Colorectal cancer screening among underserved Korean Americans in Los Angeles County

Predicting adoption of colorectal cancer screening among Korean Americans using a decision tree model

BACKGROUND

Colorectal cancer screening (CRCS) rates remain suboptimal among Korean Americans despite recommendations from health organizations. Little is known about the mechanism underlying their CRCS adoption within complex systems. This study aimed to examine the multi-level predictors of CRCS adoption among Korean Americans using a decision tree model.

METHODS

A cross-sectional survey was performed to assess CRCS adoption and multiple levels of influence - individual (i.e. CRCS self-efficacy, CRCS attitudes, risk of colorectal cancer, psychological distress, health status), interpersonal (i.e. social support, social networks, CRCS recommendations), and organizational/community (i.e. health insurance, primary doctor, primary clinic) factors. A total of 433 Korean Americans aged 50-75 in a metropolitan area in the Southeastern U.S. completed a self-report questionnaire. To determine the important variables that predict CRCS adoption, the study generated a decision tree predictive model using R statistical software.

RESULTS

The results indicated that CRCS self-efficacy and CRCS attitudes at the individual level and CRCS recommendations and social support at the interpersonal level differentiate adopting or not adopting CRCS. Furthermore, CRCS recommendations (n = 138, 56%, prob = 0.64) and CRCS self-efficacy (n = 51, 21%, prob = 0.88) were the most powerful predictors of CRCS adoption.

CONCLUSION

The findings highlight the critical roles of CRCS recommendations from healthcare providers and family/friends and patients' confidence in performing screening-related tasks in influencing CRCS adoption among Korean Americans. Practice efforts should target individual and interpersonal characteristics when developing interventions for promoting CRCS among Korean Americans, especially who are not adherent to screening guidelines.

Addressing Health Disparities Across the Cancer Continuum—a Los Angeles Approach to Achieving Equity

Introduction

Different models have been developed to address inequities across the cancer care continuum. However, there remains a scarcity of best practices on understanding and responding to the burden of cancer in a defined catchment area.As such, the National Cancer Institute (NCI) recently provided a framework to maximize the impact on cancer burden, including a greater focus on community outreach and engagement. In this paper, we describe how Cedars Sinai Cancer (CSC), a health system that serves one of the most diverse counties in the US, implemented the framework to define its catchment area, characterize its population, identify high risk priority groups, and make decisions to address health disparities.

Methods

We provide a review of the methods used to assess socio-ecological levels of influence. Data were reviewed from numerous national, statewide, and county sources and supplemented by locally administered questionnaires, heat maps, and community profile summaries to gain more localized snapshots of cancer disparities in Los Angeles County. Lastly, feedback was solicited from external peer groups, community stakeholders, and key decision-makers, and the proposed catchment area was aligned with the State’s Cancer Plan and the NCI Catchment Area and Community Outreach and Engagement Mandate.

Results

The selected CSC catchment area meets NCI criteria and has potential to demonstrate impact both at the population level and within specialty populations. As a result, strategies are being developed to organize community outreach and engagement, as well as research across basic, clinical, and population sciences to guide cancer control and prevention efforts.

Discussion

To maintain a high level of cultural inclusion and sensitivity, multiple layers of data are needed to understand localized pictures of cancer disparities and underlying causes. Community engagement remains essential to implementing policy, best practice, and translational science for broader impact.

Impact

The clinical and translation work conducted at any cancer center requires an understanding of the determinants of health that contribute to the differences in cancer incidence and mortality among different groups. The NCI-aligned approach that we highlight is critical to support the design of future cancer control strategies that address and possibly reduce local health inequities.

A Qualitative Analysis of Barriers to Colorectal Cancer Screening among Korean Americans

Colorectal cancer (CRC) is the second most-commonly diagnosed cancer among Korean Americans after breast cancer, with incidence rates exceeding that of lung, prostate, and stomach cancers. However, CRC screening rates are lower among Korean Americans than the general U.S. population. To understand barriers to screening in this population, we conducted 11 focus groups with 51 Korean Americans ages 40+ in the Washington, DC, metropolitan area between 2011 and 2016. Our analysis used the Health Belief Model as a framework. Motivators to seek screening include a family or personal history of cancer or gastrointestinal disease (high perceived susceptibility), knowing people with CRC (high severity), favorable test results reducing worry (high benefits), and physician recommendations (cues to action). Barriers to screening include the common misperception that Korean lifestyles prevent CRC (low susceptibility), the belief that cancer is normal for older adults (low severity), the assumption that screening only benefits symptomatic people (low benefits), the costs and potential risks of testing along with a preference for traditional Korean approaches to wellness (high barriers), and lack of health insurance (low self-efficacy). Interventions seeking to increase the rate of cancer screening in the Korean American community will benefit from emphasizing the burden from CRC among Korean Americans (increasing perceived susceptibility to CRC), explaining that colonoscopies can prevent CRC rather than just diagnosing it (increasing perceived benefits of screening), reducing anxieties about test procedures and embarrassment (reducing perceived barriers to screening), and improving clinical communication (improving cues to action and self-efficacy).

Barriers and facilitators to colorectal cancer screening among older Korean Americans: A focus group study

A qualitative study was undertaken to explore the barriers and facilitators to colorectal cancer (CRC) screening among older Korean Americans (KAs). Four focus groups with 25 male and female KA participants and one focus group comprising five KA health professionals were conducted in the Atlanta Metropolitan area. Interpretive analyses of the interview data revealed barriers regarding CRC screening for KAs included a lack of CRC knowledge, embarrassment during the screening tests, CRC-related fatalism, and modesty, no perceived need for the screening, poor English proficiency, and mistrust of the American healthcare system. The results also indicated that doctors' screening recommendations and access to Korean doctors positively influence KAs' decision to participate in CRC screening. Public health social workers should consider integrating age- and gender-specific cultural contexts when developing interventions and programs for CRC screening targeted to older KAs.

The Importance of Health Insurance in Addressing Asian American Disparities in Utilization of Clinical Preventive Services: 12-Year Pooled Data from California

Purpose: Previous research has shown that Asian Americans are less likely to receive recommended clinical preventive services especially for cancer compared with non-Hispanic whites. Health insurance expansion has been recommended as a way to increase use of these preventive services. This study examines the extent to which utilization of preventive services by Asians overall and by ethnicity compared with non-Hispanic whites is moderated by health insurance. Methods: Data from the California Health Interview Survey (CHIS) was used to examine preventive service utilization among non-Hispanic whites, Asians, and Asian subgroups 50-64 years of age by insurance status. Six waves of CHIS data from 2001 to 2011 were combined to allow analysis of Asian subgroups. Logistic regression models were run to predict the effect of insurance on receipt of mammography, colorectal cancer (CRC) screening, and flu shots among Asians overall and by ethnicity compared with whites. Results: Privately insured Asians reported significantly lower adjusted rates of mammography (83.1% vs. 87.6%) and CRC screening (54.7% vs. 59.4%), and higher rates of influenza vaccination (48.7% vs. 38.5%) than privately insured non-Hispanic whites. Adjusted rates of cancer screening were lower among Koreans and Chinese for mammography, and lower among Filipinos for CRC screening. Conclusion: This study highlights the limitations of providing insurance coverage as a strategy to eliminate disparities for cancer screening among Asians without addressing cultural factors.

Community-Clinical Linkage Intervention to Improve Colorectal Cancer Screening Among Underserved Korean Americans

Korean Americans report the lowest and declined rates of colorectal cancer (CRC) screening, compared to general population in the United States. The present study aimed to evaluate the efficacy of a community-based multifaceted intervention designed to improve CRC screening among Korean Americans. A cluster-randomized trial involving 30 Korean church-based community organizations (n = 925) was conducted. Fifteen churches were assigned to intervention (n=470) and the other 15 to control (n = 455) groups. Main components of the intervention included interactive group education, patient navigation, physician engagement, and provision of fecal immunochemical test (FIT) kit. CRC screening rates were assessed at a 12-month follow-up. Participants in the intervention group were significantly more likely to receive CRC screening (69.3%) as compared with those in the control group (16%). The intervention was particularly effective in promoting FIT among the more disadvantaged individuals in the Korean American community. Regression analysis revealed that controlling for the intervention effect, male gender, high school education, annual income of $20,000-40,000 were significantly associated with increased screening by FIT, whereas English inefficiency was significantly and lack of health insurance was marginally significantly associated with decreased screening by colonoscopy/sigmoidoscopy. Culturally and linguistically appropriate multifaceted intervention combining FIT provision with community-clinical linkage has a potential to be a cost-effective and practical approach to effectively targeting hard-to-reach disadvantaged minority populations and enhance CRC screening to reduce cancer disparities.

Factors Associated with Reported Colorectal Cancer Screening Among Lao-American Immigrants in Minnesota

Colorectal Cancer (CRC) is common in Lao Americans, but screening is suboptimal. To investigate CRC screening rates of Lao Americans in Minnesota, and how predisposing characteristics, enabling resources, and perceived need are associated with screening. We conducted a convenience-sample cross-sectional survey of 50-75-year-old Lao Americans, using step-wise multivariate logistic regression to identify factors associated with ever being screened. Of the 118 survey participants, 45% ever received CRC screening. In univariate regression, some enabling resources (having a primary care provider, higher self-efficacy in pursuing screening) and perceived needs (knowledge of who should be screened, higher number of chronic illnesses) were associated with screening. In multivariate logistic regression, the odds of ever being screened was 12.4 times higher for those with a primary care provider than for those without (p = 0.045). The findings reinforce a need for developing culturally tailored interventions focused on Lao-American immigrants to promote CRC screening.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

Analyzing paths from online health information seeking to colorectal cancer screening using health literacy skills frame and cognitive mediation model

OBJECTIVE

To test the hypothesized paths for Online Health Information Seeking (OHIS) behaviors in developing health literacy, leading to colorectal cancer (CRC) screening among Korean Americans (KAs) using Health Literacy Skills Frameworks (HLSF) and Cognitive Mediation Model (CMM).

METHODS

A total of 433 KAs aged 50 through 75 in a metropolitan area in the Southeastern U.S. completed a cross-sectional survey regarding sociodemographics, OHIS behaviors, information overload, health literacy, decisional balance, and CRC screening history. Path analyses were implemented to assess the hypothesized causal models by examining the relationships among these variables.

RESULTS

OHIS was positively associated with information overload and health literacy; information overload was negatively associated with health literacy. Health literacy was positively associated with decisional balance; decisional balance was positively associated with uptake of sigmoidoscopy and colonoscopy.

CONCLUSION

The findings supported both theoretical frameworks, HLSF and CMM, for OHIS to develop health literacy, leading to CRC screening. These findings highlight the significant roles of information overload and attitudes and beliefs about screening in enhancing health literacy and CRC screening among KAs.

PRACTICE IMPLICATIONS

Practice efforts for facilitating CRC screening among medically underserved older KAs should target improving access to and use of OHIS and culturally-tailored health information delivery.

The Chinese and Korean American immigrant experience: a mixed-methods examination of facilitators and barriers of colorectal cancer screening

OBJECTIVE

Among Asian Americans, colorectal cancer (CRC) is the second leading cause of cancer deaths. Despite strong evidence that screening can reduce CRC-related mortality, fewer Chinese and Koreans receive screening as compared to non-Hispanic whites and blacks. The objective of this study was to examine facilitators and barriers as well as strategies to promote CRC screening in this population.

DESIGN

This study employed a mixed-methods design. We conducted 17 key informant interviews and 12 focus groups in the Washington, D.C. metropolitan area. 120 Chinese and Korean focus group participants, aged 50 to 85, also provided quantitative data through self-administered surveys. All participants were asked to discuss facilitators and barriers of CRC screening, including in relation to culture.

RESULTS

Participants who had a regular physician and doctor's recommendation for CRC screening were more likely to ever receive a colonoscopy (adjusted odds ratio (aOR) = 3.51; 95% confidence interval (CI): 1.26, 9.79 and aOR = 6.61; 95% CI: 2.63, 16.65, respectively). A doctor's recommendation was also significantly associated with receipt of a fecal occult blood test (FOBT) (aOR = 4.00; 95% CI: 1.43, 11.15). In terms of barriers, those who reported having no time and not having symptoms were less likely to have a colonoscopy (aOR = 0.15; 95% CI: 0.03, 0.82 and aOR = 0.02; 95% CI: 0.002, 0.23, respectively) than those who had time and symptoms. Preventive healthcare was often not viewed as a priority, particularly for those living the'immigrant life,' who gave precedence to work. Cultural barriers to CRC screening included language (e.g. limited English proficiency and low health literacy); fear of finding CRC and burdening the family especially children; fatalism; and stigma towards cancer.

CONCLUSIONS

Future interventions and programs aiming to increase CRC screening among Chinese and Korean Americans should address both cultural and non-cultural factors that influence CRC screening uptake.

Eliciting vulnerable patients' preferences regarding colorectal cancer screening: a systematic review

BACKGROUND

Patient preferences are important to consider in the decision-making process for colorectal cancer (CRC) screening. Vulnerable populations, such as racial/ethnic minorities and low-income, veteran, and rural populations, exhibit lower screening uptake. This systematic review summarizes the existing literature on vulnerable patient populations' preferences regarding CRC screening.

METHODS

We searched the CINAHL, PsycINFO, PubMed, Scopus, and Web of Science databases for articles published between January 1, 1996 and December 31, 2017. We screened studies for eligibility and systematically abstracted and compared study designs and outcomes.

RESULTS

A total of 43 articles met the inclusion criteria, out of 2,106 articles found in our search. These 43 articles were organized by the primary sub-population(s) whose preferences were reported: 27 report on preferences among racial/ethnic minorities, eight among low-income groups, six among veterans, and two among rural populations. The majority of studies (n=34) focused on preferences related to test modality. No single test modality was overwhelmingly supported by all sub-populations, although veterans seemed to prefer colonoscopy. Test attributes such as accuracy, sensitivity, cost, and convenience were also noted as important features. Furthermore, a preference for shared decision-making between vulnerable patients and providers was found.

CONCLUSION

The heterogeneity in study design, populations, and outcomes of the selected studies revealed a wide spectrum of CRC screening preferences within vulnerable populations. More decision aids and discrete choice experiments that focus on vulnerable populations are needed to gain a more nuanced understanding of how vulnerable populations weigh particular features of screening methods. Improved CRC screening rates may be achieved through the alignment of vulnerable populations' preferences with screening program design and provider practices. Collaborative decision-making between providers and vulnerable patients in preventive care decisions may also be important.

Access to Health Care, Beliefs, and Behaviors about Colorectal Cancer Screening among Korean Americans

Background: Colorectal cancer (CRC) is one of the most common cancers among Korean Americans (KAs) and their CRC screening rates are low. To raise the rates of CRC screening among KAs, it is necessary to improve our understanding of factors that influence their CRC screening behaviors. This study examined socio-demographics, access to health care, health and cultural beliefs, and behaviors about the fecal occult blood test (FOBT) for CRC screening among KAs aged 50 and older. Methods: Based on the health belief model, the cultural assessment model for health, and the Powe fatalism model, this study measured socio-demographics (age, gender, years in the U.S., marital status, education, employment, income, and acculturation), health care access (health insurance, having a regular doctor, physician recommendation, and trust in doctor), health beliefs (susceptibility, severity, benefits, barriers, and self-efficacy), and cultural beliefs (physical space, health temporal orientation, personal control, and fatalism) and FOBT. A cross-sectional survey (n=202) was conducted. Data analysis was conducted using descriptive analysis, Pearson correlation, and multivariate logistic regression. Results: This study found that physician recommendation was the strongest factor in lifetime FOBT utilization in KAs. The results also revealed a positive association among health temporal orientation, health fatalism, and lifetime FOBT among KAs, while previous research found a negative association between fatalism and cancer screening. Years in the U.S., employment, and having a regular doctor were significantly associated with having had a FOBT in the previous year. Conclusion: Study results suggested the need for public education programs to increase physician recommendation among KAs. Furthermore, the positive relationships among health temporal orientation, health fatalism, and FOBT utilization in KAs suggests that KAs have a desire to maintain health and find cancer early despite their fatalistic view on health.

Colorectal Cancer Screening among Korean Americans in Chicago: Does It Matter Whether They had the Screening in Korea or the US?

Background:

Colorectal cancer (CRC) is one of the most common cancers in Korean Americans (KAs) and CRC screening can detect CRC early and may reduce the incidence of CRC by leading to removal of precancerous polyps. Many KAs in the US leave the country, primarily to travel to Korea, for health screening. The aim of this study was to (a) assess CRC screening rates, including fecal occult blood test (FOBT), flexible sigmoidoscopy, and colonoscopy and (b) explore factors related to these tests among KAs by location of CRC screening.

Methods:

Descriptive and correlational research design with cross-sectional surveys was used with 210 KAs. Socio-demographics (age, gender, years in the US, marital status, education, employment, household income, and proficiency in spoken English), access to health care (health insurance and usual source of health care), and location of CRC screening utilization (Korea, the US, or both Korea and US) were measured and analyzed using descriptive statistics and multinominal logistic regression.

Results:

Out of 133 KA participants who had had lifetime CRC screening (i.e., had ever had FOBT, flexible sigmoidoscopy, or colonoscopy), 19% had visited Korea and undergone CRC screening in their lifetimes. Among socio-demographic factors and access to health care factors, having a usual source of health care in the US (OR=8.45) was significantly associated with having undergone lifetime CRC screening in the US. Having health insurance in the US and having had lifetime CRC screening in the US were marginally significant (OR=2.54).

Conclusion:

Access to health care in the US is important for KAs to have CRC screening in the US. As medical tourism has been increasing globally, the location of CRC screening utilization must be considered in research on cancer screening to determine correlates of CRC screening.

Effectiveness of a Tailored Colorectal Cancer Educational Seminar in Enhancing the Awareness, Knowledge, and Behavior of Korean Americans Living in the Los Angeles Koreatown Area

Background

Improving rates of colorectal cancer (CRC) screening can reduce CRC-related mortality, which is estimated to cause about 50,630 deaths in the U.S. by the end of 2018. There is a noted increasing prevalence of CRC among Korean Americans. Although CRC screening has been widely implemented, Korean Americans over the age of 50 have the lowest rates of proper CRC screening, compared to those of other Asian ethnicities. Barriers, such as language and culture, may be making participation in screening procedures difficult for those with immigrant backgrounds. Thus, this study aimed to determine whether proper CRC education can enhance awareness, knowledge, and behavior in screening among Korean Americans living in the Los Angeles Koreatown area.

Design

This study was conducted among 100 self-identified Korean Americans between the ages of 45-75, who voluntarily participated in this study through local community outreach from January to June 2018. Educational brochures were provided for those in the control group, while those in the intervention group attended an additional short educational seminar. All participants were asked to complete a questionnaire after, and data were collected on site.

Results

We found that intervention had a significant effect on awareness regarding colorectal polyps (OR (odds ratio): 22.47; 95% CI: 6.42-78.62; p-value <0.001) and fecal occult blood tests (FOBTs)/stool blood test (OR, 245.37; 95% CI: 34.55-1742.75; p-value <0.001). Willingness for CRC screening in following 6 months significantly increased (OR: 87.17; 95% CI: 19.01-399.63; p-value <0.001). Knowledge on options for CRC screening (OR: 126.63; 95% CI: 23.61-679.07; p-value <0.001) and stool blood tests (OR: 157.17; 95% CI: 18.02-1370.41; p-value <0.001) were significantly enhanced. In additional univariate analysis, we found that Korean Americans with higher level of education, birthplace in US or better general health showed better CRC awareness or knowledge.

Conclusion

There is a significant gap in our knowledge and understanding of the contributing factors that may be leading to low CRC screening rates in Korean Americans. This study suggests that well-tailored educational seminars can overcome certain barriers to screening and improve CRC knowledge and awareness, which is critical to achieving greater screening compliance. Our findings provide important references for designing effective strategies to increasing CRC screening rates among Korean Americans.

Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable? A mixed-methods feasibility study in Scotland

OBJECTIVES

We aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders.

DESIGN

This was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability.

PARTICIPANTS

Bowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland.

PRIMARY AND SECONDARY OUTCOME MEASURES

Several predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention.

RESULTS

The intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities.

CONCLUSIONS

This intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening.

Unraveling the Determinants to Colorectal Cancer Screening Among Asian Americans: a Systematic Literature Review

Colorectal cancer (CRC) is one of the top three cancers experienced among Asian American (AA) men and women. One effective way to decrease incidence and mortality from CRC is the adherence of regular CRC screening; however, AA continue to receive the lowest screening rates compared to other racial/ethnic groups. When disaggregating this heterogeneous population, further disparities exist between subgroups. Examination of facilitators and barriers to cancer screening among AA subgroups is fairly recent and the synthesis of this information is limited. As such, a systematic review was conducted examining the facilitators and the barriers among Chinese, Filipino, Korean, and Japanese Americans using a systematic literature review method. The Health Belief Model served as the primary theoretical framework for this study and used to organize and synthesize the facilitators and barriers to CRC screening. In total, 22 articles yielded 29 examinations of each of the AA subgroups. Different facilitators and barriers to screening uptake for each subgroup were revealed; however, consistent across all the subgroups was physician recommendation as a facilitator and participants' unawareness of screening tests and those stating having no problems/symptoms of CRC as a barrier across screening modalities. Tailored approach in outreach and intervention efforts are suggested when achieving to improve CRC screening in AA ethnic subgroups.

Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown.

OBJECTIVE

To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms.

INTERVENTIONS

Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review.

RESULTS

Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups.

CONCLUSIONS AND RELEVANCE

A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02054598.

Lay health educators and print materials for the promotion of colorectal cancer screening among Korean Americans: A randomized comparative effectiveness study

BACKGROUND

Colorectal cancer (CRC) is the second most commonly diagnosed cancer among Korean American men and women. Although CRC screening is effective in reducing the burden of this disease, studies have shown that Korean Americans have low screening rates.

METHODS

The authors conducted a 2-arm cluster randomized controlled trial comparing a brochure (print) with a brochure and lay health educator (LHE) outreach (print + LHE) in increasing CRC screening rates among Korean American individuals. Self-administered written surveys at baseline and at 6 months assessed knowledge of CRC and its screening, ever screening, and being up to date with screening.

RESULTS

A total of 28 LHEs recruited 348 participants aged 50 to 75 years from their social networks. Significant percentages of participants reported not having health insurance (29.3%) or a usual source of care (35.6%). At 6 months postintervention, the print + LHE participants had a greater increase in knowledge compared with those in the print arm (P = .0013). In multivariable analyses, both groups had significant increases in ever screening (print plus LHE: odds ratio [OR], 1.60 [95% confidence interval (95% CI), 1.26-2.03] and print: OR, 1.42 [95% CI, 1.10-1.82]) and being up to date with screening (print plus LHE: OR, 1.63 [95% CI, 1.23-2.16] and print: OR, 1.40 [95% CI, 1.04-1.89]). However, these increases did not differ significantly between the study arms. Having insurance and having seen a provider within the past year were found to be positively associated with screening.

CONCLUSIONS

Compared with a brochure, LHE outreach yielded greater increases in knowledge but resulted in similar increases in CRC screening in a Korean American population with barriers to health care access. More work is needed to appropriately address logistical and system barriers in this community. Cancer 2017;123:2705-15. © 2017 American Cancer Society.

Feasibility Pilot of a Randomized Faith-Based Intervention to Reduce Secondhand Smoke Exposure Among Korean Americans

INTRODUCTION

Interventions are needed to prevent exposure to secondhand smoke (SHS), which persists in certain immigrant enclaves, including Koreans in the United States. A faith-based and culturally acceptable intervention was developed and pilot tested in collaboration with Korean churches to address SHS exposure among people of Korean descent.

METHODS

A pilot cluster randomized intervention trial was conducted with 11 Korean churches in southern California and 75 Korean adults who were exposed to SHS. Study participants received a multicomponent intervention, which consisted of motivational interviewing by telephone and educational materials tailored with related biblical messages; the intervention was bolstered by church-based group activities and environmental cues. The control group received the same type and frequency of intervention components, but the components related only to fruit and vegetable consumption. Data were collected on the feasibility of the intervention and study procedures. SHS exposure and awareness and knowledge of SHS exposure were assessed by telephone interviews at baseline and follow-up.

RESULTS

At follow-up, a larger percentage of the intervention group than the control group reported correct SHS knowledge and disapproval of SHS. The intervention group's SHS exposure was reduced by 8.5 cigarettes per week (vs a reduction of 1 cigarette per week among the control group).

CONCLUSIONS

Initial findings are promising for improving knowledge, attitudes, and protective behaviors surrounding SHS exposure. Results suggest that a faith-based intervention for Korean Americans who are exposed to SHS is feasible, acceptable, and potentially effective in reducing their exposure to SHS.

Race/Ethnicity and Primary Language: Health Beliefs about Colorectal Cancer Screening in a Diverse, Low-Income Population

Colorectal cancer (CRC) is an important cause of cancer death in adults in the U.S.; screening is effective but underutilized, particularly among minorities. The purpose of this paper was to explore whether health belief model (HBM) constructs pertaining to CRC screening differ by race/ethnicity and primary language. Data were from the baseline surveys of 933 participants (93.5%) in a randomized trial promoting CRC screening in San Francisco. Composite scores for each construct were created from multiple items, dichotomized for analysis, and analyzed using multivariate logistic regression. Most participants were Asian (29.7%) or Hispanic (34.3%), and many were non-English speakers. Non-English speaking Hispanics (p<.001) and English-speaking Asians (p=.002) reported lower perceived susceptibility than non-Hispanic Whites (NHW). Non-English speaking Hispanics reported more and non-English speaking Asians fewer perceived barriers (psychological and structural) than NHW. Understanding how different populations think about CRC screening may be critical in promoting screening in diverse populations.

The impact of medical tourism on colorectal screening among Korean Americans: A community-based cross-sectional study

Background

Colorectal cancer (CRC) remains the most commonly diagnosed cancer among Korean Americans (KAs) in part due to low screening rates. Recent studies suggest that some KA patients engage in medical tourism and receive medical care in their home country. The impact of medical tourism on CRC screening is unknown. The purpose of this paper was to 1) investigate the frequency of medical tourism, 2) examine the association between medical tourism and CRC screening, and 3) characterize KA patients who engage in medical tourism.

Methods

This is a community-based, cross-sectional study involving self-administered questionnaires conducted from August 2013 to October 2013. Data was collected on 193 KA patients, ages 50–75, residing in the Seattle metropolitan area. The outcome variable is up-to-date with CRC screening, defined as having had a stool test (Fecal Occult Blood Test or Fecal Immunochemical Test) within the past year or a colonoscopy within 10 years. Predictor variables are socio-demographics, health factors, acculturation, knowledge, financial concerns for medical care costs, and medical tourism.

Results

In multi-variate modeling, medical tourism was significantly related to being up-to-date with CRC screening. Participants who engaged in medical tourism had 8.91 (95% CI: 3.89–23.89) greater odds of being up-to-date with CRC screening compared to those who did not travel for healthcare. Factors associated with engaging in medical tourism were lack of insurance coverage (P = 0.008), higher levels of education (P = 0.003), not having a usual place of care (P = 0.002), older age at immigration (P = 0.009), shorter years-of-stay in the US (P = 0.003), and being less likely to speak English well (P = 0.03).

Conclusions

This study identifies the impact of medical tourism on CRC screening and characteristics of KA patients who report engaging in medical tourism. Healthcare providers in the US should be aware of the customary nature of medical tourism among KAs and consider assessing medical tests done abroad when providing cancer care.

Trial registration

Not applicable.

Impact of provider-patient communication on cancer screening adherence: A systematic review

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Psychometric evaluation of the Caregiver Self-Efficacy Scale with Korean Americans

This study evaluated the psychometric properties of a Korean version of the Caregiver Self-Efficacy Scale (CSE-K). The sample included 145 Korean American caregivers. Confirmatory factor analyses (CFA) were conducted to examine the factor structure of the CSE-K. We tested convergent validity of the CSE-K by examining its relationships with caregiver depression and burden. Internal consistency reliability of the CSE-K was also tested. The initial model of CFA based upon the structure of the original CSE revealed the poor model fit; however, the revised model produced the excellent model fit. Convergent validity was established, and excellent internal consistency reliability was found in the CSE-K. The results of this study show that the CSE-K is a reliable and valid measurement to assess caregiver self-efficacy for Korean American caregivers.

Determinants of cancer screening in Asian-Americans

PURPOSE

Recent data suggest that Asian-Americans (AsAs) are more likely to present with advanced disease when diagnosed with cancer. We sought to determine whether AsAs are under-utilizing recommended cancer screening.

METHODS

Cross-sectional analysis of the 2012 Behavioral Risk Factor Surveillance System comprising of AsAs and non-Hispanic White (NHW) community-dwelling individuals (English and Spanish speaking) eligible for colorectal, breast, cervical, or prostate cancer screening according to the United States Preventive Services Task Force recommendations. Age, education and income level, residence location, marital status, health insurance, regular access to healthcare provider, and screening were extracted. Complex samples logistic regression models quantified the effect of race on odds of undergoing appropriate screening. Data were analyzed in 2015.

RESULTS

Weighted samples of 63.3, 33.3, 47.9, and 30.3 million individuals eligible for colorectal, breast, cervical, and prostate cancer screening identified, respectively. In general, AsAs were more educated, more often married, had higher levels of income, and lived in urban/suburban residencies as compared to NHWs (all p < 0.05). In multivariable analyses, AsAs had lower odds of undergoing colorectal (odds ratio [OR] 0.78, 95 % confidence interval [CI] 0.63-0.96), cervical (OR 0.45, 95 % CI 0.36-0.55), and prostate cancer (OR 0.55, 95 % CI 0.39-0.78) screening and similar odds of undergoing breast cancer (OR 1.29, 95 % CI 0.92-1.82) screening as compared to NHWs.

CONCLUSIONS

AsAs are less likely to undergo appropriate screening for colorectal, cervical, and prostate cancer. Contributing reasons include limitations in healthcare access, differing cultural beliefs on cancer screening and treatment, and potential physician biases. Interventions such as increasing healthcare access and literacy may improve screening rates.

Korean Immigrant Women’s Health Care Utilization in the United States

A systematic literature review was performed to review empirical evidence, published between 1946 and 2015, regarding Korean immigrant women’s health care utilization and factors affecting their health care utilization in the United States. Andersen’s behavioral model of health services utilization was used as a framework and was expanded to analyze the pattern of health services utilization and to identify characteristics of access to health care. A total of 32 reports were included. Variables were categorized into 1 of 5 individual determinants: cultural, enabling, predisposing, need, and reinforcing factor. A total of 423 relationships were found between individual determinants and health care utilization. All reinforcing variables were effective in increasing Korean immigrant women’s health care utilization in a positive way. Interventions targeting multiple factors were strongly effective in encouraging Korean immigrant women to utilize health services for cancer screening. However, these studies yielded inconsistent findings related to outcome measures due to the variability of measurement criteria.

Heterogeneous demographic and cultural profiles of Chinese American patients nonadherent to colorectal cancer screening: a latent class analysis

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death in Chinese Americans, but their CRC screening rates remain low.

OBJECTIVE

We examined subgroups of Chinese American patients nonadherent to CRC screening guidelines to better inform clinical practices to effectively promote screening.

METHODS

Using latent class analysis of data from 327 participants recruited from 18 primary care clinics, we classified nonadherent patients based on sociodemographics, screening barriers, and attitudinal and clinical factors for CRC screening.

RESULTS

The best-fitting latent class analysis model described 3 distinctive classes: Western healthcare class (36%), Eastern healthcare class (18%), and mixed healthcare class (46%). Western healthcare class patients were highly educated, with average US residency of 20 years, a high level of English proficiency, the least Eastern cultural views of care, and the greatest exposure to physician recommendations, but reported having no time for screenings. Eastern healthcare class patients were highly educated seniors and recent immigrants with the least CRC knowledge and the most Eastern cultural views. Mixed healthcare class patients had low level of education, resided in the United States for 20 years, and half had sought services of their physicians for at least 3 years, but their knowledge and cultural views were similar to those of Eastern healthcare class patients.

CONCLUSIONS

Nonadherent Chinese American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of nonadherent patients.

IMPLICATIONS FOR PRACTICE

Training primary care physicians to recognize patients' different demographic characteristics and healthcare beliefs may facilitate physicians' communication with patients to overcome their barriers and improve screening behaviors.

Cultural Factors Associated with Breast and Cervical Cancer Screening in Korean American Women in the US: An Integrative Literature Review

PURPOSE

This study examined current research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in Korean American (KA) women.

METHODS

Based on Ganong's guidelines, the literature on cultural factors associated with breast and cervical cancer screening in KA women was searched using MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Sixty-eight articles on breast cancer screening and 66 articles on cervical cancer screening were retrieved from both databases, and a total of 22 articles were included in the literature review based on the selection criteria.

RESULTS

Of the 22 studies reviewed, 14 (63.6%) were descriptive and 8 (36.4%) were interventional. Many studies have used individual focused cognitive theories such as health belief model and different types of operationalization for measures of cultural beliefs. Cultural factors associated with breast and cervical cancer screening in KA women that were identified in descriptive quantitative and qualitative studies included family, embarrassment, preventive health orientation, fatalism, and acculturation. Most culturally relevant interventional studies used education programs, and all education was conducted by bilingual and bicultural health educators at sociocultural sites for KA women.

CONCLUSIONS

Theories focusing on interpersonal relationships and standardized, reliable, and valid instruments to measure cultural concepts are needed to breast and cervical cancer screening research in KA women. Traditional cultural factors associated with cancer screening should be considered for practical implications and future research with KA women.

Cancer Information Seeking Behaviors of Korean American Women: A Mixed-Methods Study Using Surveys and Focus Group Interviews

Despite the high risk of cancer to the population, Korean Americans are known to have lower knowledge about cancer related information and a lower level of adherence to cancer prevention guidelines. This indicates the necessity of cancer interventions targeting the Korean American population. To reach this population effectively, it is imperative to understand Korean Americans' cancer information seeking behaviors. This study (a) identified cancer information sources that are trusted and used by Korean American women and (b) examined how general media exposure and trust in cancer information sources are related to the use of these sources. It also (c) explored perceived usefulness and limitations of cancer information sources. A mixed methods study using seven focus group interviews with 34 Korean American women and surveys with 152 Korean American women was conducted in the Washington, DC, metropolitan area from 2011 to 2012. The results indicate that Korean American women viewed health care professionals as the most trusted cancer information source but used the Internet and Korean ethnic media more often for cancer information seeking because of language, cultural, and economic barriers. Korean American women were most likely to obtain cancer information from media they used frequently for general purposes. Correlations between usage frequency and trust in doctor/health providers and the Internet as cancer information sources were negligible. When seeking cancer information, important factors for Korean American women were accessibility, affordability, and language proficiency, cultural sensitivity, meeting immediate needs, understandability, convenience, and reliability of cancer information sources. Findings from this study support developing interventions using Korean language media, including print, television and the Internet for health promotion and cancer prevention targeting Korean American women.

Framing risks and benefits of medical tourism: a content analysis of medical tourism coverage in Korean American community newspapers

This study examines Korean American community newspapers' representation of risks and benefits involved with medical tourism offered in Korea. Using framing theory, this research attempts to explain Korean Americans' highly positive perceptions and high willingness to use health and medical services in Korea through medical tourism rather than using such services in the United States. The result of content analyses indicated that Korean American community newspapers are rarely engaged in risk communication and lack sufficient information about potential risks of medical tourism while emphasizing diverse benefits. Korean ethnic media, as the primary source of health communication for Korean Americans, should provide more reliable health and medical information for the population's appropriate health management.

Cancer information-seeking behaviors and information needs among Korean Americans in the online community

Korean Americans tend to have less access to health service and cancer screening tests than all US population. It is necessary to understand their current cancer information-seeking behaviors and information needs to more effectively provide adequate cancer information. However, there is little known about their cancer information seeking behaviors and needs. The purpose of the study was to understand cancer information seeking behaviors and information needs among Korean Americans. Data were collected from MissyUSA, which is one of the biggest websites for the Korean community in the USA. A total of 393 free-texts from January to June 2013 were reviewed; 120 were deleted because the messages were not related to cancer health information. A total of 273 posted free-texts were analyzed for this study, using an open source text-mining software program called AntConc 3.2.4. The extracted terms were categorized based on coding systems, after linguistic variations were handled. Terms such as "surgery," "breast cancer," "examination," "cancer" (unspecified), "Korea," and "pain" were most frequently identified. Medical topics accounted for 71.4 % of the main topics of the postings. Treatment was the most frequently discussed in the medical topics while in the non-medical category, the most frequently discussed topic was recommendations for hospitals or doctors. In relation to types of cancer, breast cancer was the greatest concern, followed by cervical and liver cancer. The findings from this study can help in establishing more effective strategies to provide better cancer information among Korean Americans by assessing their cancer information seeking trends and information needs.

Colorectal cancer screening among Korean Americans: a systematic review

The incidence of colorectal cancer (CRC) among Korean Americans (KAs) has increased in recent years, even as the rate in nearly ever other population group in the United States has decreased. Reversing this trend will require improving screening rates, but a variety of sociocultural factors may inhibit this goal. We conducted a systematic review of the published literature on cancer screening among KAs, and identified thirteen eligible studies that examined CRC screening. KAs have CRC screening rates that are significantly lower than the national average. Only about one in four KAs ages 50 and older reports having ever had a fecal ocult blood test (FOBT) and only about 40 % have ever had a sigmoidoscopy or colonoscopy. KA adults are also significantly less likely than the general US population to say they have heard of FOBT, sigmoidoscopy, or colonoscopy. In the KA population, screening rates are higher among adults with higher socioeconomic status, greater acculturation to the United States, more cancer knowledge, more social support, and better access to healthcare services. Improving cultural and financial access to health education and healthcare services may increase CRC screening among KAs and reduce the incidence of the disease.

Patient trust in physician influences colorectal cancer screening in low-income patients

BACKGROUND

Colorectal cancer (CRC) screening is effective but underutilized. Although physician recommendation is an important predictor of screening, considerable variation in CRC screening completion remains.

PURPOSE

To characterize the influence of patient trust in care providers on CRC screening behavior.

METHODS

Data were collected as part of a cluster-randomized CRC screening intervention trial performed in the San Francisco Community Health Network from March 2007 to January 2012 (analysis, Spring 2012). All study participants received a recommendation to complete CRC screening from their primary care provider (PCP). Included participants were aged 50-79 years, not current with screening, and completed the Wake Forest Trust Scale (WFTS) measuring trust in PCPs and doctors in general. Primary outcome was CRC screening completion (colonoscopy or fecal occult blood testing) within 12 months following enrollment. Multivariable association adjusted for race/ethnicity, language, and other sociodemographics was estimated using generalized estimating equations with logit link and binomial distribution.

RESULTS

WFTS response was 70.3% (701). Most participants (83%) were Latino, Asian, or black. Most had income <$30,000 (96%) and public health insurance (86%). Higher trust in PCP was associated with screening completion (OR=1.11, 95% CI=1.03, 1.17), but trust in doctors was not (OR=1.02, 95% CI=0.82, 1.28). Race, language, and other sociodemographic factors were not significant in multivariable analysis.

CONCLUSIONS

After controlling for traditional factors, trust in PCP remained the only significant driver of CRC screening completion in low-income patients. Interventions to promote CRC screening may be improved by including efforts to enhance patient trust in PCP.

The healthcare experiences of Koreans living in North Carolina: a mixed methods study

This study examined the healthcare experiences of Korean immigrants aged 40-64 living in the North Carolina Triangle area of the Southeastern United States. Using a mixed methods design, we collected quantitative data via a questionnaire from 125 participants and conducted a focus group with 10 interviewees from December 2010 to February 2011. The quantitative data were analysed using t-tests and chi-square tests, and a thematic analysis was used for the focus group study. Questionnaire findings showed that only 27.2% had sufficient English skills to communicate adequately. Participants with insurance were significantly more likely to be employed (P < 0.001), had higher incomes (P = 0.011) and higher education (P < 0.001), and had greater English-speaking ability (P = 0.011) than those without insurance. Participants who did not use healthcare services showed significantly less knowledge (P < 0.001) of and less satisfaction (P = 0.034) with the healthcare system than those using healthcare services. Sixty-two participants (49.6%) reported having no health insurance for one or more of the following reasons: high costs (75.8%), medical tourism (22.6%) and lack of information or knowledge (6.5%). The following themes emerged from the data collected during the focus group: (i) barriers to utilisation of healthcare services; (ii) facilitators of utilisation of healthcare services; and (iii) social support seeking for health management. Our mixed methods study findings indicate that healthcare disparities exist among Korean immigrants and that a number of factors, including health literacy, may contribute to their poor health outcomes. Continued collaboration among community members, healthcare professionals and academicians is needed to discuss the community's health concerns and to develop sustainable programmes that will ensure meaningful access to care for those with limited English proficiency and medically underserved populations.

Relationship between self-assessed and tested non-English-language proficiency among primary care providers

BACKGROUND

Individuals with limited English proficiency experience poor patient-clinician communication. Most studies of language concordance have not measured clinician non-English-language proficiency.

OBJECTIVES

To evaluate the accuracy of the self-assessment of non-English-language proficiency by clinicians compared with an oral proficiency interview.

SUBJECTS

Primary care providers (PCPs) in California and Massachusetts.

MEASURES

PCPs first completed a self-assessment of non-English-language proficiency using a version of the Interagency Language Roundtable (ILR) Scale, followed by the Clinician Cultural and Linguistic Assessment (CCLA), a validated oral proficiency interview. We used nonparametric approaches to analyze CCLA scores at each ILR scale level and the correlation between CCLA and ILR scale scores.

RESULTS

Sixteen PCPs in California and 51 in Massachusetts participated (n=67). Participants spoke Spanish (79%), followed by Cantonese, Mandarin, French, Portuguese, and Vietnamese. The respondents self-assessed as having "excellent" proficiency 9% of the time, "very good" proficiency 24% of the time, "good" proficiency 46% of the time, "fair" proficiency 18% of the time, and "poor" proficiency 3% of the time. The average CCLA score was 76/100. There was a positive correlation between self-reported ILR scale and CCLA score (σ=0.49, P<0.001). The variance in CCLA scores was wider in the middle categories than in the low or high ILR categories (P=0.003).

CONCLUSIONS

Self-assessment of non-English-language proficiency using the ILR correlates to tested language proficiency, particularly on the low and high ends of the scale. Participants who self-assess in the middle of the scale may require additional testing. Further research needs to be conducted to identify the characteristics of PCP whose self-assessments are inaccurate and, thus, require proficiency testing.

Colorectal cancer screening among Asian Americans

OBJECTIVES

Colorectal cancer (CRC) is the most commonly diagnosed cancer for all US populations including Asian Americans. CRC screening has considerable benefits to prevent CRC and reduce mortality. The purpose of this article was to review the published literature on rates of colorectal cancer screening and factors associated with colorectal cancer screening practice among Asian Americans.

METHODS

Through searching electronic reference databases from 2000 to 2013, 30 articles were found on Chinese, Filipino, Japanese, Korean, and Vietnamese Americans.

FINDINGS

Asian Americans had significantly low rates for CRC screening; Korean Americans reported the lowest rates, while higher screening rates were found among Japanese Americans. Older age, longer length of stay in the US, and having a physician's recommendation were the most common facilitators to receiving screening. The common inhibiting factors were financial issues, employment status, and worries/fears about the procedure.

CONCLUSIONS

Despite a number of Asian Americans being vulnerable to CRC, individual Asian subgroups were underserved with CRC screening and intervention. Further studies should focus on each individual Asian subgroup and culturally proficient CRC screening intervention programs should be developed for each.

Understanding current racial/ethnic disparities in colorectal cancer screening in the United States: the contribution of socioeconomic status and access to care

BACKGROUND

Prior studies have shown racial/ethnic disparities in colorectal cancer (CRC) screening but have not provided a full national picture of disparities across all major racial/ethnic groups.

PURPOSE

To provide a more complete, up-to-date picture of racial/ethnic disparities in CRC screening and contributing socioeconomic and access barriers.

METHODS

Behavioral Risk Factor Surveillance System data from 2010 were analyzed in 2013. Hispanic/Latino participants were stratified by preferred language (Hispanic-English versus Hispanic-Spanish). Non-Hispanics were categorized as White, Black, Asian, Native Hawaiian/Pacific Islander, or American Indian/Alaska Native. Sequential regression models estimated adjusted relative risks (RRs) and the degree to which SES and access to care explained disparities.

RESULTS

Overall, 59.6% reported being up-to-date on CRC screening. Self-reported CRC screening was highest in the White (62.0%) racial/ethnic group; followed by Black (59.0%); Native Hawaiian/Pacific Islander (54.6%); Hispanic-English (52.5%); American Indian/Alaska Native (49.5%); Asian (47.2%); and Hispanic-Spanish (30.6%) groups. Adjustment for SES and access partially explained disparities between Whites and Hispanic-Spanish (final relative risk [RR]=0.76, 95% CI=0.69, 0.83); Hispanic-English (RR=0.94, 95% CI=0.91, 0.98); and American Indian/Alaska Native (RR=0.91, 95% CI=0.85, 0.97) groups. The RR of screening among Asians was unchanged after adjustment for SES and access (0.78, p<0.001). After full adjustment, screening rates were not significantly different among Whites, Blacks, or Native Hawaiian/Pacific Islanders.

CONCLUSIONS

Large racial/ethnic disparities in CRC screening persist, including substantial differences between English-speaking versus Spanish-speaking Hispanics. Disparities are only partially explained by SES and access to care. Future studies should explore the low rate of screening among Asians and how it varies by racial/ethnic subgroup and language.

Culturally tailored interventions of chronic disease targeting Korean Americans: a systematic review

OBJECTIVE

Because little is known about promising interventions to prevent and control chronic disease in Korean Americans, we conducted a systematic literature review to investigate: (1) theoretical frameworks and strategies employed by interventions targeting Korean Americans; (2) cultural factors considered by these interventions; and (3) the extent of their success in engaging Korean participants and improving their health.

DESIGN

Following the PRISMA guidelines, PubMed, PsycInfo, and Web of Science were searched to identify primary research articles evaluating interventions to prevent or control chronic disease, tailored to Korean Americans, and published from 1980 through 2011. Of 238 articles identified, 21 articles describing16 unique intervention tests met inclusion criteria. These interventions targeted cancer (10), hypertension (2), diabetes (1), mental health (1), tobacco cessation (1), and general health (1).

RESULTS

All included studies were published since 2000, reflecting the relatively recent establishment of intervention research with Korean Americans. All 16 programs delivered linguistically appropriate messages and education. The 11 programs that realized significant intervention effects also provided or coordinated social support from culturally relevant and well-trained lay health workers, nurses, or family members during an intervention and/or follow-up period.

CONCLUSIONS

Culturally matched and linguistically appropriate messages and education may not be enough to prevent or control chronic disease among immigrant Korean Americans. Culturally sensitive and committed social support should be provided to catalyze behavioral changes and sustain the effect of the interventions.

Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial

IMPORTANCE

Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited.

OBJECTIVE

To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population.

DESIGN, SETTING, AND PARTICIPANTS

We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system.

INTERVENTIONS

Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visit–based screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion.

MAIN OUTCOME MEASURES

Screening participation in any CRC test within 1 year after randomization.

RESULTS

Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. CONCLUSIONS AND REVELANCE: Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01191411.

The influences of immigration on health information seeking behaviors among Korean Americans and Native Koreans

Korean Americans (KAs) have low screening rates for cancer and are often not well informed about their chronic diseases. Reduced access to health-related information is one reason for gaps in knowledge and the widening health disparities among minority populations. However, little research exists about KAs' health information seeking behaviors. Guided by the Structural Influence Model, this study examines the influence of immigration status on KAs' trust in health information sources and health information seeking behaviors. Cross-sectional surveys were conducted in the Washington, D.C., metropolitan area as well as in the Gwangju metropolitan city in South Korea during 2006-2007. Two hundred and fifty-four KAs and 208 native Koreans who were 40 years of age or older completed the surveys. When comparing native Koreans to KAs, we found KAs were 3 times more likely to trust health information from newspapers or magazines (odds ratio [OR] = 3.13; 95% confidence interval [CI] = 1.49-6.54) and 11 times more likely to read the health sections of newspapers or magazines (OR = 11.35; 95% CI = 3.92-32.91) in multivariate adjusted models. However, they were less likely to look for health information from TV (OR = 0.29; 95% CI = 0.12-0.72) than native Koreans. Our results indicate that immigration status has profound influences on KAs' health information seeking behaviors. Increasing the availability of reliable and valid health information from printed Korean language magazines or newspapers could have a positive influence on increasing awareness and promoting screening behaviors among KAs.

Impact of Asian Ethnicity on Colorectal Cancer Screening

OBJECTIVES

Although research shows that African Americans and Hispanics frequently receive less colorectal cancer screening (CRCS) than whites, few studies have focused on CRCS among Asians. The aims of this study were to compare CRCS between Asians and whites and to evaluate for clinical predictors of CRCS.

METHODS

From the 2007 California Health Interview Survey, we identified all Asian and white respondents who were eligible for CRCS. Logistic regression was performed to evaluate for differences in CRCS. We used stratified and interaction analyses to examine whether associations between race and CRCS were modified by insurance status, birthplace, or language skills, while controlling for other confounders.

RESULTS

Baseline characteristics were similar between Asians and whites. Only 58% of Asians and 66% of whites reported undergoing up-to-date CRCS (P < 0.01). In multivariate analyses, visiting a physician more than 5 times produced the highest odds of being up-to-date with screening. When compared with whites, Asians had decreased odds of being up-to-date with screening. Stratified analyses showed that this disparity existed mainly in the insured, but not in the uninsured, and it was not modified by place of birth or English language proficiency.

CONCLUSIONS

Despite its ability to reduce mortality, CRCS is suboptimal in our US population-based cohort of Asians when compared with whites. A contributing factor to this problem for the Chinese and Koreans may be a lack of awareness regarding CRCS, whereas the source of the problem in the Vietnamese seems to be related to healthcare access.

Interest in health promotion among Korean American Seventh-day Adventists attending a religious retreat

BACKGROUND

Little is known about interest in faith-based health promotion programs among Asian American populations. Among the Christian denominations, the Seventh-day Adventist (SDA) church is known to place a strong doctrinal emphasis on health.

OBJECTIVES

To understand appropriate ways to develop and implement health promotion programs and to conduct research among Korean American SDAs.

METHODS

We collaborated with the North American Division of Korean SDA Churches which sponsors annual week-long religious retreats for their church members. We developed and administered a 10-page questionnaire at their 2009 retreat in order to assess socio-demographic and church characteristics, religiosity, perceived relationship between health and religion, and interest and preferences for church-based health promotion programs.

RESULTS

Overall, 223 participants completed our survey (123 in Korean and 100 in English). The sample consisted of regular churchgoers who were involved in a variety of helping activities, and many holding leadership positions in their home churches. The vast majority was interested in receiving health information at church (80%) in the form of seminars, cooking classes and workshops (50-60%). Fewer respondents were interested in support groups (27%). Some interests and preferences differed between English and Korean language groups.

CONCLUSION

Korean American SDA church retreat participants from a large geographic area are very interested in receiving health information and promoting health at their churches and can potentially serve as "agents of influence" in their respective communities.

Dissemination of colorectal cancer screening by Filipino American community health advisors: a feasibility study

BACKGROUND

Filipino Americans underutilize life-saving screening tests for colorectal cancer, resulting in late stage of diagnosis and poor survival relative to other racial/ethnic groups. Education regarding colorectal cancer screening and distribution of free fecal occult blood test (FOBT) kits are evidence-based interventions that can significantly increase screening. However, this community will only benefit if the intervention is broadly disseminated.

METHODS

We assessed the feasibility of promoting colorectal cancer screening in Filipino American community settings working with community health advisors, and the practicality of conducting one-on-one or small group education, in addition to passing out free FOBT kits.

RESULTS

Twenty community health advisors from 4 organizations engaged in recruitment and education activities with 132 participants. Community health advisors consistently completed screening questionnaires to establish eligibility and kept logs of FOBT distribution. However, they did not consistently record eligible participants who did not consent to participate. Process checklists that indicated what information was covered in each educational session and postsession follow-up logs were partially completed. Almost all participants reported receipt of intervention components and receipt of screening at 4-month follow-up and reported high acceptability of the program.

DISCUSSION

The pilot study established the feasibility of working with community health advisors to promote colorectal cancer screening in Filipino American community settings. Findings informed the design of a dissemination trial that is currently ongoing with regards to monitoring recruitment, intervention implementation and follow-up and allowing flexibility regarding one-on-one or small group education.

Going against the tide: increasing incidence of colorectal cancer among Koreans, Filipinos, and South Asians in California, 1988-2007

OBJECTIVE

Colorectal cancer has declined markedly in California for all major racial/ethnic groups, including Asian/Pacific Islanders as a whole. Analyzing cancer data for Asian/Pacific Islanders collectively masks important differences that exist between individual Asian subgroups. This study examines secular, sex-, age-, and socioeconomic-specific trends in colorectal cancer incidence among six Asian subgroups-Chinese, Japanese, Filipino, Korean, Vietnamese, and South Asian-to determine whether these groups experienced a decline in colorectal cancer incidence and to assess possible differences in colorectal cancer incidence trends among these groups.

METHODS

Cases of invasive colorectal cancer diagnosed among Japanese, Chinese, Filipinos, Koreans, Vietnamese, and South Asians between 1988 and 2007 were identified using the California Cancer Registry database. Secular, sex-, age-, and socioeconomic-specific trends in the age-adjusted colorectal cancer incidence rates for each Asian subgroup were examined using joinpoint analysis to estimate the annual percent change (APC).

RESULTS

Among males, Koreans (APC, 3.6 %) were the only group that experienced a significant increase in colorectal cancer incidence. Among females, Koreans (APC, 2.7 %), South Asians (APC, 2.8 %), and Filipinos (APC, 1.6 %) experienced significant increases. Stratification by age at diagnosis revealed that Korean males (APC, 3.4 %) and females (APC, 2.9 %) as well as Filipino females (APC, 1.8 %) aged 50 years and older experienced a significant increase in colorectal cancer incidence. Korean males aged less than 50 years (APC, 3.4 %) also experienced a significant increase. Japanese (APC, -1.2 %) and Chinese (APC, -1.6 %) males aged 50 years and older experienced a significant decrease in colorectal cancer incidence. Stratification by socioeconomic status (SES) revealed that Korean males (APC, 2.5 %) and females (APC, 2.9 %) as well as Filipino females (APC, 2.1 %) in the lowest SES category experienced a significant increase in colorectal cancer incidence. Korean males (APC, 5.2 %) and females (APC, 3.1 %) as well as Filipino males (APC, 1.5 %) in the highest SES category also experienced a significant increase. Japanese males (APC, -2.5 %) and females (APC, -2.0 %) as well as Chinese males (APC, -2.8 %) and females (APC, -2.9 %) in the lowest SES category experienced a significant decrease. Chinese males in the middle (APC, -3.4 %) and highest (APC, -3.5 %) SES categories also experienced significant decreases in colorectal cancer incidence.

CONCLUSIONS

In contrast to the decreasing trends in colorectal cancer incidence reported among all major racial/ethnic groups including Asian/Pacific Islanders, colorectal cancer is actually increasing among some Asian subgroups in California including Korean males and females, as well as South Asian and Filipino females. Furthermore, the colorectal cancer incidence trends for these Asian subgroups differ with respect to age at diagnosis and socioeconomic status. These findings suggest that more efforts need to be made to target these populations with culturally sensitive cancer prevention and screening programs. More research is needed to examine the differences in the colorectal cancer burden among these populations.

Colorectal cancer screening behavior and willingness: an outpatient survey in China

AIM

To identity the factors influencing colorectal cancer (CRC) screening behavior and willingness among Chinese outpatients.

METHODS

An outpatient-based face-to-face survey was conducted from August 18 to September 7, 2010 in Changhai Hospital. A total of 1200 consecutive patients aged ≥ 18 years were recruited for interview. The patient's knowledge about CRC and screening was pre-measured as a predictor variable, and other predictors included age, gender, educational level, monthly household income and health insurance status. The relationship between these predictors and screening behavior, screening willingness and screening approach were examined using Pearson's χ(2) test and logistic regression analyses.

RESULTS

Of these outpatients, 22.5% had undergone CRC screening prior to this study. Patients who had participated in the screening were more likely to have good knowledge about CRC and screening (OR: 5.299, 95% CI: 3.415-8.223), have health insurance (OR: 1.996, 95% CI: 1.426-2.794) and older in age. Higher income, however, was found to be a barrier to the screening (OR: 0.633, 95% CI: 0.467-0.858). An analysis of screening willingness showed that 37.5% of the patients would voluntarily participated in a screen at the recommended age, but 41.3% would do so under doctor's advice. Screening willingness was positively correlated with the patient's knowledge status. Patients with higher knowledge levels would like to participate in the screening (OR: 4.352, 95% CI: 3.008-6.298), and they would select colonoscopy as a screening approach (OR: 3.513, 95% CI: 2.290-5.389). However, higher income level was, again, a barrier to colonoscopic screening (OR: 0.667, 95% CI: 0.505-0.908).

CONCLUSION

Patient's level of knowledge and income should be taken into consideration when conducting a feasible CRC screening.

Patient-physician language concordance and primary care screening among spanish-speaking patients

BACKGROUND

Language discordance between patient and physician is associated with worse patient self-reported healthcare quality. As Hispanic patients have low rates of cardiovascular and cancer screening, we sought to determine whether patient-physician language concordance was associated with differences in rates of screening.

METHODS

We performed a retrospective medical record review of 101 Spanish-speaking patients cared for by 6 Spanish-speaking PCPs (language-concordant group) and 205 Spanish-speaking patients cared for by 44 non-Spanish-speaking PCPs (language-discordant group). Patients were included in the study if they were of age 35 to 75 years and had used interpreter services 2001 to 2006 in 2 Boston-based primary care clinics. Our outcomes included screening for hyperlipidemia, diabetes, cervical cancer, breast cancer, and colorectal cancer with age-appropriate and sex-appropriate subgroups. Our main predictor of interest was patient-physician language concordance. In multivariable modeling, we adjusted for age, sex, insurance status, number of primary care visits, and comorbidities. We adjusted for clustering of patients within individual physicians and clinic sites using generalized estimating equations.

RESULTS

Patients in the language-discordant group tended to be female compared with patients in the language-concordant group. There were no significant differences in age, insurance status, number of primary care visits, or Charlson comorbidity index between the 2 groups. Rates of screening for hyperlipidemia, diabetes, cervical cancer, and breast cancer were similar for both language-concordant and language-discordant groups. However, patients in the language-concordant group were less likely to be screened for colorectal cancer compared with the language-discordant group risk ratio 0.78 (95% confidence interval, 0.61-0.99) after multivariable adjustment.

CONCLUSIONS

This study finds that Spanish-speaking patients cared for by language-concordant PCPs were not more likely to receive recommended screening for cardiovascular risk factors and cancer. Furthermore, language concordance was associated with lower likelihood colorectal cancer screening. Further research is needed to examine which conditions are optimal to improve cardiovascular and cancer screening for Spanish-speaking patients, particularly for colorectal cancer, which has a low rate of screening.

Alternative approaches to assessing intervention effectiveness in randomized trials: application in a colorectal cancer screening study

BACKGROUND

Previous analysis of a randomized community-based trial of a multi-component intervention to increase colorectal cancer (CRC) screening among Filipino Americans (n = 548) found significantly higher screening rates in the two intervention groups compared to the control group, when using intent-to-treat analysis and self-reported screening as the outcome. This report describes more nuanced findings obtained from alternative approaches to assessing intervention effectiveness to inform future intervention implementation.

METHODS

The effect of the intervention on CRC screening receipt during follow-up was estimated using methods that adjusted for biases due to missing data and self-report and for different combinations of intervention components. Adjustment for self-report used data from a validation substudy. Effectiveness within demographic subgroups was also examined.

RESULTS

Analyses accounting for self-report bias and missing data supported the effectiveness of the intervention. The intervention was also broadly effective across the demographic characteristics of the sample. Estimates of the intervention effect were highest among participants whose providers received a letter as part of the intervention.

CONCLUSIONS

The findings increase confidence that the intervention could be broadly effective at increasing CRC screening in this population. Subgroup analyses and attempts to deconstruct multi-component interventions can provide important information for future intervention development, implementation, and dissemination.