정기 검진의 한 부분
 02 증상이 있기 때문에
 99 다른 이유 (_____________________)
E8
결장 내시경 검사를 해 본 적이 있으십니까?
 01 예
E9
 02 아니오
가장 최근에 대장암 검사를 위하여 결장 내시경 검사를 하신 게 언제입니까?
01 한번도 해 본 적 없슴
 02 일 년 이내
 03 1 년 이상 5 년 이내
 04 5 년 이상 10 년 이내
 05 10 년 이상
E10
가장 최근에 결장 내시경 검사를 하신 주된 이유는 무엇입니까?
01 정기 검진의 한 부분
02 증상이 있기 때문에
99 다른 이유 (_____________________)
E11
최근에 위의 검사를 한 적이 없거나 하지 않은 가장 중요한 이유는 무엇입니까?
 01 이유 없다/생각해 본 적 없다
 02 이런 검사가 필요했는지 몰랐다.
 03 의사가 이런 검사가 필요하다고 말하지 않았다.
 04 아무 증상/문제가 없었다.
 05 미루어 왔다/게으름
06 너무 비싸다/의료 보험 없다/비용 문제
07 검사가 너무 아프고, 불쾌하거나 창피하다.
 08 다른 종류의 대장직장암 검사를 했다.
 09 주치의가 없다.
 99 기타 (_________________________)
177
F. Powe Fatalism Inventory (PFI)
다음의 질문에 답하여 주십시오.
1. 무슨 음식을 먹느냐에 관계없이 대장암에 걸릴 사람은 어쨌던지 대장암에 걸릴
것이라고 나는 생각한다.
예
아니오
2. 누군가 대장암에 걸렸다면 그것을 치료하기에는 이미 너무 늦은 것이라고 나는
예
아니오
예
아니오
4. 대장암에 걸릴 사람은 그들이 무엇을 하느냐에 상관없이 대장암에 걸릴 것이라고
나는 생각한다.
예
아니오
5. 누군가 대장암에 걸렸다면, 이미 대장암에 걸리기로 되어 있었다고 생각한다.
예
아니오
6. 누군가 대장암에 걸린다면, 그는 곧 죽을 것이라고 나는 생각한다.
예
아니오
7. 누군가 대장암에 걸린다면, 그들은 대장암으로 죽을 거라는 것이라고 나는
예
아니오
8. 대장암을 검사하는 것이 정말 대장암에 걸렸을 까봐 사람들을 겁 먹게 할 수 있다고
나는 생각한다.
예
아니오
9. 대장암이 걸릴 사람은 대장암에 걸릴 것이라고 나는 생각한다.
예
아니오
10. 만약 어떤 사람이 대장암을 가졌다면, 대장암으로 죽을 수 있다는 것을 알고 싶지
예
아니오
11. 대장암에 걸린다면, 초기 또는 말기에 발견되었든지 상관없이 대장암으로 죽을
것이라고 나는 생각한다.
예
아니오
12. 대장암이 걸려 치료하더라도, 여전히 대장암으로 죽을 것이라도 나는 생각한다.
예
아니오
13. 대장암에 걸릴 사람은 의사나 간호사가 하라고 하는 것에 상관없이 어쨌든지
예
아니오
14. 대장암에 걸릴 사람은 건강한 음식을 먹는 것과는 상관없이 여전히 대장암에 걸릴
것이라고 나는 생각한다.
예
아니오
15. 대장암은 언제 발견되었고 어떻게 치료하느냐에 관계없이 우리를 죽게 할
예
아니오
생각한다.
3. 대장암에 걸리지 않을 사람은 안 걸릴 것이기 때문에, 평생 기름진 음식을 먹어도
된다고 나는 생각한다.
생각한다.
않기 때문에, 암이라는 것을 알기 원치 않을 것이라고 나는 생각한다.
대장암에 걸릴 것이라고 나는 생각한다.
것이라고 나는 생각한다.
178
G. Health Care Access
다음 문항을 읽으시고 본인에게 가장 적합하게 해당하는 답에 표시해 주십시오.
G1
아프시거나 건강에 대한 조언이 필요하실 때 보통 가시는 곳이 있으십니까?
01 예
G2
02 아니오
건강관리를 위하여 가장 자주 가시는 곳이 어디입니까?
 01 의사 오피스 / 다른 HMO
 02 진료소/병원/병원 진료소
 03 응급실
 04 기타 장소 (구체적:__________________)
 05 특별히 없슴
G3
어떤 종류의 의료 보험을 가지고 계십니까?
01 의료 보험이 없슴
02 현재 또는 과거 직장/노동 조합 의료 보험
03 학교, 전문인 협회, 무역그룹, 또는 기타 조직 의료보험
04 개인 보험
05 메디케어
06 메디케이드/메디-칼 (메디-칼은 저소득 아이들과 가족, 임산부, 장애인이나 노인을 위한 플랜)
07 핼씨 패밀리 (19 세 까지의 아이들의 의료 보험을 지불하기 위한 주 정부 프로그램)
08 챔퍼스/챔프-은퇴 군인/트라이케어, 은퇴 군인 의료보험 또는 기타 군인 의료 보험
G4
99 기타 (__________________)
지난 12 개월 동안, 의료 보험이 전혀 없었던 적이 있으십니까?
01 예
G5
02 아니오
어떤 의료 보험이 없으셨던 가장 주된 이유는 무엇입니까?
01 너무 비쌈/형편이 안 됨
02 실업/직장 변경/근무 조건 때문에 자격이 안됨
03 건강상 또는 다른 문제로 자격이 안됨
04 시민권/이민자 신분상 자격이 안됨
05 가족 상황이 바뀜
06 의료 보험을 신뢰하지 않음
07 의료 보험 회사를 변경하는 과정에서 지연됨
08 무료로 의료서비스를 받을 수 있슴/스스로 의료비를 지불함
99 기타 (구체적:________________)
179
G6
지난 12 개월 동안, 본인의 건강 때문에 병원 응급실을 가신 적이 있으십니까?
01 예
G7
02 아니오
지난 12 개월 동안, 의사를 몇 번이나 만나셨습니까?
____________번
G8
본인의 건강 문제로 의사를 마지막으로 만난 지 얼마나 되셨습니까?
01 일년 이내
02 1 년 이상 2 년 이내
03 2 년 이상 5 년 이내
04 5 년 이상
05 의사를 만난 적 없음
G9
지난 12 개월 동안 의사, 전문의, 또는 다른 의료인을 만날 필요가 있었지만, 지연되거나
의료서비스를 받을 수 없었던 적이 있습니까?
 01 예
G10
02 아니오
의료인을 만날 필요가 있었지만 만나지 못 한 이유가 비용이나 의료 보험이 없어서 입니까?
01 예
02 아니오
180
H.
Assessment of Colon Cancer Literacy (ACCL)
다음 문항을 읽고 맞는지, 틀리는지, 또는 확실치 않은지 표시해 주십시오.
맞다
1. 미국에서 대장암은 남성 여성에게서 3번째로 흔한 암이다.
2. 대장암은 환경이 아닌 오로지 유전에 의해서만 발생한다.
3. 모든 대장 용종은 악성이다.
4. 모든 대장암은 잠재적으로 조직을 침투한다.
5. 악성이라는 것은 암이 이미 퍼졌다는 것을 의미한다.
6. 임파절에 대장암이 퍼진 것을 전이라고 부른다.
7. 대장암 수술 동안 임파절 또한 제거된다.
8. 모든 스토마 (주머니)는 영구적이다.
9. 항암치료는 퍼진 대장암 치료에 사용된다.
10. 방사선 치료는 보통 대장암 치료를 위해 사용된다.
틀리다
확실치 않음
181
I.
Physician’s Recommendation
다음 문항을 읽으시고 본인에게 가장 적합하게 해당하는 답에 표시하여 주십시오.
I1
당신은 주치의로 의사나 의료인이 있으십니까?
01 예
I2
02 아니오
지난 5 년 동안, 의사가 결장 내시경, 대장 내시경 또는 대변 잠혈 검사를 권했습니까?
01 예
02 아니오
 03 지난 5 년간 의사에게 가지 않았다.
I3
의사의 암 검사 권유를 따르지 않은 가장 주된 이유는 무엇입니까?
 01 이유 없다/생각해 본 적 없다
 02 이런 검사가 필요한지 몰랐다
 03 아무런 증상/문제가 없었다
 04 미루어 옴/게으름
 05 너무 비싸다/의료 보험이 없다/비용문제
 06 너무 아프고, 불쾌하거나 창피하다.
 99 기타 (_________________________)
182
J. Champion’s Health Belief Model Scales
아래의 문항에서 대장암에 관한 당신의 생각에 가장 적절한 답에 표시해 주십시오.
1.
매우 그렇다
2. 그렇다
3. 보통이다
4. 그렇지 않다
5. 매우 그렇지 않다
Susceptibility
J1. 나는 미래에 분명히 대장암이 걸릴 것 같다.
1
2
3
4
5
J2. 언젠가 대장암에 걸릴 것 같이 느껴진다.
1
2
3
4
5
J3. 향후 10 년 내에 대장암에 걸릴 가능성이 높다.
1
2
3
4
5
J4. 내가 대장암에 걸릴 가능성은 높다.
1
2
3
4
5
J5. 나는 보통 사람들이 대장암에 걸리는 것 보다 더 걸릴 것 같다.
1
2
3
4
5
J6. 대장암에 대한 생각은 나를 겁 먹게 한다.
1
2
3
4
5
J7. 대장암에 대해 생각하면 심장박동이 빨라진다.
1
2
3
4
5
J8. 대장암에 대해 생각하는 것이 두렵다.
1
2
3
4
5
J9. 대장암을 경험할 것이라는 문제는 오래 지속될 것이다.
1
2
3
4
5
J10. 대장암에 걸리는 것은 나의 배우자와의 관계를 위협할 것이다.
1
2
3
4
5
J11. 내가 대장암에 걸린다면 내 인생 전체가 변할 것이다.
1
2
3
4
5
J12. 내가 만약 대장암에 걸렸다면 5 년 이상 살 수 없을 것이다.
1
2
3
4
5
J13. 대장암 검사를 정기적으로 한다면 내 마음이 편할 것이다.
1
2
3
4
5
J14 내가 대장암 검사를 정기적으로 한다면 대장 직장암에 대해 덜 걱정할 것이다.
1
2
3
4
5
J15. 대장암 검사를 정기적으로 한다면 암을 조기에 발견할 수 있게 해 준다.
1
2
3
4
5
J16. 대장암 검사를 정기적으로 한다면 대장암으로 죽을 가능성이 줄을 것이다
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Seriousness
Benefits
J17. 대장암 검사를 정기적으로 한다면 대장암이 생겼을 때 근치적 수술이나
외관상 보기 흉한 수술을 할 가능성이 줄 것이다.
J18. 대장암 검사를 정기적으로 한다면 조기에 암과 같은 것을 발견할 수
있도록 도와 줄 것이다.
183
1.
매우 그렇다
2. 그렇다
3. 보통이다
4. 그렇지 않다
5. 매우 그렇지 않다
Barriers
J19. 대장암에 대해 이야기하는 것이 불편하게 느껴진다.
1
2
3
4
5
J20. 대장암 검사를 정기적으로 하는 것이 대장암에 대해 더 걱정하게 만들 것이다.
1
2
3
4
5
J21. 뭔가 잘 못된 것이 발견될 것 같아 대장암 검사를 하는 것이 두렵다.
1
2
3
4
5
J22. 대장암 검사를 받는 것이 창피하다.
1
2
3
4
5
J23. 대장암 검사를 정기적으로 받는 것은 시간이 너무 많이 걸릴 것이다.
1
2
3
4
5
J24. 대장암 검사를 정기적으로 받는 것은 불쾌할 것이다.
1
2
3
4
5
J25. 대장암 검사를 정기적으로 받는 것은 비용이 많이 들 것이다.
1
2
3
4
5
J26. 대장암 검사가 어떻게 행해지는지 잘 모르기 때문에 검사 받는 것이 두렵다.
1
2
3
4
5
J27. 대장암 검사를 받으려면 어떻게 해야 하는지 잘 모른다.
1
2
3
4
5
J28. 대장암 검사를 받는 것은 너무 고통스럽다.
1
2
3
4
5
J29. 대장암 검사 예약하는 것을 자주 잊어 버린다.
1
2
3
4
5
J30. 대장암 검사 받는 것보다 더 중요한 다른 문제가 있다.
1
2
3
4
5
J31. 나는 나이가 들어 정기적인 대장암 검사가 필요가 없다.
1
2
3
4
5
J32. 내 의사는 정기적인 대장암 검사를 거의 권하지 않는다.
1
2
3
4
5
J33. 교통수단을 찾기가 너무 어려워 정기적인 대장암 검사를 받을 수 없다.
1
2
3
4
5
J34. 대장암 검사를 지불할 의료 보험이 없다.
1
2
3
4
5
J35. 대장암 검사를 받을 수 있을 정도로 영어를 잘 하지 못한다.
1
2
3
4
5
184
K. Acculturation
아래의 각 문항 중 본인의 견해를 가장 잘 대변하는 번호에 표시에 주십시오. 여기서 “아시안”이란 미국에
사는 아시안임을 말합니다.
K1.
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
한국어?
다른 아시아 언어?
영어?
한국어?
다른 아시아 언어?
영어?
한국음악이나 한국영화?
다른 아시아 음악이나 영화?
주류사회 백인 음악이나 영화?
한국음식?
다른 아시아 음식?
주류사회 백인 음식?
다음 음식을 얼마나 자주 드시나요 a.
b.
c.
K7.
2
2
2
한국어?
다른 아시아 언어?
영어?
다음 음식을 얼마나 좋아 하시나요 a.
b.
c.
K6.
아주 잘함
6
얼마나 자주 다음 음악을 들으시거나 영화를 보시나요-a.
b.
c.
K5.
1
1
1
5
다음 언어를 어느 정도 읽고 쓰실 수 있나요 -a.
b.
c.
K4.
어느 정도
3
4
다음 언어를 어느 정도 이해 하시나요 -a.
b.
c.
K3.
2
다음 언어를 어느 정도 말할 수 있나요-a.
b.
c.
K2.
전혀 못함
1
한국음식?
다른 아시아 음식?
주류사회 백인음식?
다음 역사에 대해서 얼마나 아시나요 a.
b.
c.
한국 역사?
다른 아시아 역사?
백인 주류사회의 역사?
185
전혀 못함
1
K8.
어느 정도
3
4
5
아주 잘함
6
다음 문화와 전통에 대해서 얼마나 아시나요 a.
b.
c.
K9.
2
한국사회의 문화와 전통?
다른 아시아 집단의 문화와 전통?
백인 주류사회의 문화와 전통?
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
다음 전통을 실천하고 명절을 지키시나요-a.
b.
c.
한국사회의 전통과 명절?
다른 아시아 집단의 전통과 명절?
백인 주류사회의 전통과 명절?
K10. 다음 집단과 어느 정도 일체감을 느끼시나요 a.
b.
c.
한국교민?
다른 아시아 교민?
주류사회 백인?
K11. 다음의 집단과 어느 정도 동질감을 느끼시나요 a.
b.
c.
한국교민?
다른 아시아 교민?
주류사회 백인?
K12. 다음의 사람들과 얼마 만큼 교류하고 관계를 맺고 있습니까 a.
b.
c.
한국교민?
다른 아시아 교민?
주류사회 백인?
1
1
1
K13. 다음의 사람들과 얼마 만큼 교류하고 관계를 맺고 싶으십니까a.
b.
c.
한국교민?
다른 아시아 교민?
주류사회 백인?
K14. 다음 집단에 속한 것에 대해 얼마나 자긍심을 갖고 있나요 a.
b.
c.
한국교민?
다른 아시아 교민?
주류사회 백인?
*K15. 다음 사람들에 대해 어느 정도 부정적이십니까 a.
b.
c.
한국 교민?
다른 아시아 교민?
주류사회 백인?
* 순서가 바뀐 항목
186
REFERENCES
Abraham, C. & Sheeran, P. (2008). The Health Belief Model. In M. Conner & P. Norman (2nd
Eds.), Predicting health behavior (pp. 28-80). Berkshire, England: Open University Press.
Agre, P., Stieglitz, E., & Milstein, G. (2006). The case for development of a new test of health
literacy. Oncology Nursing Forum, 33(2), 283-289.
American Cancer Society (2010). California cancer facts and figure 2010. Selected cancer
demographics. California’s diverse populations. Retrieved Oct. 3, 2010 from
www.ccrcal.org/pdf/Reports/ACS2010-9-29-09.pdf
American Cancer Society (2010). Cancer facts and figures 2010. Retrieved June 10, 2010 from
http://www.cancer.org/acs/groups/content/@nho/documents/document/acspc-024113.pdf
Austin, L. T., Ahmad, F., McNally, M., & Stewart, D. E. (2002). Breast and cervical cancer
screening in Hispanic women: A literature review using the Health Belief Model.
Women’s Health Issues, 12(3), 122-128.
Baker, D. W., Williams, M. V., Parker, R. M., Gazmararian, J. A., & Nurss, J. (1999).
Development of a brief test to measure functional health literacy. Patient Education &
Counseling, 38, 33-42.
Barnes, P. M., Adams, P. F., & Powell-Griner, E. (2010). Health characteristics of the Asian
adult population: United States, 2004-2006. Advanced Data from vital and health
statistics, 394(22), 1-21.
Barnoy, S., Bar-Tal, Y., & Treister, L. (2003). Effect of unrealistic optimism, perceived control
over disease, and experience with female cancer on behavioral intensions of Israel
women to undergo screening tests. Cancer Nursing, 26(5), 363-369.
Bass, S. B., Gordon, T. F., Ruzek, S. B., Wolak, C., Ward, S., Paranjape, A., Lin, K., Meyer, B.,
& Ruggieri, D. G. (2011). Perception of colorectal cancer screening in urban African
American clinic patients: Differences by gender and screening status. Journal of Cancer
Education, 26(1), 121-128.
Beck, C. T., Froman, R. D., & Bernal, H. (2005). Acculturation level and postpartum depression
in Hispanic mothers. American Journal of Maternal Child Nursing, 30(5), 299-304.
Bernstein, K. S. (2007). Mental health issues among urban Korean American immigrants.
Journal of Transcultural Nursing, 18(2), 175-180.
Betancourt, J. R. & Maina, A. W. (2004). The Institute of Medicine Report “unequal treatment”:
Implications for academic health centers. The Mount Sinai Journal of Medicine, 71(5),
314-321.
187
Brislin, R. W. (1970). Back-translation for cross-cultural research. Journal of Cross-Cultural
Psychology, 1(3), 187-216.
California Cancer Registry (2010). Colorectal cáncer in California, 1988-2007: Questions and
answers. Retrieved Oct. 3, 2010 from www.ccrcal.org/Inside_CCR/CRC-FAQ.shtml
California Health Interview Survey (2013). AskCHIS. Retrieved March 15, 2013, from
http://ask.chis.ucla.edu/main/DQ3/output.asp?_rn=0.6797296
California Health Interview Survey (2011). CHIS 2009 adult questionnaire version 3.4.
Retrieved Jan. 10, 2011 from
http://www.chis.ucla.edu/pdf/CHIS2009adultquestionnaire.pdf
California Health Interview Survey (2005). Ask CHIS. Retrieved Sept. 10, 2009 from
http://www.chis.ucla.edu
California Health Interview Survey (2005). CHIS 2003. Methodology series: Report 1-sample
design. Los Angeles, CA: UCLA Center for Health Policy Research.
California Health Interview Survey (2005). CHIP 2003. Methodology series: Report 5Weighting and variance estimation. Los Angeles, CA: UCLA Center for Health Policy
Research.
Center, M. M., Jemal, A., & Ward, E. (2009). International trends in colorectal cancer incidence
rates. Cancer Epidemiology and Biomarkers Prevention, 18(6), 1688-1694.
Center for Disease Control and Prevention (2011). Social determinants of health. Retrieved Dec.
12, 2011, from http://www.cdc.gov/socialdeterminants/Definitions.html
Champion, V. L. (1984). Instrument development for health belief model constructs. Advanced
Nursing Science, 6, 73-85.
Champion, V. L. & Skinner, C. S. (2008). The Health Belief Model. In K. Glanz, B. K. Rimer &
K. Viswanath (4th Eds.), Health behaviors and health education (pp. 45-65). San
Francisco, CA: John Wiley & Sons.
Chen, M.S. Jr. (2005). Cancer health disparities among Asian Americans: What we do and what
we need to do. Cancer, 104 (suppl.), 2895-2902.
Chen, W. T. & Bakken, S. (2004). Breast cancer knowledge assessment in female Chinese
immigrants in New York. Cancer Nursing, 27(5), 407-412.
Chung, R. H. G., Kim, B., S. K., & Abreu, J. M. (2004). Asian American Multidimensional
Acculturation Scale: Development, factor analysis, reliability, and validity. Cultural
Diversity and Ethnic Minority Psychology, 10(1), 66-80.
188
Clarke, V. A., Lovegrove, H., Williams, A., & Machperson, M. (2000). Unrealistic optimism and
the Health Belief Model. Journal of Behavioral Medicine, 23(4), 367-376.
Colombo, F. & Hurst, J. (2002). Review of the Korean health care system. Paris: OECD.
Coronado, G. D., Thompson, B., McLerran, D., Schwartz, S. M., & Koepsell, T. D. (2005). A
short acculturation scale for Mexican American populations. Ethnicity and Disease, 15(1),
53-62.
Costanza, M. E. (2008). Why don’t people adopt recommended health behaviors? Journal of
Cancer Education, 23, 138-139.
Daniels, R. (2007). The Immigration Act of 1965: Intended and unintended consequences.
Historians on America. U. S. Department of State, 76-83.
Davis, T. C., Dolan, N. C., Ferreira, M. R., Tomori, C., Green, K. W., Sipler, A. M., & Bennett,
C. L. (2001). The role of inadequate health literacy skills in colorectal cancer screening.
Cancer Investigation, 19(2), 193-200.
Dolan, N. C., Ferreira, M. R., Davis, T. C., Fitzgibbon, M. I., Rademarker, A., Liu, D., Schmitt,
B. P., Gorby, N., Wolf, M. S., & Bennett, C. L. (2004). Colorectal cancer screening
knowledge, attitudes, and beliefs among veterans: does literacy make a difference?
Journal of Clinical Oncology, 22, 2617-2622.
Etnyre, A. Rauschhuber, M., Gilliland, I., Cook, J., Mahon, M., Allwein, D. et al. (2006).
Cardiovascular risk among older Hispanic women: A pilot study. Journal of the
American Association of Occupational Health Nurses, 54(3), 120-128.
Ferrer, R. R., Ramirez, M., Beckman, L. J., Danao, L. L., & Ashing-Gina, K. T. (2012). The
impact of cultural characteristics on colorectal cancer screening adherence among
Filipinos in the United States: a pilot study. Psycho-Oncology, 20, 862-870.
Flynn, P. M., Betancourt, H., & Ormseth, S. R. (2011). Culture, emotion, and cancer screening:
an integrative framework for investigating health behavior. Annals of Behavioral
Medicine, 42(1), 79-90.
Freeman, H. P. & Chu, K. C. (2005). Determinants of cancer disparities: barriers to cancer
screening, diagnosis, and treatment. Surgical Oncology Clinics of North America, 14,
655-669.
Gerend, M. A. & Pai, M. (2008). Social determinants of Black-White disparities in breast cancer
mortality: A review. Cancer Epidemiology and Biomarkers Prevention, 17(11), 29132923.
Gorin, S. S. (2005). Correlates of colorectal cancer screening compliance among urban Hispanics.
Journal of Behavioral Medicine, 28(2), 125-137.
189
Green, P. M. & Kelly, B. A. (2004). Colorectal cancer knowledge, perceptions, and behaviors in
African Americans. Cancer Nursing, 27(3), 206-215.
Guidry, J. J., Matthews-Juarez, P., & Copeland, V. A. (2003). Barriers to breast cancer control
for African American women: The interdependence of culture and psychosocial issues.
Cancer, 97 (1 suppl.), 318-323.
Ham, O. K. (2006). Factors affecting mammography behavior and intention among Korean
women. Oncology Nursing Forum, 33(1), 113-119.
Han, H., Kang, J., Kim, K. B., Ryu, J. P., & Kim, M. T. (2007). Barriers to and strategies for
recruiting Korean Americans for community-partnered health promotion research.
Journal of Immigrant and Minority Health, 9, 137-146.
Han, H., Kim, J., Kim, M. T., & Kim, K. B (2011). Measuring health literacy among immigrants
with a phonetic primary language: A case of Korean American women. Journal of
Immigrant and Minority Health, 13(2), 253-259.
Han, H., Lee, H., Kim, M. T., & Kim, K. B. (2009). Tailored health worker intervention
improves breast cancer screening outcomes in non-adherent Korean-American women.
Health Education Research, 24(2), 318-329.
Holubar, S. D., Hassinger, J. P., Dozois, E. J., Wolff, B. G., Kehoe, M., & Cima, R. R. (2009).
Impact of a multimedia e-learning module on colon cancer literacy: A community-based
pilot study. Journal of Surgical Research, 156 (2), 305-311.
Houser, J. (2008). Descriptive research questions and procedures. In J. Houser (Ed.), Nursing
research (pp.323-358). Sudbury, MA: Jones and Bartlett Publishers, Inc.
Houser, J. (2008). The sample strategy. In J. Houser (Ed.), Nursing research (pp.211-240).
Sudbury, MA: Jones and Bartlett Publishers, Inc.
Houser, J. (2008). Analysis and reporting of quantitative data. In J. Houser (Ed.), Nursing
research (pp. 427-470). Sudbury, MA: Jones and Bartlett Publishers, Inc.
Im, E. O., Lee, E. O., & Park, Y. S. (2002). Korean women’s breast cancer experience. Journal
of Nursing Research, 24(7), 751-765.
Im, E. & Yang, K. (2006). Theories on immigrant women’s health. Health Care for Women
International, 27, 666-681.
Jacobs, L. A. (2002). Health beliefs of first –degree relatives of individuals with colorectal
cancer and participation in health maintenance visits: A population-based survey. Cancer
Nursing, 25(4), 251-265.
190
Jacobs, E. A., Karavolos, K., Rathouz, P. J., Ferris, T. G., & Powell, L.H. (2005). Limited
English proficiency and breast and cervical cancer screening in a multiethnic population.
American Journal of Public Health, 95(8), 1410-1416.
James, T. M., Greiner, K. A., Ellerbeck, E. F., Feng, C., & Ahluwalia, J. S. (2006). Disparities in
colorectal cancer screening: A guideline-based analysis of adherence. Ethnicity and
Disease, 16, 228-233
Jang, Y., Kim, G., & Chiriboga, D. A. (2005). Health, healthcare utilization, and satisfaction
with service: Barriers and facilitators for older Korean Americans. Journal of American
Geriatrics Society, 53, 1613-1617.
Jo, A. M., Maxwell, A. E., Rick, A. J., Cha, J., & Bastani, R. (2009). Why are Korean American
physicians reluctant to recommend colorectal cancer screening to Korean American
patients? Exploratory Interview findings. Journal of Immigrant and Minority Health,
11(4), 302-309.
Jo, A. M., Maxwell, A. E., Wong, W. K., & Bastani, R. (2008). Colorectal cancer screening
among underserved Korean Americans in Los Angeles County. Journal of Immigrant and
Minority Health, 10, 119-126.
Johnson, K. & Weiss, B. D. (2008). How long does it take to assess literacy skills in clinical
practice? Journal of the American Board of Family Medicine, 21, 211-214.
Jones, P. S., Lee, J. W., Phillips, L. R., Zhang, X. E., & Jaceldo, K. B. (2001). An adaptation of
Brislin’s translation model for cross-cultural research. Nursing Research, 50(5), 300-304.
Jones, E. G., Mallinson, K., & Phillips, L., & Kang, Y. (2006). Challenges in language, culture,
and modality. Nursing Research, 55(1), 1-7.
Juon, H. S., Choi, S., Klassen, A., & Roter, D. (2006). Impact of breast cancer screening
intervention on Korean-American women in Maryland. Cancer Detection and
Prevention, 30(3), 297-305.
Juon, H. S., Han, W., Shin, H., Kim, B. K., & Kim, M. T. (2003). Predictors of older Korean
Americans’ participation in colorectal cancer screening. Journal of Cancer Education,
18(1), 37-42.
Juon, H. S., Kim, M., Shankar, S., & Han, W. (2004). Predictors of adherence to screening
mammography among Korean Americans women. Preventive Medicine, 39, 474-481.
Juon, H. S., Seung-Lee, C., & Klassen, A. C. (2003). Predictors of regular Pap smears among
Korean American women. Preventive Medicine, 37, 585-592.
Kagawa-Singer, M., Dadia, A. V., Yu, M. C., & Surbone, A. (2010). Cancer, culture, and health
disparities: Time to chart a new course? CA Cancer Journal of Clinician, 60, 12-39.
191
Kandula, N. R., Wen, M., Jacobs, E. A., & Lauderdale, D. S. (2006). Low rates of colorectal,
cervical, and breast cancer screening in Asian Americans compared with non-Hispanic
White. Cultural influences or access to care? Cancer, 107(1), 184-192.
Kim, E. (2009). Multidimensional acculturation attitudes and depressive symptoms in Korean
Americans. Issues in Mental Health Nursing, 30, 98-103.
Kim, K., Yu, E. S., Chen, E. H., Kim, J., Kaufman, M., & Purkiss, J. (1999). Cervical cancer
screening knowledge and practices among Korean American women. Cancer Nursing,
22, 297-302.
Klabunde, C. N., Brown, M., Barbash, R. B., White, M. C., Thompson, T., Plescia, M., & King,
S. C. (2012). Cancer screening – United States, 2010. Morbidity and Mortality Weekly
Report, 61(3), 41-45.
Korean American Coalition (2011). Statistics. Retrieved Sept. 27, 2011 from
http://kacla.org/?page_id=1589
Le, C. N. (2009). Asian small businesses. Asian-Nation: The landscape of Asian American.
Retrieved Oct. 10, 2010, from http://www.asian-nation.org/small-business.shtml.
Lee, E. E., Fogg, L. F., & Menon, U. (2008). Knowledge and belief related to cervical cancer and
screening among Korean American Women. Western Journal of Nursing Research,
30(8), 960-974.
Lee, E. E., Fogg, L. F., & Sadler, G. R. (2006). Factors of breast cancer screening among Korean
immigrants in the United States. Journal of Immigrant and Minority Health, 8(3), 223233.
Lee, E. E., Tripp-Reimer, T., Miller, A. M., Sadler, G. R., & Lee, S. Y. (2007). Korean American
women’s beliefs about breast and cervical cancer and associated symbolic meanings.
Oncology Nursing Forum, 34(3), 713-720.
Lee, H., Kim, J., & Han, H. (2009). Do cultural factors predict mammography behaviors among
Korean immigrants in the USA? Journal of Advanced Nursing, 65(12), 2574-2584.
Lee, J., Demissie, K., Lu, S., & Rhoads, G. G. (2007). Cancer incidence among Korean
American immigrants in the United States and native Koreans in South Korea. Cancer
Control, 14(1), 78-85.
Lee, J. H., Goldstein, M. S., Brown, E. R., & Ballard-Barbash, R. (2010). How does
acculturation affect the use of complementary and alternative medicine providers among
Mexican- and Asian-Americans? Journal of Immigrant Minority and Health, 12, 302309.
192
Lee, T. W., Kang, S. J., Lee, H. J., & Hyun, S. I. (2009). Testing health literacy skills in older
Korean adults. Patient Education & Counseling, 75, 302-307.
Lee, M. C. (2000). Knowledge, barriers, and motivator related to cervical cancer screening
among Korean American women. Cancer Nursing, 23, 168-175.
Lee, K. W., Park, J., Oh, A., & Chun, S. (2010). Korean-American history. Retrieved April 13,
2010 from http://apa.si.edu/Curriculum%20Guide-Final/unit1.htm
Lew, A. A., Moskowitz, J. M., Ngo, L., Wismer, B.A., Wong, J.M., Ahn, Y., & Tager, I. B.
(2003). Effect of provider status on preventive screening among Korean American
women in Alameda County, California. Preventive Medicine, 36(2), 141-149.
Lim, J. & Yi, J., & Zebrack, B. (2008). Acculturation, social support, and quality of life for
Korean immigrant breast and gynecological cancer survivors. Ethnicity & Health, 13(3),
243-260.
Liora, N. (1999). Cultural views of cancer around the world. Cancer Nursing, 22(1), 39-45.
Ma, G. X., Shive, S., Tan, Y., Gao, W., Rhee, J., Park, M., Kim, J., & Toubbeh, J. I. (2009).
Community-based colorectal cancer intervention in underserved Korean Americans.
Cancer Epidemiology, 33, 381-386.
Maxwell, A. E. & Song, H. (2003). Cancer screening of Korean Americans in Los Angeles
County: Adding pieces to the puzzle. Korean and Korean American Studies Bulletin, 13,
59-70.
Maxwell, A. E., Bastani, R., & Warda, U. S. (2000). Demographic predictors of cancer screening
among Filipino and Korean immigrants in the United States. American Journal of
Preventive Medicine, 18 (1), 62-68.
Maxwell, A. E. & Crespi, C. M. (2009). Trends on colorectal cancer screening utilization among
ethnic groups in California: Are we closing the gap? Cancer Epidemiology Biomarkers
and Prevention, 18(3), 752-759.
Maxwell, A. E., Crespi, C. M., Antonio, C. M., & Lu, P. (2010). Explaining disparities in
colorectal cancer screening among five Asian ethnic groups: A population-based study in
California. BMC Cancer, 10, 214. Retrieved Oct. 4, 2010 from
http://www.biomedcentral.com/content/pdf/1471-2407-10-214.pdf
Miller, D. P., Brownlee, C. D., McCoy, T. P., & Pignone, M. P. (2007). The effect of health
literacy on knowledge and receipt of colorectal cancer screening: a survey study. BMC
Family Practice, 8, 16. Retrieved Jan 3, 2012 from
http://www.biomedcentral.com/content/pdf/1471-2296-8-16.pdf
193
Molina-Barcelo, A., Salas-Trejo, D., Peiro-Perez, R., & Malaga Lopez, A. (2011). To participate
or not? Giving voice to gender and soci-economic differences in colorectal cancer
screening programs. European Journal of Cancer Care, 20, 669-678.
Monteros, K. E. & Gallo, L. C. (2011). The relevance of fatalism in the study of Latinas’ cancer
screening behavior: A systemic review of the literature. Internal Journal of Behavioral
Medicine, 18(4), 310-318.
Morgan, P. D., Fogel, J., Tyler, I. D., & Jones, J. R. (2010). Culturally targeted educational
intervention to increase colorectal health awareness among African Americans. Journal
of Health Care for the Poor and Underserved, 21, 132-147.
Nash, A. (2010). Korean Americans. Retrieved April 13, 2010, from
http://www.everyculture.com/multi/Ha-La/Korean-Americans.html
National Cancer Institute (2010). A snapshot of CRC: Incidence and mortality rate trends.
Retrieved June 17, 2010 from
http://www.cancer.gov/aboutnci/servingpeople/snapshots/colorectal.pdf
National Cancer Institute (2010). Colorectal cancer: Six years of research progress March 2008.
Retrieved June 17, 2010 from http://planning.cancer.gov/library/2008colorectal.pdf
National Cancer Institute (2010). Cancer advances in focus colorectal cancer. Retrieved June, 17,
2010, from http://www.cancer.gov/cancertopics/cancer-advances-in-focus/colorectal
National Cancer Institute (2009). Theory at a glance: A guide for health promotion practice.
Retrieved Jan. 28, 2009 from http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf5aa48ee1da4d/TAAG3.pdf
National Network for Libraries of Medicine (2011). Health literacy. Retrieved Jun 1, 2011 from
http://nnlm.gov/outreach/consumer/hlthlit.html,
Park, S. Y. & Bernstein, K. S. (2008). Depression and Korean American immigrants. Archives of
Psychiatric Nursing, 22(1), 12-19.
Pendlimari, R., Holubar, S. D., Hassinger, J. P., & Cima, R. R. (2011). Assessment of colon
cancer literacy in screening colonoscopy patients: A validation study. Journal of Surgical
Research, 1- 6. Retrieved March 1, 2012, from
http://pdn.sciencedirect.com.ezproxy2.library.arizona.edu/science?_ob=MiamiImageURL
&_cid=272608&_user=9555371&_pii=S0022480411004161&_check=y&_origin=search
&_zone=rslt_list_item&_coverDate=2011-05-18&wchp=dGLzVlVzSkzV&md5=ad9257f3ed80bff307ac1c380e742be9/1-s2.0-S0022480411004161main.pdf
194
Peterson, N. B., Dwyer, K. A, Mulvaney, S. A., Dietrich, M. S., & Rothman, R. L. (2007). The
influence of health literacy on colorectal cancer screening knowledge, beliefs and
behavior. Journal of the National Medical Association, 99(10), 1105-1112.
Phillips, K. A., Liang, S. Y., Ladabaum, U., et al. (2007). Trends in colonoscopy for colorectal
cancer screening. Medical Care, 45, 160-167.
Polit, D. F. & Beck, C. T. (2004). Sampling designs. In D. F. Polit & C. T. Beck (7th Eds.),
Nursing research: Principles and methods (pp. 289-314). Philadelphia, PA: Lippincott
Williams & Wilkins.
Pons-Vigues, M., PuigpinoPons-Vigues, M., Puigpino-Riera, R., Serral, G., Pasarin, M. I.,
Rodriguez, D., Perez, G., Benet, J., Casamitjana, M., & Borrell, C. (2012). Knowledge,
attitude and perceptions of breast cancer screening among native and immigrant women
in Barcelona, Spain. Psycho-Oncology, 21, 618-629.
Powe, B. D. (2007). Eliminating cancer disparities. Cancer, 109 (2 suppl.), 345-347.
Powe, B. D. (2001). Cancer fatalism among elderly African American women: Predictors of the
intensity of the perceptions. Journal of Psychosocial Oncology, 19(3/4), 85-96.
Powe, B. D. (1997). Cancer fatalism: Spiritual perspectives. Journal of Religion and Health,
36(2), 135-144.
Powe, B. D. (1995a). Fatalism among elderly African Americans: Effects on colorectal cancer
screening. Cancer Nursing, 18(5), 385-392.
Powe, B. D. (1995b). Cancer fatalism among elderly Caucasians and African Americans.
Oncology Nursing Forum, 22(9), 1355-1359.
Powe, B. D. & Finnie, R. (2003). Cancer fatalism. The state of the science. Cancer Nursing,
26(6), 454-465.
Price-Haywood, E. G., Roth, K. G., Shelby, K., & Cooper, L. A. (2010). Cancer risk
communication with low health literacy patients: A continuing medical education
program. Journal of General Internal Medicine, 25(supp. 2), S126-129.
Ransohoff, D. F. (2009). How much does colonoscopy reduce colon cancer mortality? Annual
Internal Medicine, 150, 50-52.
Remennick, L. (2003). “I have no time for potential troubles”: Russian immigrant women and
breast cancer screening in Israel. Journal of Immigrant Health, 5(4), 153-163.
Rimer, B. K. (2008). Models of individual health behavior. In K. Glanz, B. K. Rimer, & K.
Viswanath (4th Eds.), Health Behavior and Health Education: Theory, research, and
practice (pp. 41-44). San Francisco, CA: John Wiley & Sons.
195
Russell, K. M., Champion, V. L., & Perkins, S. M. (2003). Development of cultural belief scales
for mammography screening. Oncology Nursing Forum, 30(4), 633-640.
Ryu, H., Young, W. B., & Park, C. (2001). Korean American health insurance and health service
utilization. Research in Nursing and Health, 24(6), 494-505.
Sarfaty, M. & Wender, R. (2007). How to increase colorectal cancer screening rates in practice.
CA Cancer Journal for Clinicians, 57, 354-366.
Sarna, L., Tae, Y. S., Kim, Y. H., Brecht, M. L., & Maxwell, A. E. (2001). Cancer screening
among Korean Americans. Cancer Practice, 9(3), 134-140.
Shaw, A., Ibrahim, S., Reid, F., Ussher, M., & Rowlands, G. (2009). Patient’s perspectives of the
doctor-patient relationship and information giving across a range of literacy levels.
Patient Education and Counseling, 75(1), 114-200
Shim, Y. R. & Schwartz, R. C. (2008). Degree of acculturation and adherence to Asian values as
correlates of psychological distress among Korean immigrants. Journal of Mental Health,
17(6), 607-617.
Shin, H., Song, H., Kim, J., & Probst, J. C. (2005). Insurance, acculturation, and health service
utilization among Korean Americans. Journal of Immigrant Health, 7(2), 65-74.
Smith, R. A., Cokkinides, V., Brooks, D., Saslow, D., & Brawley, O. W. (2010). Cancer
screening in the United States, 2010: A review of current American Cancer Society
guidelines and issues in cancer screening. CA Cancer Journal for Clinicians, 60, 99-119.
Sohn, L. & Harada, N. D. (2004). Time since immigration and health service utilization of
Korean-American older adults living in Los Angeles County. Journal of American
Geriatrics Society, 52, 1946-1950.
Sohn, L. & Harada, N. D. (2005). Knowledge and use of preventive health practice among
Korean women in Los Angeles county. Preventive Medicine, 41(1), 167-178.
Song, H., J., Han, H. R., Lee, J. E., Kim, J. Y., Kim, B. K., Ryu, J. P., & Kim, M. (2010). Does
access to care still affect health care utilization by immigrants? Testing of an empirical
explanatory model of health care utilization by Korean American immigrants with high
blood pressure. Journal of Immigrant and Minority Health, 12(4), 513-519.
Song, Y. J., Hofstetter, C. R., Hovell, M. F., Paik, H. Y., Park, H. R, Lee, & J. Irvin, V. (2004).
Acculturation and health risk behaviors among California of Korean descent. Preventive
Medicine, 39, 147-156.
Southern California Association of Governments (2011). 2011 Local profiles of SCAG
jurisdictions. Retrieved Jan. 6, 2012 from http://www.scag.ca.gov/resources/profiles.htm
196
Strecher, V. J. & Rosenstock, I. M. (1997). The Health Belief Model. In K. Glanz, F. M. Lewis,
& B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and
practice (2nd ed., pp. 41-59). San Francisco, CA: Jossey-Bass.
Suh, E. (2007). Korean immigrant women’s perceptions on breast cancer screening practices: A
comparison with the Health Belief Model. Oncology Nursing Forum, 34(2), 526.
Thomson, M. D. & Hoffman-Goetz, L. (2009). Defining and measuring acculturation: A
systemic review of public health studies with Hispanic populations in the United States.
Social Science & Medicine, 69, 983-991
Todd, L., & Hoffman-Goetz, L. (2011). Predicting health literacy among English-as-a-SecondLanguage older Chinese immigrant women to Canada: Comprehension of colon cancer
prevention information. Journal of Cancer Education, 26, 326-332.
Tropp, L. R., Erkut, S., Coll, C., Alacon, O., & Garcia, H. A. V. (1999). Psychological
adjustment: Development of a new measure for Puerto Ricans on the US mainland.
Educational and Psychological Measurement, 59, 351-367.
Ueland, A. S., Hornung, P. A., & Greenwald, B. (2006). Colorectal cancer prevention and
screening. Gastroenterology Nursing, 29(5), 357-363.
Umar, A. & Greenwald, P. (2009). Alarming colorectal cancer inceidence trends: A case for
early detection and prevention. Cancer Epidemiology, Biomarkers, and Prevention, 18(6),
1672-1673.
U.S. Bureau of Census (2011). The American Community Survey. Retrieved Jan. 6, 2012, from
http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=
ACS_10_1YR_S1501&prodType=table
U.S. Bureau of Census (2011). 2010 Census summary file 1, PCT7, Asian alone or in
combination with one or more races, and with one more Asian categories for selected
groups.
U.S. Census Bureau (2007). The American community survey reports. The American
Community-Asians: 2004. U. S. Department of Commerce. Retrieved Jan. 05, 2011 from
http://www.census.gov/prod/2007pubs/acs-05.pdf
U.S. Census Bureau (2002). A profile of the nation’s foreign-born population from Asia (2000
update). U. S. Department of Commerce.
U.S. Department of Health and Human Services (2011). Healthy People 2020 Topics &
Objectives. Retrieved June 1, 2011 from
http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx
197
von Wagner, C., Semmler, C., Good, A., & Wardle, J. (2009). Health literacy and self-efficacy
for participation in colorectal cancer screening: The role of information processing.
Patient Education and Counseling, 75(3), 352-357.
Wackerbarth, S. B., Peters, J. C., & Haist, S. A. (2005). “Do we really need all that equipment?”
Factors influencing colorectal cancer screening decisions. Quality Health Research, 15,
539-554.
Weinberg, D. S., Miller, S., Rodoletz, M., Egleston, B., Fleisher, L., Buzaglo, J., Keenan, E., &
Marks, J., (2009). Colorectal cancer knowledge is not associated with screening
compliance or intention. Journal of Cancer Education, 24(3), 225-232.
Weinrich, S. P., Weinrich, M. C., Boyd, M. D., Johnson, E., & Frank-Stromborg, M. (1992).
Knowledge of colorectal cancer among older persons. Cancer Nursing, 15(5), 322-330.
Wolf, M. S., Davis, T. C., Shrank, W., Rapp, D. N., Bass, P. F., Connor, U. M., Clayman, M., &
Parker, R. M. (2007). To err is human: Patient misinterpretation of prescription drug label
instructions. Patient Education and Counseling, 67(3), 293-300.
Wood, M. E. (2008). Theoretical framework to study exercise motivation for breast cancer risk
reduction. Oncology Nursing Forum, 35(1), 89-95.
World Health Organization (2011). Social determinants of health. Retrieved Dec. 12, 2011, from
http://www.who.int/social_determinants/en/
Yip, M. P., Tu, S. P., Chun, A., Yasui, Y., & Taylor, V. M. (2006). Participation in colorectal
cancer screening among Chinese Americans. Asian Pacific Journal of Cancer
Prevention, 7(4), 645-650.
Yoon, E., Lee, R. M., & Goh, M. (2008). Acculturation, social connectedness, and subjective
well-being. Cultural Diversity and Ethnic Minority Psychology, 14(3), 246-255.
http://pdn.sciencedirect.com.ezproxy2.library.arizona.edu/science?_ob=MiamiImageURL
&_cid=272608&_user=9555371&_pii=S0022480411004161&_check=y&_origin=article
&_zone=toolbar&_coverDate=18-May2011&view=c&originContentFamily=serial&wchp=dGLzVBAzSkWz&md5=433a66fa9054c4bb963b291a12556502/1-s2.0-S0022480411004161main.pdf