Abstract
Background.
Preventive care is important for reducing morbidity and mortality among the elderly, but racial/ethnic disparities exist in use of preventive care services. We aimed to develop a better understanding of preventive care service utilization among Chinese older adults in the Greater Chicago area.
Methods.
We used data collected from the Population Study of Chinese Elderly in Chicago study, a population-based survey of 3,159 community-dwelling Chinese older adults in the Greater Chicago area. Preventive care services assessed include use of flu, pneumonia, and hepatitis B vaccines as well as colon, breast, cervical and prostate cancer screening. We also examined sociodemographic, health and quality of life correlates for preventive care service use.
Results.
We found that although Chinese older adults had lower utilization rates for the pneumonia vaccine and cancer screening, their utilization of the flu shot was consistent with national utilization rates. No sociodemographic, self-reported health, or quality of life characteristics were associated with all nine of the preventive care services.
Conclusion.
Use of preventive care services except flu vaccination was low among Chinese older adults in the Greater Chicago area. However, future longitudinal studies may be necessary to further elucidate preventive care service utilization patterns among Chinese older adults.
Key Words: Screening, Cancer, Flu, Pneumonia, Hepatitis B.
Preventive care such as immunization and cancer screenings has been increasingly recognized for its importance in reducing morbidity and mortality among older adults in the United States. Elderly populations are vulnerable to influenza-related complications and invasive pneumococcal infection. In 2010, influenza and pneumonia caused approximately 43,000 deaths among people aged 65 and older (1). Because influenza and pneumococcal vaccination remain the most effective ways to prevent and control influenza and pneumonia, annual flu shots and one-time pneumonia shots have been recommended nationwide. With cancer ranked as the second leading cause of death for people aged 65 and older (1), early detection is important. Cancer screening tests have proven efficacy in detecting colon cancer, breast cancer, and cervical cancer at an early stage when chances of treatment and survival are highest.
To improve public health and promote utilization of preventive care services, Healthy People 2020 (2) established long-term objectives for immunization and cancer screening, with a target increase from 66.6% to 90% for flu vaccination and increase from 60.1% to 90% for pneumonia vaccination among people aged 65 and older. Healthy People 2020 (2) cancer screening goals include participation rates of 70.5% for colon cancer screening, 81.1% for breast cancer screening, 93% for cervical cancer screening, and 15.9% for discussion with health providers about the prostate-specific antigen (PSA) test for prostate cancer.
Although preventive care utilization has greatly increased over the years, strong evidence indicates that preventive care utilization remains relatively low among ethnic minority groups, including Asian Americans. For example, among older adults aged 65 and older, Asian Americans had significant lower utilization of screening mammography than whites (3). Common barriers for use preventive care services among ethnic minority groups include lower socioeconomic status, lack of insurance, poor access to health service providers, and lack of physician recommendation (4,5). In addition, barriers more unique to Asian Americans relate to traditional beliefs and cultural heritage—such as Eastern approaches to medicine and using health care services only when symptomatic (6,7).
Although the Chinese community is the largest Asian American subgroup population, systematic studies focusing on Chinese Americans are still scarce. To date, despite the heterogeneity of Asian American subgroup with respect to culture, immigration history, and socioeconomic status, research studies generally pool Asian Americans together when comparing different racial groups. Some prior studies of preventive service utilization have focused on different Asian American subgroups, such as Chinese, Japanese, Korean, and Vietnam Americans—but these studies tend to focus on only one specific preventive care service.
To bridge these knowledge gaps, the objectives of this study are to: (i) study the utilization of immunization and cancer screening services among community dwelling Chinese older adults in the Greater Chicago area; and (ii) assess the extent to which sociodemographic characteristics and self-reported health and quality of life factors are associated with preventive care service use.
Methods
Population and Settings
The Population Study of Chinese Elderly in Chicago (PINE) is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older (60–105) in the Greater Chicago area. In brief, the purpose of the PINE study is to collect community-level data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University Medical Center, and many community-based social services agencies and organizations throughout the Greater Chicago area (8).
To ensure study relevance and enhance community participation, the PINE study implemented extensive culturally and linguistically appropriate community recruitment strategies guided by community-based participatory research (CBPR) approach (9). With over 20 social services agencies, community centers, health advocacy agencies, faith-based organizations, senior apartments, and social clubs serving as the basis of study recruitment sites, eligible participants were approached through routine social services and outreach efforts serving Chinese American families in the Chicago city and suburban areas (9). Out of 3,542 eligible older adults approached, 3,159 agreed to participate in the study, yielding a response rate of 91.9%.
Based on available data drawn from U.S. Census 2010 and a random block census project conducted in Chicago’s Chinese community, the PINE study is representative of the Chinese aging population in the Greater Chicago area with respective to key demographic attributes, including age, sex, income, education, number of children, and country of origin (10). The study was approved by the Institutional Review Board of the Rush University Medical Center.
Measurements
Sociodemographics.—Sociodemographic profile characteristics included age (in years), education (in years), personal income on a 10-point scale (1 = $0–$4,999; 2 = $5,000–$9,999; 3 = $10,000–$14,999; 4 = $15,000–$19,999; 5 = $20,000–$24,999; 6 = $25,000–$29,999; 7 = $30,000–$34,999; 8 = $35,000–$39,999; 9 = $40,000–$44,999; 10 = ≥$45,000), marital status (married/not married), number of alive children, living arrangement (in a scale from 0 to 10), language preference (English/Cantonese/Mandarin/Taishanese), country of origin (China/Other), years in the United States (in years) and years in the community (in years).
Overall health status, quality of life and health changes over the last year.—Overall health status was measured by “in general, how would you rate your health” on a four point scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality of life was assessed by asking “in general, how would you rate your quality of life” on a four-point scale ranging from 1 = poor to 4 = very good. Health changes over the last year was measured by “compared to one year ago, how would you rate your now” on a three-point scale (1 = worsened; 2 = same; 3 = improved).
Utilization of preventive care services.—Preventive care services assessed include use of flu, pneumonia, and hepatitis B vaccines as well as colon, breast, cervical, and prostate cancer screening. Specifically, participants were asked whether they had received flu shot within the past 12 months, pneumonia shot within the past 5 years, and the series of three hepatitis B shots in the past. Participants were asked whether they had ever received blood stool test or colonoscopy to assess colon cancer screening, mammogram or clinical breast exam to assess breast cancer screening, pap test to assess cervical cancer screening, and PSA test to assess prostate cancer screening (Table 1).
Table 1.
Usage of Preventive Care Among Study Population
| Yes: Numbers (%) | No: Numbers (%) | |
|---|---|---|
| Immunization | ||
| £Flu shot in the past 12 mo | 2,076 (65.7) | 1,082 (34.3) |
| £Pneumonia shot in the past 5 y | 782 (25.3) | 2,309 (74.7) |
| £Hepatitis B shot | 581 (18.8) | 2,516 (81.2) |
| Colorectal cancer screening | ||
| £Blood stool test | 765 (24.3) | 2,386 (75.7) |
| Within the past year | 401 (52.6) | |
| Within the past 2 y (1 y but <2 y ago) | 95 (12.5) | |
| Within the past 3 y (2 y but <3 y ago) | 84 (11.0) | |
| Within the past 5 y (3 y but <5 y ago) | 68 (8.9) | |
| ≥5 y ago | 114 (15.0) | |
| £Colonoscopy exam | 896 (28.5) | 2,253 (71.6) |
| Within the past year | 238 (27.0) | |
| Within the past 2 y (1 y but <2 y ago) | 129 (14.6) | |
| Within the past 3 y (2 y but <3 y ago) | 130 (14.7) | |
| Within the past 5 y (3 y but <5 y ago) | 169 (19.1) | |
| Within the past 10 y (5 y but <10 y ago) | 106 (12.0) | |
| ≥10 y ago | 111 (12.6) | |
| Breast cancer screening (women only) | ||
| £Mammogram | 1,077 (59.6) | 729 (40.4) |
| Within the past 2 y | 635 (59.2) | |
| More than the past 2 y | 437 (40.8) | |
| £Clinical breast exam | 847 (46.8) | 964 (53.2) |
| Within the past 2 y | 532 (63.2) | |
| More than the past 2 y | 310 (36.8) | |
| Cervical cancer screening (women only) | ||
| £Pap test | 736 (40.7) | 1,071 (59.3) |
| Within the past 2 y | 337 (45.9) | |
| More than the past 2 y | 397 (54.1) | |
| Prostate cancer screening (men only) | ||
| £PSA test | 336 (26.5) | 930 (73.5) |
| Within the past year | 164 (49.1) | |
| Within the past 2 y (1 y but <2 y ago) | 55 (16.5) | |
| Within the past 3 y (2 y but <3 y ago) | 35 (10.5) | |
| Within the past 5 y (3 y but <5 y ago) | 30 (9.0) | |
| ≥5 y ago | 50 (15.0) | |
Note: PSA = prostate-specific antigen.
Data Analysis
Descriptive statistics were used to summarize sociodemographic, health-related and quality of life information of Chinese older adults. We used Wilcoxon two-sample test, folded-F statistics and chi-square statistics to compare the sociodemographic characteristics of those who have used preventive care services and those who have not. Pearson correlation coefficients were used to determine whether there is any significant association between sociodemographic, health-related and quality of life independent variables with utilization of preventive care services. All statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
Results
Sample Characteristics
The PINE study surveyed 3,159 Chinese older adults, their age ranged from 60 to 105 years. Approximately 60% of the participants were female. Around 80% of the participants received less than 12 years of education and less than 5% had an annual income more than $15,000. Nearly one third of Chinese older adults were separated, divorced, or widowed. More than 20% of the elderly lived alone and only 4% of the participants did not have children. About 93% of the participants reported China as their country of origin and more than three quarters preferred speaking Cantonese or Taishanese.
Immunization and Cancer Screening Utilization
Overall, 2,076 (65.7%) participants reported they had received the flu shot within the past 12 months. In contrast, only a quarter of participants reported they had received the pneumonia shot in the past 5 years and less than 20% of participants had completed the series of Hepatitis B shots. As for cancer screening coverage, only 12.9% of participants had a blood stool test within the past year and only 28.5% of participants reported ever having had a colonoscopy in their life. The breast and cervical cancer screening were also low; 635 (35.2%) of female participants reported mammogram use, 532 (29.5%) had a clinical breast exam, and 337 (18.7%) had a pap test within the past 2 years. Only 336 (26.5%) of men ever had a PSA test (Table 1).
Chinese Older adults who have received a flu shot or pneumonia shot were significantly older than those who have never used such services (flu shot: 74.5 vs 69.7, p < .01; pneumonia shot: 73.9 vs 72.4, p < .01) and they lived with fewer people (flu shot: 1.6 vs 2.4, p < .01; pneumonia shot: 1.6 vs 2.0, p < .01). Compared with those who have not received the Hepatitis B vaccine series, older adults who had completed Hepatitis B immunization were younger (71.4 vs 73.1, p < .01), had fewer children (2.5 vs 3.0, p < .05), resided in the United States for fewer years (18.4 vs 20.4, p < .01) and reported a higher quality of life (2.6 vs 2.5, p < .01) (Table 2).
Table 2.
Characteristics of Study Population by Immunization
| Flu Shot, N = 3,158 (%) | Pneumonia Shot, N = 3,091 (%) | Hepatitis B Shot, N = 3,097 (%) | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Yes (N = 2,076) | No (N = 1,082) | p Value | Yes (N = 782) | No (N = 2,309) | p Value | Yes (N = 581) | No (N = 2,516) | p Value | |
| Age, mean ± SD | 74.5 (8.2) | 69.7 (7.6) | <.01 | 73.9 (7.4) | 72.4 (8.5) | <.001 | 71.4 (7.6) | 73.1 (8.4) | <.01 |
| Education (y), mean ± SD | 8.8 (5.2) | 8.6 (4.8) | <.001 | 10.4 (5.1) | 8.2 (4.9) | .31 | 10.7 (5.0) | 8.3 (4.9) | .76 |
| Income (USD), mean ± SD | 2.0 (1.1) | 1.8 (1.1) | <.001 | 2.1 (1.4) | 1.9 (1.1) | <.001 | 2.1 (1.5) | 1.9 (1.1) | .34 |
| Marital status, mean ± SD | 0.7 (0.5) | 0.8 (0.4) | <.001 | 0.7 (0.5) | 0.7 (0.5) | .86 | 0.8 (0.4) | 0.7 (0.5) | <.01 |
| Living arrangement, mean ± SD | 1.6 (1.7) | 2.4 (2.1) | <.001 | 1.6 (1.7) | 2.0 (1.9) | <.001 | 1.9 (1.8) | 1.9 (1.9) | .08 |
| Number of children, mean ± SD | 3.0 (1.6) | 2.7 (1.4) | <.001 | 2.7 (1.5) | 2.9 (1.5) | .19 | 2.5 (1.4) | 3.0 (1.5) | <.05 |
| Years in the United States, mean ± SD | 21.8 (13.2) | 16.6 (12.5) | <.001 | 21.2 (13.5) | 19.7 (13.1) | <.01 | 18.4 (13.9) | 20.4 (13.0) | <.001 |
| Years in the community, mean ± SD | 13.1 (11.4) | 10.2 (10.0) | <.001 | 12.7 (11.6) | 12.0 (10.9) | .34 | 10.5 (10.6) | 12.5 (11.1) | <.001 |
| Health status, mean ± SD | 2.2 (0.8) | 2.4 (0.8) | .12 | 2.2 (0.8) | 2.3 (0.8) | .70 | 2.3 (0.8) | 2.2 (0.8) | .25 |
| QOL, mean ± SD | 2.6 (0.7) | 2.5 (0.7) | .26 | 2.6 (0.7) | 2.5 (0.7) | .17 | 2.6 (0.7) | 2.5 (0.7) | <.01 |
| Health changes in the last year, mean ± SD | 2.6 (0.8) | 2.6 (0.7) | <.05 | 2.6 (0.8) | 2.6 (0.7) | <.05 | 2.6 (0.8) | 2.6 (0.8) | .43 |
Note: QOL = quality of life.
Older adults who have never had colon cancer screening were significantly older (blood stool test: 73.3 vs 72.6.7, p < .01; Colonoscopy: 73.3 vs 72.6, p < .01) and have resided in the United States for more years (blood stool test: 22.5 vs 19.2, p < .01; Colonoscopy: 22.8 vs 18.9, p < .01) than those who have been screened before for colon cancer (Table 3).
Table 3.
Characteristics of Study Population by Cancer Screening
| Colon Cancer Screening | Breast Cancer Screening | Cervical Cancer Screening | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Blood Stool Test, N = 3,151 (%) | Colonoscopy Exam, N = 3,149 (%) | Mammogram, N = 1,806 (%) | Clinical Breast Exam, N = 1,811 (%) | Pap Test, N = 1,807 (%) | |||||||||||
| Yes (N = 765) | No (N = 2,386) | p Value | Yes (N = 896) | No (N = 2,253) | p Value | Yes (N = 1,077) | No (N = 729) | p Value | Yes (N = 847) | No (N = 964) | p Value | Yes (N = 736) | No (N = 1,071) | p Value | |
| Age, mean ± SD | 73.3 (7.8) | 72.6 (8.5) | <.01 | 73.3 (7.7) | 72.6 (8.5) | <.001 | 71.5 (7.7) | 74.6 (9.3) | <.001 | 71.1 (7.6) | 74.3 (9.1) | <.001 | 70.4 (7.4) | 74.4 (8.9) | <.001 |
| Education (y), mean ± SD | 8.7 (4.9) | 8.7 (5.1) | .20 | 10.0 (5.2) | 8.2 (4.9) | <.05 | 8.9 (5.1) | 6.4 (4.6) | <.01 | 9.1 (5.1) | 6.8 (4.7) | <.05 | 9.5 (5.0) | 6.8 (4.8) | .18 |
| Income (USD), mean ± SD | 2.0 (1.3) | 1.9 (1.1) | .61 | 2.2 (1.5) | 1.9 (1.0) | <.001 | 2.1 (1.3) | 1.8 (0.7) | <.01 | 2.1 (1.3) | 1.8 (0.8) | <.001 | 2.1 (1.3) | 1.9 (0.8) | <.05 |
| Marital status, mean ± SD | 0.7 (0.5) | 0.7 (0.5) | .90 | 0.7 (0.5) | 0.7 (0.5) | .34 | 0.6 (0.5) | 0.5 (0.5) | <.01 | 0.6 (0.5) | 0.6 (0.5) | <.05 | 0.6 (0.5) | 0.5 (0.5) | <.001 |
| Living arrangement, mean ± SD | 1.8 (1.9) | 1.9 (1.9) | .43 | 1.6 (1.7) | 2.0 (1.9) | <.001 | 1.7 (1.8) | 1.9 (2.1) | 1.0 | 1.8 (1.9) | 1.7 (2.0) | <.05 | 1.8 (1.9) | 1.7 (1.9) | <.05 |
| Number of children, mean ± SD | 3.0 (1.5) | 2.8 (1.5) | .53 | 2.8 (1.5) | 2.9 (1.5) | .47 | 2.8 (1.5) | 3.2 (1.6) | <.05 | 2.8 (1.5) | 3.2 (1.6) | .06 | 2.6 (1.4) | 3.2 (1.5) | .09 |
| Years in the United States, mean ± SD | 22.5 (14.0) | 19.2 (12.8) | <.001 | 22.8 (13.9) | 18.9 (12.7) | <.001 | 20.9 (13.2) | 19.6 (12.6) | .08 | 20.4 (13.4) | 20.3 (12.5) | .81 | 20.2 (13.4) | 20.5 (12.6) | .37 |
| Years in the community, mean ± SD | 13.3 (11.8) | 11.8 (10.7) | <.01 | 13.3 (12.2) | 11.7 (10.5) | <.01 | 12.3 (11.2) | 12.5 (10.9) | .41 | 12.0 (11.0) | 12.7 (11.1) | .14 | 11.8 (11.0) | 12.8 (11.1) | <.05 |
| Health status, mean ± SD | 2.2 (0.8) | 2.3 (0.8) | .07 | 2.2 (0.8) | 2.3 (0.8) | .70 | 2.2 (0.8) | 2.2 (0.8) | .09 | 2.2 (0.8) | 2.2 (0.8) | .50 | 2.2 (0.8) | 2.2 (0.8) | .46 |
| QOL, mean ± SD | 2.5 (0.6) | 2.5 (0.7) | .10 | 2.6 (0.7) | 2.5 (0.7) | .14 | 2.6 (0.7) | 2.5 (0.7) | .95 | 2.6 (0.7) | 2.5 (0.6) | .31 | 2.7 (0.7) | 2.5 (0.7) | .63 |
| Health changes in the last year, mean ± SD | 2.6 (0.8) | 2.6 (0.8) | .24 | 2.6 (0.8) | 2.6 (0.7) | <.05 | 2.6 (0.8) | 2.6 (0.8) | .50 | 2.6 (0.8) | 2.6 (0.8) | .91 | 2.6 (0.8) | 2.6 (0.8) | .90 |
Note: QOL = quality of life.
Compared with women who have never been screened for breast or cervical cancer, women who have used such services were significantly younger (mammogram: 71.5 vs 74.6, p < .01; clinical breast exam: 71.1 vs 74.3, p < .01; pap test: 70.4 vs 74.4, p < .01) and had a higher annual income (mammogram: 2.1 vs 1.8, p < .01; clinical breast exam: 2.1 vs 1.8, p < .01; pap test: 2.1 vs 1.9, p < .05) (Table 3).
Correlations between sociodemographic and health-related factors with cancer screening use is also presented in Table 4. Age, income, number of children and years spent in the United States were associated with immunization utilization, but the association directions for different immunization services were sometimes inconsistent. Years spent in the United States and in community were positively associated with colon cancer screening. Positive associations were also found among different preventive care services.
Table 4.
Correlations Between Immunization, Cancer Screening, and Sociodemographic Characteristics
| Age | Sex | Edu | Income | MS | Living | Children | Yrs in U.S. | Yrs in Com | Origin | LP-CT | OHS | QOL | HC | FLU | PNU | HEP | BST | CLN | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| FLU | 0.27*** | 0.06*** | 0.02 | 0.08*** | −0.12*** | −0.20*** | 0.09*** | 0.19*** | 0.12*** | −0.03 | 0.00 | −0.09*** | 0.03 | −0.04* | 1 | ||||
| PNU | 0.08*** | −0.01 | 0.19*** | 0.08*** | 0.00 | −0.09*** | −0.05** | 0.05** | 0.02 | −0.06*** | −0.16*** | −0.01 | 0.09*** | −0.03 | 0.30*** | 1 | |||
| HEP | −0.08*** | −0.00 | 0.19*** | 0.06** | 0.05** | 0.01 | −0.12*** | −0.06** | −0.07*** | −0.07*** | −0.17*** | 0.04* | 0.07**** | −0.00 | 0.13*** | 0.45*** | 1 | ||
| BST | 0.03 | −0.00 | −0.00 | 0.03 | 0.00 | −0.01 | 0.05** | 0.10*** | 0.06** | −0.03 | 0.03 | −0.02 | −0.00 | 0.00 | 0.10*** | 0.13*** | 0.07*** | 1 | |
| CLN | 0.04* | −0.00 | 0.16*** | 0.11*** | −0.02 | 0.08*** | −0.03 | 0.14*** | 0.07*** | −0.12*** | −0.14*** | −0.07*** | 0.04* | −0.04* | 0.13*** | 0.15*** | 0.12*** | 0.21*** | 1 |
| MAM | −0.18*** | N/A | 0.24*** | 0.12*** | 0.07** | −0.03 | −0.13*** | 0.04 | −0.01 | −0.08** | −0.16*** | −0.01 | 0.09*** | 0.02 | 0.10*** | 0.20*** | 0.21*** | 0.15*** | 0.22*** |
| CBE | −0.19*** | N/A | 0.23*** | 0.13*** | 0.06* | 0.03 | −0.13*** | 0.00 | −0.03 | −0.05* | −0.15*** | 0.00 | 0.08*** | 0.02 | 0.06*** | 0.15*** | 0.16*** | 0.12*** | 0.16*** |
| PAP | −0.23*** | N/A | 0.27*** | 0.11*** | 0.10*** | 0.03 | −0.18*** | −0.01 | −0.04 | −0.08*** | −0.20*** | 0.00 | 0.12*** | −0.03 | 0.04*** | 0.15*** | 0.19*** | 0.11*** | 0.22*** |
| PSA | 0.14*** | N/A | 0.18*** | 0.10*** | −0.01 | −0.15*** | −0.05 | 0.13*** | 0.08** | −0.08** | −0.20*** | −0.06* | 0.08** | −0.00 | 0.15*** | 0.20*** | 0.18*** | 0.16*** | 0.23*** |
Notes: BST = blood stool test; CBE = clinical breast exam; Children = number of children; CLN = colonoscopy; Edu = education; Living = living arrangement; FLU = flu shot; HC = health changes over last year; HEP = hepatitis B shot; LP-CT = language preference of Cantonese and Taishanese; MAM = mammogram; MS = marital status; OHS = overall health status; Origin = country of origin; PAP = pap test; PSA= prostate-specific antigen test; PNU = pneumonia shot; QOL = quality of life; Yrs in com = years in the community; Yrs in U.S. = years in the United States.
*p < .05, **p < .01, ***p < .001.
Discussion
The PINE study indicates that although utilization of the flu vaccine was rather common, usage of other recommended preventive care services was generally low among our sample of Chinese older adults in the Greater Chicago area. Approximately two-thirds of our study participants had received the flu shot within the last 12 months, which is consistent with vaccination rates nationally and in the state of Illinois for adults aged 65 and older (11). Although 25.3% of Chinese older adults surveyed reported receiving a pneumonia shot or pneumococcal vaccine within the past 5 years, the pneumococcal vaccine coverage rate over the lifetime for adults aged 65 and older was about 60% nationally, according to the 2012 National Health Interview Survey (12). Although this 60% national level reflected ever having used the pneumococcal vaccine in their lifetime instead of during the past 5 years as was assessed in our study, it is possible that Chinese older adults underused immunization services against pneumococcal diseases and this potential disparity warrants further investigation.
For colon cancer screening tests, including the blood stool test and colonoscopy, our study participants reported an overall lower usage rates than the national level. Approximately 13% had a blood stool test within the last 12 months and a quarter had a colonoscopy within the past 10 years. In comparison, among adults aged from 50 to 64 years nationally, over 55% reported having had a blood stool test within the past year, sigmoidoscopy in the past 5 years, or a colonoscopy in the past 10 years and this rate was even higher, 63.7%, among people aged 65 and older (13).
The reported hepatitis B immunization rate among Chinese older adults in our sample was less than 20%, which is alarming in light that Asian Americans, especially those born in foreign countries, are at high risk of Hepatitis B virus (HBV) infection (14). With the strategy of having children vaccinated for hepatitis B, HBV acute infection rates have dropped by 96% among children and adults in the United States (15). However, there are still approximately 1.4–2 million chronic HBV carriers in the United States (16). A large body of literature has reported that Asian Americans have disproportionally high chronic HBV infection rates; the majority of the HBV infections were acquired before they immigrated to the Unites States (17,18).
With over 90% of our study participants reported China as their country of origin, a country where HBV infection is highly endemic, Chinese older adults in the Greater Chicago area may be at high risk of HBV infection. Although the reported Hepatitis B vaccination rate of around 18% among study participants was slightly higher than the vaccine coverage rate of 15.1% nationally for adults over 60 years with diabetes (another group with increased risk of HBV infection) (12), it is important to increase Hepatitis B vaccination coverage among U.S. Chinese older adults.
In addition, our study findings call for more primary care physicians to carry out HBV screening tests—a suggestion based on several factors. First, our 18% self-reported Hepatitis B vaccination rate may be an overestimate of Chinese older adults’ capacity against HBV infection. A population-based study in California from 2001 to 2006 found that among the 12% of Asian Americans who reported prior Hepatitis B vaccination, approximately 5% carried HBV and 20% failed to develop protective antibodies (19). Therefore, we need to be cautious when using self-reported vaccination data to estimate Chinese older adults’ capacity against HBV infection. Additionally, because 50%–60% of chronically infected HBV carriers do not experience any symptoms (20), it is all the more important for Chinese older adults to get HBV infection screening tests so that they can be better informed of their health status.
Although no single sociodemographic characteristic or self-reported health and life quality factor was found to be significantly associated with all nine preventive care services assessed in our study, each variable was associated with at least one preventive care service use. Some characteristics were associated with more preventive care use than others. For example, number of years spent in the United States was positively significantly associated with having received the flu shot, pneumonia shot, blood stool test, and colonoscopy while gender was only positively associated with flu vaccine utilization (ie, higher flu vaccine utilization among the female). However, it is worth noting that a characteristic can be associated with preventive care services in different directions. For example, Chinese older adults who reported better overall health status had a lower flu shot and colonoscopy screening rate, but higher hepatitis B shot coverage than adults who reported poorer overall health status. These mixed results need to be further studied.
Of all the associations revealed in this study, the association between living arrangement and use of flu shot and pneumonia shot warrants further research. These significant negative associations indicate that Chinese older adults who lived alone or with one other person were more likely to receive the flu shot and pneumonia shot, whereas Chinese older adults who lived with more people were less likely to have received these vaccinations. Such an observation is partially consistent with prior study findings. In a study of 13,038 community-dwelling older adults 65 years and older in the United States, there were no significant differences in flu vaccination rates between older adults living alone and older adults living with more people (eg, such as living with both the spouse and adult offspring). However, when older adults lived with the spouse only, they were more likely to receive preventive care services than those living with more people or living alone (21). Possible explanations for this trend among Chinese older adults may pertain to the spouse’s central role in use of preventive care services (22), whereas offspring (especially those who are employed) may have more difficulty in assisting older adults with preventive care (21). On the other hand, when Chinese older adults living with more people especially with their children, they could become occupied by additional household chores such as taking care of grandchildren, which may restrict their ability to pursue preventive health services. It is also possible that compared with older adults living with more people, Chinese older adults living alone or with fewer people may have a higher level of self-reliance and may be more proactive in managing their own care and more willing to get vaccinations to stay healthy. Further studies are necessary to better understand how living arrangement is related to preventive care service utilization patterns among Chinese older adults.
Our study also showed significant positive associations among preventive care services. In other words, U.S. Chinese older adults who had used one preventive care service were more likely to use other preventive care services. This pattern may be related with Chinese older adults’ knowledge of and attitudes toward preventive care services. More than 90% of our study participants are immigrants from China. Therefore, in consideration that some important preventive care services were not provided in China’s national programs (23,24), it is possible that a majority of our study participants were lacking in knowledge of preventive care use and benefits. In addition, their acceptance of preventive care might be dampened by various concerns, ranging from vaccination side-effects to acculturation issues as identified in prior studies (4–7). Therefore, it is possible that Chinese older adults with more knowledge of preventive care in the United States and a higher acceptance level of these services were more likely to use multiple preventive care services, whereas those with less knowledge and a lower acceptance level tended not to have used preventive care services. Further research is necessary to explore whether culturally appropriated education and outreach can improve Chinese older adults’ knowledge and use of preventive care services.
Our study is subject to a few limitations. First, because provision of preventive care services, costs, and payment resources may vary by region, generalizing the findings from this study to Chinese populations in other U.S. regions and in other countries should be done with caution. Second, we used self-report data in our assessment of preventive care service use, which is subject to selective memory issues, especially for data related to the hepatitis B vaccination, an immunization procedure requiring three shots. Third, our study did not explore the barriers and facilitators for utilization of preventive care services. More research is necessary to examine potential barriers and facilitators identified among other ethnic groups, such as physician recommendation (5).
This study has practical implications for researchers, health care providers, and policy makers. We found a significant disparity in U.S. Chinese older adults’ use of different preventive care services. Although utilization of pneumonia vaccine and cancer screening services among Chinese older adults was much lower than that of the general populations, the 66% flu shot vaccination rate was consistent with the national level. Further studies of this apparent contrast may help researchers, health care providers, and policy makers to better understand the barriers to the use of preventive care services among Chinese older adults and develop appropriate strategies to promote other preventive care services. For example, by identifying the traditional and nontraditional locations where Chinese older adults received the flu shot, future research can explore the feasibility of providing other vaccination services together with the flu shot at these locations, which may increase vaccination levels across the board for U.S. Chinese older adults.
Conclusion
Our study indicates that the use of preventive care services, with the exception of the flu vaccine, was low for Chinese older adults in the Greater Chicago area. Because Chinese Americans are at high risk for the HBV and their current HBV immunization rate is low, we call for more attention to this issue. In addition, future longitudinal studies are necessary to improve our understanding of preventive care service utilization patterns among Chinese older adults.
Funding
X.D. and M.A.S. were supported by National Institute on Aging grants (R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, P20CA165588, R24MD001650, RC4 AG039085), Paul B. Beeson Award in Aging, The Starr Foundation, American Federation for Aging Research, John A. Hartford Foundation, and The Atlantic Philanthropies.
Acknowledgments
We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong, Vivian Xu, and Yicklun Mo with the Chinese American Service League (CASL); Dr. David Lee with the Illinois College of Optometry; David Wu with the Pui Tak Center; Dr. Hong Liu with the Midwest Asian Health Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary Jane Welch with the Rush University Medical Center; Florence Lei with the CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr. Jing Zhang with Asian Human Services; Marta Pereya with the Coalition of Limited English Speaking Elderly; and Mona El-Shamaa with the Asian Health Coalition.
References
- 1. Heron M. Deaths: leading causes for 2010. Natl Vital Stat Rep. 2013;62. [PubMed] [Google Scholar]
- 2. US Department of Health Human Services—Office of Disease Prevention Health Promotion. Healthy People 2020. Washington, DC; 2012. http://www.healthypeople.gov/2020/topicsobjectives2020/default.aspx Accessed April 22, 2014. [Google Scholar]
- 3. Chen JY, Diamant A, Pourat N, Kagawa-Singer M. Racial/ethnic disparities in the use of preventive services among the elderly. Am J Prev Med. 2005;29:388–395. [DOI] [PubMed] [Google Scholar]
- 4. Garrett CR, Treichel CJ, Ohmans P. Barriers to health care for immigrants and nonimmigrants: a comparative study. Minn Med. 1998;81:52–55. [PubMed] [Google Scholar]
- 5. Nowalk MP, Zimmerman RK, Shen S, Jewell IK, Raymund M. Barriers to pneumococcal and influenza vaccination in older community‐dwelling adults (2000–2001). J Am Geriatr Soc. 2004;52:25–30. [DOI] [PubMed] [Google Scholar]
- 6. Liang W, Yuan E, Mandelblatt JS, Pasick RJ. How do older Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethn Health. 2004;9:283–304. [DOI] [PubMed] [Google Scholar]
- 7. Wang JH, Mandelblatt JS, Liang W, Yi B, Ma IJ, Schwartz MD. Knowledge, cultural, and attitudinal barriers to mammography screening among nonadherent immigrant Chinese women: ever versus never screened status. Cancer. 2009;115:4828–4838. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Dong X, Wong E, Simon MA. Study design and implementation of the PINE study. J Aging Health. 2014;26:1085–1099. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Dong X, Chang E-S, Simon M, Wong E. Sustaining community-university partnerships: lessons learned from a participatory research project with elderly Chinese. Gateways: Intl J Comm Res Engag. 2011;4:31–47. [Google Scholar]
- 10. Simon M, Chang E, Rajan K, Welch M, Dong X. Demographic characteristics of US Chinese older adults in the greater Chicago area: assessing the representativeness of the PINE study. J Aging Health. 2014;26:1100–1115. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Centers for Disease Control and Prevention. 2012–13 State and Regional Vaccination Coverage Report II. 2013. http://www.cdc.gov/flu/fluvaxview/reports/reporti1213/reportii/index.htm Accessed April 26, 2014. [Google Scholar]
- 12. Williams WW, Lu P-J, O’Halloran A, et al. Noninfluenza vaccination coverage among adults—United States, 2012. MMWR. 2014;63:95–102. [PMC free article] [PubMed] [Google Scholar]
- 13. American Cancer Society. Colorectal Cancer Facts & Figures 2014–2016. 2014. http://www.cancer.org/acs/groups/content/documents/document/acspc-042280.pdf Accessed July 11, 2014. [Google Scholar]
- 14. Hepatitis B Foundation. High Risk Groups 2014. http://www.hepb.org/professionals/high-risk_groups.htm Accessed April 25, 2014. [Google Scholar]
- 15. Centers for Disease Control and Prevention. Vaccination of Adults. 2013. http://www.cdc.gov/hepatitis/HBV/VaccAdults.htm Accessed April 25, 2014. [Google Scholar]
- 16. Cohen C, Holmberg SD, McMahon BJ, et al. Is chronic hepatitis B being undertreated in the United States? J Viral Hepat. 2011;18:377–383. [DOI] [PubMed] [Google Scholar]
- 17. Jenkins CN, Buu C, Berger W, Son DT. Liver carcinoma prevention among Asian Pacific Islanders. Getting hepatitis B shots into arms. Cancer. 2001;91(suppl 1):252–256. [DOI] [PubMed] [Google Scholar]
- 18. Mast EE, Margolis HS, Fiore AE, et al. ; Advisory Committee on Immunization Practices (ACIP). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep. 2005;54:1–31. [PubMed] [Google Scholar]
- 19. Lin SY, Chang ET, So SK. Why we should routinely screen Asian American adults for hepatitis B: a cross-sectional study of Asians in California. Hepatology. 2007;46:1034–1040. [DOI] [PubMed] [Google Scholar]
- 20. Centers for Disease Control and Prevention. Medical Management of Chronic Hepatitis B and Chronic Hepatitis 2002. http://www.cdc.gov/idu/hepatitis/manage_chronich_hep_b-c.pdf Accessed July 10, 2014. [Google Scholar]
- 21. Lau DT, Kirby JB. The relationship between living arrangement and preventive care use among community-dwelling elderly persons. Am J Public Health. 2009;99:1315–1321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Liang J, Brown JW, Krause NM, Ofstedal MB, Bennett J. Health and living arrangements among older Americans: does marriage matter? J Aging Health. 2005;17:305–335. [DOI] [PubMed] [Google Scholar]
- 23. Yu H, Yang W, Varma JK. To save children’s lives, China should adopt an initiative to speed introduction of pneumonia vaccines. Health Aff (Millwood). 2012;31:2545–2553. [DOI] [PubMed] [Google Scholar]
- 24. Wang B, He M, Wang L, Engelgau MM, Zhao W, Wang L. Breast cancer screening among adult women in China, 2010. Prev Chronic Dis. 2013;10. [DOI] [PMC free article] [PubMed] [Google Scholar]