Abstract
Background:
Social support is a key indicator of utilization of preventive health care among older adults, but we have limited knowledge on these associations in U.S. Chinese older adults. This study aims to examine the association between sources of social support and cancer screening behaviors among Chinese older adults in the greater Chicago area.
Methods:
Data were drawn from the Population Study of Chinese Elderly in Chicago. Social supports were measured by asking the frequency of receipt of support from spouse, non-spouse family members, and friends. Use of cancer screenings were evaluated by asking the history of utilization of colon, breast, cervical, and prostate cancer screenings.
Results:
After adjusting for covariates, results indicated significant association between higher social support and higher utilization of cancer screenings. Regarding to different sources of social support, higher levels of social supports from family members (odds ratio [OR], 1.15 [1.07, 1.25]) and friends (OR, 1.14 [1.06, 1.23]) were associated with higher utilization of breast cancer screening. However, higher levels of social support from family members (OR, 0.94 [0.88, 0.99]) and friends (OR, 0.94 [0.88, 1.00]) were associated with lower utilization of colon cancer screening. No associations were found between social support and prostate cancer screening.
Conclusions:
This study provides evidence that different types of social support were associated with variations in the utilization of cancer screenings. Future longitudinal studies are needed to explore the causal relationship between social support and cancer screening use.
Keywords: Social support, Cancer screening, Preventive health care
Cancer is the second most common cause of death in the United States and older adults experiencing a disproportionately increasing incidence rate as the aging process after 50 years old (1). Colon cancer, breast cancer, and prostate cancer are common types of cancer among older adults (2). Cervical cancer is another common cancer among women although the morbidity of cervical cancer can be reduced by applying Papanicolaou (Pap) smear (3). Cancer screenings have been known as important tools to help reduce mortality for many cancers, with the U.S. Preventive Services Task Force (USPSTF) recommends cancer screenings for breast, cervical, and colorectal cancer should be conducted periodically (4–6). In addition, the American Cancer Society recommends prostate-specific antigen (PSA) test be offered annually since age 50 for men who have at least a 10-year life expectancy (7). Although the rates of cancer screening utilization has greatly increased over years, the cancer screening rates are still low among older adult (8). Furthermore, disparities in the use of cancer screening still exist in minority group in the United States (9–12). Lower socioeconomic status, lack of insurance, poor access to health service providers, and lack of physician recommendation might be the common barriers among minority groups (9,13,14).
Strong evidence indicates that social support is a potential pathway to encourage preventive health behaviors such as cancer screening (15,16). Previous studies have showed that social support from multiple sources were associated with different utilization of cancer screening in general populations (17). Few studies were conducted among minority groups in the United States. One study conducted among female American Pacific Islanders reports stronger social support from their husband or partner was related to higher rate of cervical cancer screening within the past 3 years (18).
As the largest Asian American minority group, the Chinese community has unique cultural traits and special social support patterns. Previous studies conducted in greater Chicago area showed that U.S. Chinese older adults received high level of social support which related to various factors (19), and received lower rate of cancer screening compared to other population (11). However, most previous relevant studies regarding to cancer screening were conducted in Asia (20), or focused on only social support or only cancer screening (5,21,22). To our knowledge, limited studies have been conducted to examine the relationship between social support and cancer screening among U.S. Chinese older adults.
To bridge these knowledge gaps, our study aims to examine the role of social support with cancer screening utilization, and to understand the association between sources of social support and utilization of different cancer screening among U.S. Chinese older adults in greater Chicago area. Our central hypotheses were that older adults who have higher levels of perceived social support from spouse, family members, and friends have higher rates of cancer screening.
Methods
Population and Settings
The Population Study of Chinese Elderly in Chicago is an ongoing community-engaged, population-based epidemiology study of U.S. Chinese older adults aged 60 and older in the greater Chicago area. Briefly, the purpose of the PINE study is to examine the key cultural determinants of health and well-being by collecting community-level data of U.S. Chinese older adults. Data in this article were drawn from the first wave data of PINE study which were collected between 2011 and 2013. The project was initiated by a synergistic community-academic collaboration among Rush Institute for Healthy Aging, Northwestern University, and many community-based social services agencies and organizations from the greater Chicago area (23). Detailed information for population and settings were published in previous study (23,24).
Measurements
Independent variable: social support
Social support was assessed by asking the frequency of receipt of support from their spouse, family members, and friends (25). Four questions for each sources, as key indicators of relationship quality, were collected during face-to-face interview (26). Social supports from all sources were measured by asking the questions: “How often can you open up to spouse/family members/friends to talk about worries?; how often can you rely on spouse/family members/friends for help?; how often your spouse/family members/friends demanded too much on you?; how often you received criticize from spouse/family members/friends?”. Responses on each question was coded on a 3-point scale ranging from 1 = hardly ever to 3 = often. In this study, social support from spouse or family members or friends was calculated as the sum of 4 items and social strains were coded reversely during analysis process. Overall social support was calculated by adding up the score of social support from different sources.
Dependent variables: cancer screening
All participants were asked whether they had ever received blood stool test or colonoscopy to assess colon cancer screening. Female participants were asked whether they had ever received mammogram to assess breast cancer screening and Pap test for cervical cancer screening. Male participants were asked whether they had ever received PSA test to assess prostate cancer screening. Detailed information regarding to utilization of cancer screening were published in previous paper (11). Answer was coded to 1 = yes if they had the screening regardless time, otherwise the response was coded to 0 = no.
Covariates
Basic sociodemographic information including age, gender (0 = male, 1 = female), year of education, annual personal income, living arrangement, marital status (0 = not current married; 1 = married), number of children, language preference (0 = English or Mandarin; 1 = Cantonese or Taishanese), years in the United States, years in the community, and medical comorbidities were collected in all participants. Medical comorbidities were measured by the presence of nine diseases, such as heart disease and stroke.
Statistical analysis
Descriptive data analysis was conducted to compare the differences of sum of total social support and social support from spouse or family members or friends between older adults with and without use of each cancer screening during their life time. Wilcoxon two-sample tests were conducted to compared mean of social support by utilization of cancer screening. Spearman Correlation coefficients were calculated to examine association between social support and utilization of cancer screening. Multivariate logistic regressions were conducted to assess the association between each group of social support and cancer screening after control for potential confounding variables. All covariates, including basic sociodemographic factors, socioeconomic factors, living arrangement, marital status, number of children, cultural and immigration factors, and medical comorbidities, were adjusted in regression models. Only one category of social support was added to each model each time. Odds ratios (ORs), 95% confidence intervals, and significance levels were reported for logistic regression. All statistical analyses were conducted by using SAS, version 9.2 (SAS Institute Inc., Cary, NC).
Results
Of 3,157 Chinese older adults who were interviewed, the mean age was 72.8 years (standard deviation ± 8.3, range = 60–105) and 58.9% were female. The mean number of years of completed education was 8.7 years (standard deviation ± 5.1), and a total of 85.1% of the PINE cohort had an annual personal income lower than US $10,000. As for utilization of cancer screening service, only 24.3% of participants had a blood stool test before and only 28.5% of participants reported ever having had a colonoscopy in their life. The rate of breast and cervical cancer screening were also low that 35.2% of female participants reported mammogram use, 40.7% had a Pap test in their life. Only 26.5% of men ever had a PSA test. Table 1 shows utilization of each cancer screenings and the perceived overall and subtypes of social support by cancer screening. Older adults who had ever had breast cancer screening and cervical cancer screening reported significant higher overall social support. However, older adults who had ever had colon cancer screening (colonoscopy exam) reported significant lower overall social support.
Table 1.
Social Support Status of Study Population by Cancer Screening
| Breast Cancer Screening | Cervical Cancer Screening | Colon Cancer Screening | Prostate Cancer Screening | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mammogram | Pap Test | Blood Stool Test | Colonoscopy Exam | Prostate-Specific Antigen Test | ||||||||||||||||
| N | Yes | No | p | N | Yes | No | p | N | Yes | No | p | N | Yes | No | p | N | Yes | No | p | |
| Overall social support | 1,802 | 32.27 ±3.19 | 31.80 ±3.36 | .004 | 1,803 | 32.25 ±3.22 | 31.93 ±3.29 | .034 | 3,139 | 31.81 ±3.03 | 31.83 ±3.42 | .319 | 3,137 | 31.59 ±3.35 | 31.93 ±3.32 | .004 | 1,259 | 31.48 ±3.37 | 31.57 ±3.33 | .712 |
| Social support from spouse | 1,053 | 10.89 ±1.65 | 10.95 ±1.58 | .499 | 1,054 | 10.84 ±1.65 | 10.97 ±1.60 | .108 | 2,249 | 11.06 ±1.51 | 10.84 ±1.62 | .003 | 2,250 | 10.74 ±1.67 | 10.95 ±1.56 | .005 | 1,137 | 10.78 ±1.66 | 10.93 ±1.52 | .228 |
| Social support from family members | 1,797 | 11.10 ±1.32 | 10.95 ±1.36 | .013 | 1,799 | 11.05 ±1.33 | 11.03 ±1.35 | .817 | 3,132 | 10.87 ±1.51 | 10.90 ±1.40 | .333 | 3,130 | 10.77 ±1.40 | 10.95 ±1.38 | .000 | 1,257 | 10.69 ±1.41 | 10.74 ±1.41 | .518 |
| Social support from friends | 1,570 | 10.33 ±1.46 | 9.96 ±1.43 | <.001 | 1,572 | 10.44 ±1.44 | 9.99 ±1.45 | <.001 | 2,675 | 9.97 ±1.29 | 10.11 ±1.52 | .016 | 2,674 | 10.11 ±1.48 | 10.06 ±1.47 | .448 | 1,041 | 10.04 ±1.46 | 9.88 ±1.45 | .099 |
Spearman correlation test was performed between social support and cancer screening (Table 2). Positive correlations were found between social support and utilization of breast, cervical cancer screenings. Whereas, negative correlations were founded between perceived social support from spouse and family members and colonoscopy. In addition, significant positive correlations were found between social support by sources.
Table 2.
Correlation Between Social Support by Sources and Use of Cancer Screening Service
| BST | CLN | MAM | PAP | PSA | OSS | SSS | SSFM | SSFR | |
|---|---|---|---|---|---|---|---|---|---|
| OSS | 0.02 | −0.02 | 0.15# | 0.16# | 0.01 | 1 | |||
| SSS | 0.07# | −0.05* | 0.00 | −0.03 | −0.02 | 0.69# | 1 | ||
| SSFM | −0.04 | −0.06+ | 0.08# | 0.01 | −0.02 | 0.71# | 0.31# | 1 | |
| SSFR | −0.05* | 0.02 | 0.13# | 0.16# | 0.04 | 0.69# | 0.11# | 0.26# | 1 |
Note: BST = blood stool test; CLN = colonoscopy; MAM = mammogram; OSS = overall social support; PAP = Pap test; PSA = prostate-specific antigen test; SSFM = social support from Family; SSFR = social support from friends; SSS = social support from spouse.*p < .05, +p < .01, #p < .001.
To exclude the impact of covariates, logistic regression analyses were conducted. Results of fully adjusted model are presented in Table 3. Results shows that, in general, every point higher in of overall social support is associated with higher utilization of breast cancer screening (OR, 1.06 [1.02, 1.19]) and cervical cancer screening (OR, 1.03 [1.00, 1.07]). Interestingly, every point higher in overall social support is associated with lower utilization of colon cancer screening (Colonoscopy; OR. 0.98 [0.95, 1.00]). Regarding different sources, among female participants, every point higher in of social support from non-spouse family (OR, 1.15 [1.07, 1.25]) and friends (OR, 1.14 [1.06, 1.23]) were associated with higher utilization of breast cancer screenings. Same association was found between social support from friends and cervical cancer screening (OR, 1.18 [1.10, 1.28]). For colon cancer screening, significant results were found that every point higher in of social support from spouse was associated with higher utilization of cancer screening. However, higher social support from other family members (OR, 0.94 [0.88, 1.00]) and friends (OR, 0.94 [0.88, 0.99]) were associated with lower utilization of colon cancer screenings. No significant associations were found between reported social support and prostate cancer screening.
Table 3.
Association Between Social Supports and Cancer Screenings
| Mammogram | Pap test | Blood Stool Test | Colonoscopy | PSA test | |
|---|---|---|---|---|---|
| Odds Ratio (95% CI) | |||||
| Age | 0.94 (0.92, 0.95)# | 0.92 (0.91, 0.94)# | 0.99 (0.98, 1.01) | 0.99 (0.98, 1.00) | 1.02 (1.00, 1.04) |
| Gender | — | — | 0.95 (0.78, 1.14) | 1.00 (0.83, 1.20) | — |
| Education | 1.07 (1.04, 1.10)# | 1.08 (1.05, 1.10)# | 1.01 (0.99, 1.03) | 1.06 (1.03, 1.08)# | 1.04 (1.00, 1.07) |
| Income | 1.22 (1.06, 1.39)+ | 1.12 (1.00, 1.25) | 1.00 (0.92, 1.08) | 1.10 (1.02, 1.18)* | 1.05 (0.94, 1.18) |
| Living arrangement | 0.95 (0.90, 1.01) | 1.01 (0.95, 1.07) | 1.02 (0.97, 1.07) | 0.95 (0.91, 1.00) | 0.89 (0.81, 0.97)+ |
| Marital status | 0.92 (0.73, 1.17) | 0.86 (0.68, 1.09) | 1.10 (0.89, 1.36) | 0.95 (0.77, 1.16) | 1.23 (0.79, 1.91) |
| Member of children | 1.02 (0.94, 1.10) | 0.98 (0.90, 1.06) | 1.08 (1.02, 1.15)* | 1.04 (0.98, 1.11) | 0.94 (0.88, 1.08) |
| Language preference | 0.56 (0.40, 0.77)# | 0.55 (0.40, 0.74)# | 1.13 (0.88, 1.46) | 0.62 (0.49, 0.79) | 0.46 (0.31, 0.66)# |
| Length of residence in the United States | 1.03 (1.02, 1.05)# | 1.02 (1.01, 1.04)# | 1.02 (1.01, 1.03)# | 1.02 (1.01, 1.03)# | 1.02 (1.00, 1.03)* |
| Length of residence in the community | 0.99 (0.98, 1.00) | 0.99 (0.98, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.02) |
| Medical comorbidities | 1.25 (1.16, 1.35)# | 1.25 (1.16, 1.35)# | 1.19 (1.12, 1.16)# | 1.18 (1.11, 1.25)# | 1.24 (1.14, 1.36)# |
| Overall social support | 1.06 (1.02, 1.09)# | 1.03 (1.00, 1.07)* | 1.00 (0.98, 1.03) | 0.98 (0.95, 1.00)* | 1.01 (0.97, 1.05) |
| Age | 0.96 (0.93, 0.98)# | 0.92 (0.90, 0.94)# | 1.00 (0.99, 1.02) | 1.00 (0.98, 1.01) | 1.02 (1.00, 1.04) |
| Gender | — | — | 0.91 (0.74, 1.12) | 0.97 (0.79, 1.19) | — |
| Education | 1.06 (1.02, 1.10)+ | 1.06 (1.02, 1.10)+ | 1.01 (0.98, 1.04) | 1.05 (1.02, 1.08)# | 1.04 (1.01, 1.08)* |
| Income | 1.30 (1.10, 1.52)+ | 1.20 (1.05, 1.40)+ | 0.99 (0.91, 1.08) | 1.10 (1.01, 1.19)* | 1.04 (0.92, 1.16) |
| Living arrangement | 0.92 (0.86, 1.00)* | 1.04 (0.97, 1.13) | 1.03 (0.97, 1.10) | 0.96 (0.90, 1.01) | 0.88 (0.80, 0.97)+ |
| Number of children | 1.00 (0.90, 1.12) | 0.99 (0.88, 1.10) | 1.09 (1.00, 1.18) | 1.02 (0.94, 1.10) | 0.96 (0.86, 1.08) |
| Language preference | 0.54 (0.35, 0.83)+ | 0.43 (0.28, 0.64)# | 1.04 (0.77, 1.40) | 0.60 (0.45, 0.79)# | 0.45 (0.30, 0.67)# |
| Length of residence in the United States | 1.02 (1.00, 1.04)* | 1.04 (1.02, 1.05)# | 1.02 (1.01, 1.03)# | 1.03 (1.01, 1.04)# | 1.02 (1.00, 1.03)* |
| Length of residence in the community | 0.99 (0.97, 1.01) | 0.99 (0.97, 1.00) | 1.00 (0.98, 1.01) | 1.00 (0.98, 1.01) | 1.00 (0.98, 1.02) |
| Medical comorbidities | 1.31 (1.19, 1.45)# | 1.25 (1.13, 1.37)# | 1.21 (1.13, 1.30)# | 1.23 (1.15, 1.31)# | 1.24 (1.12, 1.37)# |
| Social support from spouse | 1.04 (0.95, 1.13) | 0.98 (0.90, 1.06) | 1.12 (1.04, 1.20)+ | 0.97 (0.91, 1.03) | 1.00 (0.91, 1.09) |
| Age | 0.94 (0.92, 0.95)# | 0.92 (0.91, 0.94)# | 0.99 (0.98, 1.01) | 0.99 (0.98, 1.00) | 1.02 (1.00, 1.04)* |
| Gender | — | — | 0.95 (0.79, 1.15) | 1.01 (0.84, 1.21) | — |
| Education | 1.07 (1.04, 1.10)# | 1.08 (1.05, 1.11)# | 1.01 (0.99, 1.03) | 1.06 (1.03, 1.08)# | 1.03 (1.00, 1.07)* |
| Income | 1.22 (1.07, 1.39)+ | 1.12 (1.00, 1.25)* | 1.00 (0.93, 1.08) | 1.10 (1.02, 1.18)* | 1.06 (0.94, 1.18) |
| Living arrangement | 0.95 (0.90, 1.01) | 1.01 (0.95, 1.07) | 1.02 (0.97, 1.07) | 0.96 (0.91, 1.00) | 0.89 (0.81, 0.97)* |
| Marital status | 0.93 (0.73, 1.18) | 0.86 (0.68, 1.09) | 1.10 (0.89, 1.36) | 0.94 (0.77, 1.16) | 1.24 (0.80, 1.92) |
| Number of children | 1.02 (0.94, 1.10) | 0.98 (0.90, 1.06) | 1.08 (1.02, 1.15)* | 1.04 (0.98, 1.11) | 0.98 (0.88, 1.08) |
| Language preference | 0.54 (0.39, 0.75)# | 0.54 (0.40, 0.73)# | 1.15 (0.89, 1.49) | 0.63 (0.50, 0.80)# | 0.46 (0.32, 0.67)# |
| Length of residence in the United States | 1.03 (1.02, 1.04)# | 1.02 (1.01, 1.04)# | 1.02 (1.01, 1.03)# | 1.02 (1.01, 1.03)# | 1.01 (1.00, 1.03)* |
| Length of residence in the community | 0.99 (0.98, 1.00) | 0.99 (0.98, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.02) |
| Medical comorbidities | 1.26 (1.16, 1.35)# | 1.26 (1.17, 1.35)# | 1.19 (1.12, 1.26)# | 1.18 (1.11, 1.25)# | 1.24 (1.14, 1.36)# |
| Social support from family members | 1.15 (1.07, 1.25)# | 1.05 (0.97, 1.13) | 0.99 (0.93, 1.05) | 0.94 (0.88, 0.99)* | 1.00 (0.91, 1.10) |
| Age | 0.94 (0.92, 0.96)# | 0.93 (0.91, 0.95)# | 1.00 (0.98, 1.01) | 0.99 (0.98, 1.01) | 1.02 (0.99, 1.04) |
| Gender | — | — | 0.96 (0.79, 1.17) | 0.95 (0.78, 1.15) | — |
| Education | 1.06 (1.03, 1.09)# | 1.06 (1.03, 1.10)# | 1.01 (0.99, 1.04) | 1.05 (1.02, 1.07)# | 1.04 (1.00, 1.08) |
| Income | 1.24 (1.07, 1.42)+ | 1.12 (1.00, 1.26)* | 1.01 (0.93, 1.09) | 1.10 (1.02, 1.19)* | 1.02 (0.90, 1.14) |
| Living arrangement | 0.96 (0.90, 1.03) | 1.01 (0.95, 1.08) | 1.04 (0.99, 1.09) | 0.95 (0.90, 1.00) | 0.92 (0.84, 1.01) |
| Marital status | 0.87 (0.67, 1.12) | 0.89 (0.69, 1.14) | 1.07 (0.85, 1.34) | 0.96 (0.77, 1.20) | 1.21 (0.75, 1.96) |
| Number of children | 1.04 (0.95, 1.13) | 0.99 (0.91, 1.08) | 1.10 (1.03, 1.17)+ | 1.01 (0.95, 1.08) | 0.94 (0.84, 1.06) |
| Language preference | 0.56 (0.40, 0.80)# | 0.59 (0.43, 0.82)+ | 1.09 (0.83, 1.43) | 0.58 (0.45, 0.75)# | 0.48 (0.32, 0.72)# |
| Length of residence in the United States | 1.03 (1.02, 1.04)# | 1.02 (1.01, 1.04)# | 1.02 (1.01, 1.03)# | 1.03 (1.02, 1.04)# | 1.02 (1.00, 1.03)* |
| Length of residence in the community | 0.99 (0.98, 1.00) | 0.99 (0.98, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.01) | 1.00 (0.99, 1.02) |
| Medical comorbidities | 1.26 (1.16, 1.37)# | 1.27 (1.17, 1.38)# | 1.20 (1.13, 1.28)# | 1.17 (1.10, 1.24)# | 1.27 (1.15, 1.41)# |
| Social support from friends | 1.14 (1.06, 1.23)# | 1.18 (1.10, 1.28)# | 0.94 (0.88, 1.00)* | 0.97 (0.91, 1.03) | 1.03 (0.94, 1.14) |
Note: Model adjusted age, gender, education, income, living arrangement, marital status, member of children, language preference, length of residence in the United States, length of residence in the community, and medical comorbidities. CI = confidence interval; PSA = prostate-specific antigen test.
*p < 0.05, +p < 0.01, #p < 0.001.
Discussion
Our results showed that perceived higher overall social support and social support from non-spouse family members other than spouse and friends were associated with higher breast cancer screening, and cervical cancer screening utilization in multivariate analysis. Higher social support from spouse were associated higher utilization of colon cancer screening, but higher social support from non-spouse family members and friends were associated with lower utilization of colon cancer screening. Furthermore, social support was not significantly associated with PSA test.
Our study found social support was significantly associated with cancer screening among Chinese older women in America. Interestingly, perceived social support from family members or friends, instead of spouse, had stronger relation with utilization of breast cancer screening and cervical cancer screening. To compare with other population in the United States, our result is consistent with prior result from Longitudinal Study on Aging II include 4,419 participant age from 70 to 85 years (27). By looking at cultural factors, compared to spouse or partner, Chinese women may be more willing to receive positive social support from their family members and friends who might provide more support on female-related health issue. A longitudinal study of 439 married older adults suggested that women drew more emotional support from their friends and family members instead of their spouse, while men reported more emotional support from their spouse (28). Another possible reason is the gender differences within social roles and social interaction among U.S. Chinese older men and women. In traditional Chinese culture value, the network support of men and female may differ in function, that men provide more financial assistance, while women provide more instrumental support and emotional support. Due to in-adaptation of new culture and lake of language competence, male older adults may lose their ability to provide financial support which they had in their home country, so female older adults are more likely turn to their relatives, children or friends in the United States for emotional and instrumental support (29).
There is still limited understanding regards the results that greater level of social support from family members or friends were associated with less utilization of colon cancer screening. Our finding is contrary to prior clinical trial conducted among older African American, that older adults were less likely to discuss colon cancer screening with their spouse or partner, but higher chance having such discussion with their family members or friends (30). There are several reasons for inconsistent findings across studies concerning the relationship between social support and colon cancer screening. Differences in study population might be part of the reason for discrepant finding. As mentioned before, previous studies have focused solely on either female or male, white or black population, or other minority population (18,30). Negative description of uncomfortable feeling of invasive cancer screening from family members and friends might also impede some cancer screening behaviors. Lack of awareness of the importance and misunderstanding of colon cancer screening might also prevent them from sharing their experience with their older adult friends (31,32). Advice and recommendation of using of cancer screening by their close family members might be considered as too much demands for older adults, since Chinese older adults prefer not to take medical services if they think it is unnecessary, more studies regarding the association between social strain and health behavior are needed in future. Moreover, other factors of social environment, such as social norms and culture value regarding the efficacy of screening practices as well as the recommendation and social support from health care providers, may also play an important role for colon cancer screening behaviors.
Interestingly, our results showed there is no relationship between social support and prostate cancer screening among U.S. Chinese older men. This result is consistent with previous study conducted among African American and white men in the United States (33). One potential reason might be that Chinese older males are more reluctant to talk about private health issue to other people even with their spouse due to the Chinese saving-face cultural value. In our previous study, compared to female, Chinese older men are more likely to report lower level of positive social support and higher level of social strain (19). Meanwhile, although recommended by the American Cancer Society, prostate cancer screening is not recommended by the USPSTF due to lack of evidence (7,34). Besides cultural factors, the uncertainty and controversial opinions regarding the recommendation of prostate cancer screening might also contribute to the null significant result that physicians might be less likely to encourage male patients to undergo prostate cancer screening.
The results of this study should also be treated with caution because of some limitations. First, due to the cross-sectional study design, we cannot determine a causal relationship between social support and cancer screening. Second, although the Chinese aging population is representative among great Chicago area, this result should not be extrapolated to other geographic areas. Third, the information of physician’s recommendation about cancer screening were not collected which may be associated with cancer screening utilization. Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer screening and socioeconomic and sociodemographic factors, such as gender and education, are related to perceived and adherence of physician recommendation (35). In addition, the relationship between social strain and cancer screening behavior are not fully understood in present study, further studies are needed.
Despite the limitations, this study had important theoretical and practice implications. First, to our knowledge, this study is the largest study that examined the association between different types of social support and different cancer screening utilization. Most prior studies examined the association between few cancer screenings and social support, or only one subtype of social support (22,36–38). Besides, taking cultural factors into consideration, including language preference and years in the United States, will help improve the comparability of Chinese older adults in the United States and other populations. In addition, guided by the CBPR principles, this research was designed to increase its community engagement. By conducting in-person interviews using their preferred language, Chinese older adults were more likely to share their information even regarding social strain.
The evidence of potential intervention based on social support to increase cancer screening is still emerging. First, the utilization of a community-based participatory approach may strengthen all potential interventions in the future (39). One option is that encouraging cancer screening through social support includes education programs and peer support provided by community center. Then, given the significant role of family support, future programs and interventions targeting Chinese older adults should focus more on the unique cultural values, such as filial piety value of their children (40). Education programs which integrate the education for both older adults and adult children can help all realize the importance of cancer screening and encourage adult children to take their aging parents to undergo cancer screenings. Another promising way to increase social support includes the use of community health workers (CHWs). CHWs could provide additional social support to Chinese older adults who may not able to receive enough social support from other sources; or help them build the link between Chinese older adults and their children or spouse.
Conclusion
Our study found greater social support from different sources were associated with greater utilization of breast and cervical cancer screenings among U.S. Chinese older adults in Chicago area. However, higher social support from family members and friends were also related to lower utilization of colon cancer screenings. Social support was not significantly associated with utilization of prostate cancer screening. These results raise questions that in which way other factors, such as cultural factors, social norms, and social strain, will influence utilization of cancer screening besides social support. Further longitudinal studies are needed to better understand the temporal relationship between social support and cancer screening.
Funding
This work was supported by the National Institute on Aging (R01 AG042318, R01 CA163830, R01 MD006173, R34MH100393, R34MH100443, and RC4 AG039085).
Reference
- 1. American Cancer Society. American Cancer Society: Cancer Facts and Figures 2016 2016. http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf Accessed September 26, 2016.
- 2. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008; 58:71–96. doi:10.3322/CA.2007.0010 [DOI] [PubMed] [Google Scholar]
- 3. Hakama M, Miller AB, Day NE e. Screening for cancer of the uterine cervix. From the IARC Working Group on Cervical Cancer Screening and the UICC Project Group on the Evaluation of Screening Programmes for Cancer. IARC Sci Publ. 1986; 76:1–315. [PubMed] [Google Scholar]
- 4.Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016; 315:2564–2575. doi:10.1001/jama.2016.5989 [DOI] [PubMed] [Google Scholar]
- 5. Siu AL; U.S. Preventive Services Task Force Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016; 164:279–296. doi:10.7326/M15-2886 [DOI] [PubMed] [Google Scholar]
- 6. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. ; US Preventive Services Task Force Screening for colorectal cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016; 315:2564–2575. doi:10.1001/jama.2016.5989 [DOI] [PubMed] [Google Scholar]
- 7. Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects. CA Cancer J Clin. 2007; 57:90–104. doi:10.3322/canjclin.57.2.90 [DOI] [PubMed] [Google Scholar]
- 8. Office of Disease Prevention and Health Promotion. Healthy People 2020 Topics and Objectives: Cancer 2011; https://www.healthypeople.gov/2020/topics-objectives/topic/cancer/objectives?topicId=5 Accessed September 26, 2016.
- 9. 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:10.1016/j.amepre.2005.08.006 [DOI] [PubMed] [Google Scholar]
- 10. Centers for Disease Control and Prevention. Cancer screening—United States, 2010. MMWR. 2012; 61:41–45.22278157 [Google Scholar]
- 11. Simon MA, Li Y, Dong X. Preventive care service usage among Chinese older adults in the Greater Chicago area. J Gerontol A Biol Sci Med Sci. 2014;69(suppl 2):S7–S14. doi:10.1093/gerona/glu143 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Vacek PM, Skelly JM. A prospective study of the use and effects of screening mammography in women aged 70 and older. J Am Geriatr Soc. 2015; 63:1–7. doi:10.1111/jgs.13184 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Ward E, Halpern M, Schrag N, et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin. 2008; 58:9–31. doi:10.3322/CA.2007.0011 [DOI] [PubMed] [Google Scholar]
- 14. Miranda-Diaz C, Betancourt E, Ruiz-Candelaria Y, Hunter-Mellado RF. Barriers for compliance to breast, colorectal, and cervical screening cancer tests among Hispanic patients. Int J Environ Res Public Health. 2016; 13:ijerph13010021. doi:10.3390/ijerph13010021 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000; 51:843–857. doi:10.1016/s0277-9536(00)00065-4 [DOI] [PubMed] [Google Scholar]
- 16. Seeman TE. Social ties and health: the benefits of social integration. Ann Epidemiol. 1996;6:442–451. doi: 10.1016/S1047-2797(96)00095-6 [DOI] [PubMed] [Google Scholar]
- 17. Rogers CR, Mitchell JA, Franta GJ, Foster MJ, Shires D. Masculinity, racism, social support, and colorectal cancer screening uptake among African American men: a systematic review. Am J Mens Health. 2015; 1:1–5. doi:10.1177/1557988315611227 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Mouttapa M, Tanjasiri SP, Weiss JW, et al. Associations between women’s perception of their husbands’/partners’ social support and Pap screening in Pacific Islander communities. Asia Pac J Public Health. 2016; 28:61–71. doi:10.1177/1010539515613412 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Chen R, Simon MA, Chang ES, Zhen Y, Dong X. The perception of social support among U.S. Chinese older adults: findings from the PINE Study. J Aging Health. 2014; 26:1137–1154. doi:10.1177/0898264314529332 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Seow A, Huang J, Straughan PT. Effects of social support, regular physician and health-related attitudes on cervical cancer screening in an Asian population. Cancer Causes Control. 2000; 11:223–230. doi:10.1023/A:1008954606992 [DOI] [PubMed] [Google Scholar]
- 21. Yu ES, Kim KK, Chen EH, Brintnall RA. Breast and cervical cancer screening among Chinese American women. Cancer Pract. 2001; 9:81–91. doi:10.1046/j.1523-5394.2001.009002081.x [DOI] [PubMed] [Google Scholar]
- 22. Cornman JC, Goldman N, Glei DA, Weinstein M, Chang MC. Social ties and perceived support: two dimensions of social relationships and health among the elderly in Taiwan. J Aging Health. 2003; 15:616–644. doi:10.1177/0898264303256215 [DOI] [PubMed] [Google Scholar]
- 23. Dong X, Wong E, Simon MA. Study design and implementation of the PINE study. J Aging Health. 2014; 26:1085–1099. doi:10.1177/0898264314526620 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Simon MA, Chang ES, Rajan KB, Welch MJ, Dong X. Demographic characteristics of U.S. Chinese older adults in the Greater Chicago area: assessing the representativeness of the PINE study. J Aging Health. 2014; 26:1100–1115. doi:10.1177/0898264314543472 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Smith S, Jaszczak A, Graber J, et al. Instrument development, study design implementation, and survey conduct for the national social life, health, and aging project. J Gerontol B Psychol Sci Soc Sci. 2009; 64(suppl 1):i20–i29. doi:10.1093/geronb/gbn013 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Cornwell EY, Waite LJ. Measuring social isolation among older adults using multiple indicators from the NSHAP study. J Gerontol B Psychol Sci Soc Sci. 2009; 64(suppl 1):i38–i46. doi:10.1093/geronb/gbp037 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. McFall SL, Davila M. Gender, social ties, and cancer screening among elderly persons. J Aging Health. 2008; 20:997–1011. doi:10.1177/0898264308324682 [DOI] [PubMed] [Google Scholar]
- 28. Gurung RA, Taylor SE, Seeman TE. Accounting for changes in social support among married older adults: insights from the MacArthur Studies of Successful Aging. Psychol Aging. 2003; 18:487–496. doi:10.1037/0882-7974.18.3.487 [DOI] [PubMed] [Google Scholar]
- 29. Simon MA, Chen R, Dong X. Gender differences in perceived social support in U.S. Chinese older adults. J Gerontol Geriatr Res. 2014; 3:4. doi:10.4172/2167-7182.1000163 [Google Scholar]
- 30. Christy SM, Perkins SM, Tong Y, et al. Promoting colorectal cancer screening discussion: a randomized controlled trial. Am J Prev Med. 2013; 44:325–329. doi:10.1016/j.amepre.2012.11.032 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Ma GX, Wang MQ, Toubbeh J, Tan Y, Shive S, Wu D. Factors associated with colorectal cancer screening among Cambodians, Vietnamese, Koreans and Chinese living in the United States. N Am J Med Sci (Boston). 2012; 5:1–8. doi:10.7156/v5i1p001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Wang JH, Liang W, Chen MY, et al. The influence of culture and cancer worry on colon cancer screening among older Chinese-American women. Ethn Dis. 2006; 16:404–411. [PMC free article] [PubMed] [Google Scholar]
- 33. Dickey SL, Cormier EM, Whyte J, 4th, Graven L, Ralston PA. Demographic, social support, and community differences in predictors of African-American and white men receiving prostate cancer screening in the United States. Public Health Nurs. 2016; 33:483–492. doi:10.1111/phn.12245 [DOI] [PubMed] [Google Scholar]
- 34. Moyer VA; U.S. Preventive Services Task Force Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012; 157:120–134. doi:10.7326/0003-4819-157-2-201207170-00459 [DOI] [PubMed] [Google Scholar]
- 35. Hudson SV, Ferrante JM, Ohman-Strickland P, et al. Physician recommendation and patient adherence for colorectal cancer screening. J Am Board Fam Med. 2012; 25:782–791. doi:10.3122/jabfm.2012.06.110254 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Documet P, Bear TM, Flatt JD, Macia L, Trauth J, Ricci EM. The association of social support and education with breast and cervical cancer screening. Health Educ Behav. 2015; 42:55–64. doi:10.1177/1090198114557124 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Gamarra CJ, Paz EP, Griep RH. Social support and cervical and breast cancer screening in Argentinean women from a rural population. Public Health Nurs. 2009; 26:269–276. doi:10.1111/j.1525-1446.2009.00779.x [DOI] [PubMed] [Google Scholar]
- 38. Kinney AY, Bloor LE, Martin C, Sandler RS. Social ties and colorectal cancer screening among blacks and whites in North Carolina. Cancer Epidemiol Biomarkers Prev. 2005;14:182–189. [PubMed] [Google Scholar]
- 39. Shirazi M, Shirazi A, Bloom J. Developing a culturally competent faith-based framework to promote breast cancer screening among Afghan immigrant women. J Relig Health. 2015; 54:153–159. doi:10.1007/s10943-013-9793-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Dong X, Chang E-S, Wong E, Simon MA. A qualitative study of filial piety among community dwelling, Chinese, older adults: changing meaning and impact on health and well-being. J Intergener Relatsh. 2012; 10:131–146. doi:10.1080/15350770.2012.673393 [Google Scholar]