Abstract
Background
Non-adherence to colorectal cancer (CRC) screening among Asian Americans is high but not well understood. This study examined correlates of screening intention among Filipino, Hmong and Korean Americans who were non-adherent to CRC screening.
Methods
Using cross-sectional, pre-intervention survey data from 504 Asian Americans (115 Filipinos, 185 Hmong, and 204 Koreans) aged 50 to 75 who were enrolled in a multi-site cluster randomized controlled trial of lay health educator intervention, we analyzed correlates of self-reported CRC screening non-adherence, defined as not being up-to-date for fecal occult blood test, sigmoidoscopy, or colonoscopy.
Results
Only 26.8% indicated intention to obtain screening within 6 months (Hmong: 12.4%; Korean: 30.8%; and Filipino: 42.6%; p<0.001). One third ever had prior screening, and a majority did not know screening is a CRC prevention method (61.3%) or any CRC screening guidelines (53.4%). Multivariable analyses showed that patient-provider ethnicity concordance, provider’s recommendation of screening, participants’ prior CRC screening, perceived severity and susceptibility of CRC, and guideline knowledge were positively associated with screening intention. Specifically, knowing one or more screening guidelines doubled the odds of screening intention (AOR = 2.38; 95% CI: 1.32–4.28). Hmong were less likely to have screening intention than Filipinos, which was unexplained by sociodemographics, healthcare factors, perceived needs for CRC screening or knowledge of screening guidelines.
Conclusion
CRC screening intention among non-adherent Filipino, Hmong, and Korean Americans was low. Targeting knowledge of CRC screening guidelines and perceived needs with providers may be effective strategies for increasing CRC screening intention among non-adherent Asian Americans.
Keywords: Asian Americans, cancer screening, colorectal cancer, health knowledge, intention
INTRODUCTION
Early detection of colorectal cancer (CRC) reduces CRC-related mortality.1 The United States Preventive Services Task Force (USPSTF)2 recommends CRC screening for adults aged 50 to 75 years. Recommended screening guidelines include annual fecal occult blood test (FOBT), sigmoidoscopy every 5 years, or colonoscopy every 10 years.2 In 2015, despite improvements in CRC screening adherence in the U.S. general population,3 Asian Americans, the fastest-growing racial group in the U.S.,4 reported lower CRC screening adherence (49.5%) compared to non-Hispanic Whites (65.4%) or African Americans (61.8%).5 From 2003 to 2011, a significant decline in CRC mortality among non-Hispanic Whites was observed without a corresponding decline among Asian Americans.6 Efforts to promote CRC screening among vulnerable groups with low adherence to CRC screening, including Asian American immigrants with limited English proficiency,3,7 and those with lower income or limited healthcare resources3 are urgently needed.
To direct intervention efforts effectively, it is critical to understand factors associated with CRC screening non-adherence, particularly factors that are modifiable. This study examined CRC screening intention and its correlates among a diverse group of Filipino, Hmong and Korean American adults who reported being non-adherent to CRC screening. Specifically, we postulated that knowledge about CRC screening, measured by knowing that screening is a CRC prevention method and knowing the screening guidelines, are associated with screening intention.
MATERIALS AND METHODS
This study used cross-sectional, pre-intervention data from a multi-site cluster randomized controlled trial (RCT) testing a lay health educator (LHE) intervention promoting CRC screening among Asian Americans (ClinicalTrials.gov registration: NCT01904890). Participant eligibility criteria were: age 50 to 75; self-identification as Filipino (in Hawai‘i), Hmong (in Sacramento, CA) or Korean (in Los Angeles, CA); speaking English, Philippine languages (Ilokano and Tagalog), Hmong or Korean; and having no history of CRC. Study participants were recruited by 82 LHEs from their social networks. Details of participant recruitment were reported elsewhere.8,9 Between August 2012 and January 2015, pre-intervention data were collected from eligible participants who received $20 for completing a survey in their preferred language.
Survey instruments in Philippine languages, Hmong and Korean were pre-tested with key informants from the targeted communities.8,9 Surveys were self-administered among Filipinos and Koreans; for Hmong, project staff verbally administered surveys due to the low written literacy in both English and Hmong languages. Because the present study focused on participants who reported CRC screening non-adherence, defined as not being up-to-date for FOBT within past year, sigmoidoscopy within past 5 years, or colonoscopy within past 10 years, the study sample consisted of 504 participants (51.3% of 981 total RCT participants) with 115 Filipinos, 185 Hmong, and 204 Koreans. The Institutional Review Boards of the University of California San Francisco and University of Hawai`i at Manoa approved all study procedures.
Conceptual Framework
We integrated constructs from the Theory of Planned Behavior,10 Health Belief Model (HBM)11 and Andersen’s Behavioral Model of Health Services Use (BMHSU).12 These models have been applied to CRC and other cancer screening research.13 Intention, an immediate antecedent to health behaviors,10 is an important determinant of screening behaviors.13 We examined four domains of correlates for screening intention: 1) sociodemographics; 2) healthcare factors; 3) perceived needs for CRC screening adapted from both HBM (perceived susceptibility and severity of CRC) and BMHSU (general health status and awareness of CRC); and 4) knowledge of CRC screening.
Measures
Survey items were adapted from the California Health Interview Survey, a statewide population health survey.14 Screening intention was assessed by providing a description of each CRC screening test (FOBT, sigmoidoscopy or colonoscopy) and then asking participants their intention to get each type of screening test in the next 6 months.14,15 Sociodemographic variables assessed included: Asian ethnicity, age, sex, birthplace, marital status, education, employment, self-reported household income, years lived in the U.S., and spoken English proficiency. Healthcare factors examined included: health insurance coverage, regular place of healthcare, whether their primary care doctor was Asian, whether they saw a doctor in the past year, medical interpreter use, whether doctor had ever recommended CRC screening, and ever been screened for CRC. Perceived needs for CRC screening included: self-rated health, self-reported chronic health conditions, family history of CRC, ever heard of CRC, and if participants reported being worried about getting CRC (perceived severity) or perceived having a high chance of getting CRC (perceived susceptibility). Both perceived susceptibility and severity were relevant factors for CRC screening adherence.16,17 Knowledge of CRC screening included: answering correctly that “getting medical tests to find blood or polyps in the colon can prevent colon cancer,” and a numeric score (0 to 4) for correct response to screening guidelines (screening age starting at 50, and recommended testing intervals for FOBT, sigmoidoscopy, and colonoscopy).
Statistical Analysis
Descriptive statistics were computed for all measures. We conducted bivariate and multivariable analyses of the binary outcome: CRC screening intention in the next 6 months (yes versus no). Generalized linear mixed effects models (GLMM) were used to account for clustering of participants by LHE in bivariate and multivariable models. Correlates that attained p-values <0.10 in bivariate analyses were included as covariates in the multivariable regression analyses. Age, sex, English proficiency, and prior screening were included as a priori covariates. Because of the collinearity observed between having seen a physician within the past year and prior screening, we excluded the variable for physician visit.
To identify factors associated with screening intention, grouped as domains in the order of modifiability potential, we constructed three additive multivariable models. Model 1 tested the associations with sociodemographic and healthcare factors, which included characteristics that were least modifiable. Model 2 added to Model 1 the perceived needs of screening factors, which were considered potentially modifiable. Model 3 added to Model 2 the knowledge factors, which were assumed to be most modifiable. Because of the bimodal distribution of the screening guideline knowledge score (53.4% scored at “0”, 31.8% scored “1” and 0.2% scored “4”), screening guideline knowledge was dichotomized to “1+” (one or more correct responses) versus “0” (none correct). Statistical significance was assessed at the 0.05 level (2-sided). Statistical analyses were performed using SAS version 9.3.
RESULTS
Sociodemographics, Healthcare Factors, and Perceived Needs of CRC Screening
The study sample (n=504) included 79.4% females with a mean age of 60.6 (SD = 7.3). All but 3 Filipino participants were immigrants. Table 1 presents characteristics by each Asian group. A majority had healthcare access and utilization within the past year. Hmong participants had the highest rate of prior CRC screening (50.3%) and Koreans had the lowest rate (17.2%). Over half of the Filipino and Hmong participants and one third of the Korean participants reported being worried about getting CRC. Few (12.1%) reported perceiving a high chance of getting CRC, which was similar across the 3 groups.
Table 1.
Sociodemographics, Healthcare Factors, Perceived Needs, and Knowledge among Asian Americans Reporting Colorectal Cancer (CRC) Screening Non-Adherence (n = 504)
| Filipino (n = 115) |
Hmong (n =185) |
Korean (n = 204) |
Entire Sample (n = 504) |
p- value |
|
|---|---|---|---|---|---|
| % (n) | % (n) | % (n) | % (n) | ||
|
| |||||
| Sociodemographics and Acculturation | |||||
|
| |||||
| Age (years) | |||||
| 50–64 | 60.9 (70) | 70.8 (131) | 71.1 (145) | 68.7 (346) | 0.43 |
| 65–75 | 39.1 (45) | 29.2 (54) | 28.9 (59) | 31.3 (158) | |
|
| |||||
| Female | 79.1 (91) | 75.1 (139) | 83.3 (170) | 79.4 (400) | 0.19 |
|
| |||||
| Married | 57.4 (66) | 64.3 (119) | 72.1 (147) | 65.9 (332) | 0.11 |
|
| |||||
| Born in U.S. | 2.6 (3) | 0.0 (0) | 0.0 (0) | 0.6 (3) | 0.59 |
|
| |||||
| Years lived in U.S. | |||||
| ≤ 10 years | 20.9 (24) | 18.4 (34) | 9.3 (19) | 15.3 (77) | 0.06 |
| >10 years1 | 79.1 (91) | 81.6 (151) | 90.7 (185) | 84.7 (427) | |
|
| |||||
| Education | |||||
| < High school graduate | 27.4 (31) | 95.6 (172) | 12.8 (26) | 46.1 (229) | |
| High school graduate | 20.4 (23) | 2.8 (5) | 26.5 (54) | 16.5 (82) | <0.001 |
| Some college / tech school | 27.4 (31) | 0.5 (1) | 20.6 (42) | 14.9 (74) | |
| College graduate | 24.8 (28) | 1.1 (2) | 40.2 (82) | 22.5 (112) | |
| Missing | n = 2 | n = 5 | n = 0 | n = 7 | |
|
| |||||
| Employment status | |||||
| Unemployed/ Student/ Homemaker/ Others | 11.3 (13) | 62.2 (115) | 35.8 (73) | 39.9 (201) | <0.001 |
| Employed | 61.7 (71) | 10.3 (19) | 43.6 (89) | 35.5 (179) | |
| Retired | 27.0 (31) | 27.6 (51) | 20.6 (42) | 24.6 (124) | |
|
| |||||
| Annual household income | |||||
| < $20,000 | 28.7 (33) | 55.7 (103) | 32.8 (67) | 40.3 (203) | <0.001 |
| $20,000 or more | 50.4 (58) | 3.2 (6) | 55.9 (114) | 35.3 (178) | |
| Don’t know/refused | 20.9 (24) | 41.1 (76) | 11.3 (23) | 24.4 (123) | |
|
| |||||
| Speaks English | |||||
| So-so, poorly/ not at all | 28.7 (33) | 95.7 (177) | 93.1 (190) | 79.4 (400) | <0.01 |
| Fluently/ well | 71.3 (82) | 4.3 (8) | 6.9 (14) | 20.6 (104) | |
|
| |||||
| Healthcare Factors | |||||
|
| |||||
| Has health insurance | 87.8 (101) | 92.9 (171) | 61.0 (122) | 79.0 (394) | <0.001 |
|
| |||||
| Has regular place for healthcare | 88.7 (102) | 91.9 (170) | 50.5 (103) | 74.4 (375) | <0.001 |
|
| |||||
| Saw doctor in past 12 months | 86.1 (99) | 76.7 (142) | 62.8 (128) | 73.2 (369) | <0.001 |
|
| |||||
| Medical interpreter use | |||||
| Sometimes, often/ always | 7.0 (8) | 65.3 (117) | 37.9 (77) | 40.4 (202) | <0.001 |
| Never/rarely | 93.0 (107) | 35.7 (65) | 62.1 (126) | 59.6 (298) | |
| Missing | n = 0 | n = 3 | n = 1 | n = 4 | |
|
| |||||
| Healthcare provider ethnicity | |||||
| Asian | 61.7 (71) | 38.4 (71) | 59.8 (122) | 52.4 (264) | 0.03 |
| Non-Asian | 27.0 (31) | 48.1 (89) | 2.9 (6) | 25.0 (126) | |
| No primary care provider | 11.3 (13) | 13.5 (25) | 37.3 (76) | 22.6 (114) | |
|
| |||||
| Doctor recommended CRC screening | 21.2 (24) | 8.6 (15) | 6.34 (13) | 10.6 (52) | 0.02 |
|
| |||||
| Ever been screened for CRC | 36.5 (42) | 50.3 (93) | 17.2 (35) | 33.7 (170) | <0.001 |
|
| |||||
| Perceived Needs for CRC Screening | |||||
|
| |||||
| Self-rated health status | |||||
| Excellent, very good/good | 84.8 (95) | 52.8 (94) | 52.2 (105) | 59.9 (294) | <0.001 |
| Fair/poor | 15.2 (17) | 47.2 (84) | 47.8 (96) | 40.1 (197) | |
| Missing | n = 3 | n = 7 | n = 3 | n = 13 | |
|
| |||||
| Has chronic health conditions2 | |||||
| None | 33.0 (38) | 31.4 (58) | 38.7 (79) | 34.7 (175) | 0.21 |
| 1 condition | 33.0 (38) | 30.8 (57) | 34.3 (70) | 32.7 (165) | |
| 2 or more conditions | 33.9 (39) | 37.8 (70) | 27.0 (55) | 32.5 (164) | |
|
| |||||
| Ever heard of CRC | 70.4 (81) | 41.6 (77) | 75.5 (154) | 61.9 (312) | <0.001 |
|
| |||||
| Has family history of CRC | 1.7 (2) | 1.1 (2) | 8.8 (18) | 4.4 (22) | <0.001 |
|
| |||||
| Worried about getting CRC | 63.2 (72) | 60.5(112) | 33.3 (68) | 50.1 (252) | <0.001 |
|
| |||||
| Perceived high chance of getting CRC | 16.5 (19) | 12.4 (23) | 9.3 (19) | 12.1 (61) | 0.16 |
|
| |||||
| Knowledge: Screening as a CRC Prevention Method | |||||
|
| |||||
| Getting medical tests to find blood or polyps in the colon can prevent colon cancer | 67.8 (78) | 7.0 (13) | 51.0 (104) | 38.7 (195) | <0.001 |
|
| |||||
| Knowledge: CRC Screening Guidelines | |||||
|
| |||||
| Guideline 1: Start screening age 50 | 45.2 (52) | 10.3 (19) | 34.8 (71) | 28.2 (142) | <0.001 |
|
| |||||
| Guideline 2: FOBT testing every year | 22.6 (26) | 8.7 (16) | 24.0 (49) | 18.1 (91) | <0.001 |
|
| |||||
| Guideline 3: Sigmoidoscopy every 5 years | 9.6 (11) | 1.6 (3) | 25.5 (52) | 5.2 (66) | <0.001 |
|
| |||||
| Guideline 4: Colonoscopy every 10 years | 13.0 (15) | 0.0 (0) | 5.4 (11) | 5.2 (26) | <0.001 |
|
| |||||
| Total correct, out of the 4 CRC screening guideline questions | |||||
| 0 | 38.3 (44) | 83.2 (154) | 34.8 (71) | 53.4 (269) | <0.001 |
| 1 or more | 61.7 (71) | 16.8 (31) | 65.2 (133) | 46.6 (235) | |
Note: Unless otherwise indicated, missing observations were excluded from percentage computation. Percentages may not add up to be 100.0% due to rounding. P-values accounted for clustering of participants by lay health educators.
years in the U.S. for >10 years includes the 3 Filipino participants who were born in the U.S.
chronic health conditions include self-reported high blood pressure, high cholesterol, diabetes, or cancer
Knowledge of CRC Screening and Guidelines
Table 1 shows that only 38.7% of participants knew CRC screening is a CRC prevention method, ranging from 7% among Hmong to 67.8% among Filipinos. Knowledge of screening guidelines was low across all groups, with only 28.2% knowing that screening started at age 50 and 18.1% knowing that FOBT was recommended annually. Very few (5.2%) knew the screening interval recommendations for sigmoidoscopy or colonoscopy. Half (53.4%) of participants knew none of these guidelines.
CRC Screening Intention
Only 26.8% reported screening intention within 6 months. Screening intention in descending order by group were Filipinos (42.6%), Koreans, (30.8%), and Hmong (12.4%). Table 2 shows screening intention by sample characteristics.
Table 2.
Colorectal Cancer (CRC) Screening Intention by Sociodemographics, Healthcare Factors, Perceived Needs and Knowledge among Asian Americans Reporting CRC Screening Non-Adherence (n = 504)
| CRC Screening Intention within 6 months (n = 135) |
No Intention (n = 369) |
p-value | |
|---|---|---|---|
| % (n) | % (n) | ||
|
| |||
| Sociodemographics and Acculturation | |||
|
| |||
| Ethnicity | |||
| Filipino | 42.6 (49) | 57.4 (66) | <0.001 |
| Hmong | 12.4 (23) | 87.6 (162) | |
| Korean | 30.8 (63) | 69.1 (141) | |
|
| |||
| Age (years) | |||
| 50–64 | 27.5 (95) | 72.5 (251) | 0.64 |
| 65–75 | 25.3 (40) | 74.7 (118) | |
|
| |||
| Sex | |||
| Female | 83.3 (170) | 79.4 (400) | 0.33 |
| Male | |||
|
| |||
| Marital status | |||
| Married | 29.5 (98) | 70.5 (234) | 0.07 |
| Not married | 21.5 (37) | 78.5 (135) | |
|
| |||
| Years lived in U.S. | |||
| ≤ 10 years | 28.6 (22) | 71.4 (55) | 0.70 |
| >10 years1 | 26.5 (113) | 73.5 (314) | |
|
| |||
| Education | |||
| < High school graduate | 18.3 (42) | 81.7 (187) | |
| High school graduate | 36.6 (30) | 63.4 (52) | 0.01 |
| Some college / tech school | 28.4 (21) | 71.6 (53) | |
| College graduate | 35.7 (40) | 64.3 (72) | |
| Missing | n = 0 | n = 7 | |
|
| |||
| Employment status | |||
| Unemployed | 20.4 (41) | 79.6 (160) | 0.01 |
| Employed | 35.2 (63) | 64.8 (116) | |
| Retired | 25.0 (31) | 75.0 (93) | |
|
| |||
| Annual household income | |||
| < $20,000 | 28.1 (57) | 71.9 (146) | <0.001 |
| $20,000 or more | 34.8 (62) | 65.2 (116) | |
| Don’t know/refused | 13.0 (16) | 87.0 (107) | |
|
| |||
| Speaks English | |||
| So-so/poorly/ not at all | 23.5 (94) | 76.5 (306) | <0.01 |
| Fluently/ well | 39.4 (41) | 60.6 (63) | |
|
| |||
| Healthcare Factors | |||
|
| |||
| Has health insurance | |||
| Yes | 27.2 (107) | 72.8 (287) | 0.93 |
| No | 26.7 (28) | 73.3 (77) | |
|
| |||
| Has regular place for healthcare | |||
| Yes | 28.0 (105) | 72.0 (270) | 0.29 |
| No | 23.3 (30) | 76.6 (99) | |
|
| |||
| Saw doctor in past 12 months | |||
| Yes | 29.3 (108) | 70.7 (261) | 0.04 |
| No | 20.0 (27) | 80.0 (108) | |
|
| |||
| Medical interpreter use | |||
| Sometimes, often/always | 20.8 (42) | 79.2 (160) | 0.03 |
| Never/rarely | 30.9 (92) | 69.1 (206) | |
| Missing | n = 1 | n = 3 | |
|
| |||
| Healthcare provider ethnicity | |||
| Asian | 32.2 (85) | 67.8 (179) | 0.03 |
| Non-Asian | 22.2 (28) | 77.8 (98) | |
| No primary care provider | 19.3 (22) | 80.7 (92) | |
|
| |||
| Doctor recommended CRC screening | |||
| Yes | 48.1 (25) | 51.9 (27) | <0.01 |
| No | 24.6(108) | 75.4 (331) | |
|
| |||
| Ever been screened for CRC | |||
| Yes | 31.8 (54) | 68.2 (116) | 0.10 |
| No | 24.3 (81) | 75.7 (253) | |
|
| |||
| Perceived Needs for CRC Screening | |||
|
| |||
| Self-rated health status | |||
| Excellent, very good/good | 27.6 (81) | 72.5 (213) | 0.59 |
| Fair/poor | 25.4 (50) | 74.6 (147) | |
| Missing | n = 4 | n = 9 | |
|
| |||
| Has chronic health conditions2 | |||
| None | 26.9 (47) | 73.1 (128) | 0.56 |
| 1 condition | 23.6 (39) | 76.4 (126) | |
| 2 or more conditions | 29.9 (49) | 70.1 (115) | |
|
| |||
| Ever heard of CRC | |||
| Yes | 30.1 (94) | 69.9 (218) | 0.04 |
| No | 21.4 (41) | 78.7 (151) | |
|
| |||
| Has family history of CRC | |||
| Yes | 31.8 (7) | 68.2 (15) | 0.59 |
| No | 26.6 (128) | 73.4 (354) | |
|
| |||
| Worried about getting CRC | |||
| Yes | 32.9 (83) | 67.1 (169) | <0.01 |
| No | 20.7 (52) | 79.3 (199) | |
|
| |||
| Perceived high chance of getting CRC | |||
| Yes | 50.8 (31) | 48.2 (30 | <0.01 |
| No | 23.5 (104) | 76.5 (339) | |
|
| |||
| Knowledge: Screening as a CRC Prevention Method | |||
|
| |||
| Getting medical tests to find blood or polyps in the colon can prevent colon cancer | |||
| Yes /Correct | 41.5 (81) | 58.5 (114) | <0.001 |
| No /Incorrect | 17.5 (54) | 82.5 (255) | |
|
| |||
| Knowledge: CRC Screening Guidelines | |||
|
| |||
| Total correct, out of the 4 CRC screening guideline questions | |||
| 0 | 15.2 (41) | 84.8 (228) | <0.001 |
| 1 or more | 40.0 (94) | 60.0 (141) | |
Note: Unless otherwise indicated, missing observations were excluded from percentage computation. Percentages, across each row, may not add up to be 100.0% due to rounding. P-values accounted for clustering of participants by lay health educators.
years in the U.S. for >10 years included the 3 Filipino participants who were born in the U.S.
chronic health conditions include self-reported high blood pressure, high cholesterol, diabetes, or cancer
Multivariable Regression Analyses for CRC Screening Intention
Table 3 shows the significant correlates (p<0.05) of screening intention in 3 additive multivariable regression models. Model 1, included socidemographics and healthcare factors, revealed that ethnicity, marital status, income, healthcare provider ethnicity and provider’s recommendation were significant correlates for screening intention. With perceived needs added (Model 2), marital status was no longer significant, perceived severity and susceptibility were additional significant correlates. Model 3, the final model, showed that knowing one or more screening guidelines doubled the odds of screening intention. In addition, having an Asian provider, prior screening, healthcare providers’ recommendation of CRC screening, being worried about getting CRC, and perceiving a high chance of having CRC were positively associated with screening intention. Individuals with undisclosed income were less likely to report screening intention. Hmong reported lower screening intention when compared to Filipinos, but Koreans were not different from Hmong or Filipinos.
Table 3.
Multivariable Regression Analyses of Colorectal Cancer (CRC) Screening Intention within 6 Months among Asian Americans Reporting CRC Screening Non-Adherence (n = 504)
| Model 1 | Model 2 (Model 1 + Perceived Needs) |
Model 3 (Model 2 + Knowledge) |
|
|---|---|---|---|
| AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | |
|
| |||
| Sociodemographics | |||
|
| |||
| Ethnicity (Ref: Hmong) | |||
| Filipino | 9.39 (2.88–30.52)a | 8.05 (2.45–26.47)a | 4.78 (1.43–16.06)b |
| Korean | 6.40 (1.84–22.21)a | 7.32 (1.98–26.99)a | 3.79 (0.84–17.11) |
|
| |||
| Married (Ref: Not Married) | 1.68 (1.01–2.80)d | 1.62 (0.94–2.79) | 1.55 (0.87–2.76) |
|
| |||
| Household income (Ref: < $20,000/year) | |||
| $20,000 or more | 0.61(0.34–1.08) | 0.57 (0.31–1.06) | 0.55 (0.29–1.04) |
| Don’t know/refused | 0.39 (0.20–0.77)a | 0.38 (0.19–0.79)a | 0.43 (0.21–0.91)c |
|
| |||
| Healthcare Factors | |||
|
| |||
| Healthcare provider ethnicity (Ref: No provider) | |||
| Asian | 2.44 (1.29–4.62)a | 2.25 (1.28–4.26)a | 2.44 (1.47–4.68)a |
| Non-Asian | 1.48 (0.61–3.58) | 1.31 (0.55–3.11) | 1.28 (0.52–3.16) |
|
| |||
| Doctor recommended CRC screening (Ref: No) | 2.42 (1.32–4.43)a | 2.25 (1.18–4.28)b | 2.04 (1.03–4.04)d |
|
| |||
| Ever been screened for CRC (Ref: never been screened) | 1.81 (1.11–2.94)a | 1.64 (0.99–2.71) | 1.65 (1.01–2.70)d |
|
| |||
| Perceived Needs for CRC Screening | |||
|
| |||
| Ever heard of CRC (Ref: never heard) | NA | 1.08 (0.64–1.83) | 0.96 (0.55–1.69) |
|
| |||
| Worried about getting CRC (Ref: No) | NA | 2.07 (1.22–3.52)a | 1.84 (1.05–3.24)c |
|
| |||
| Perceived high chance of getting CRC (Ref: No) | NA | 2.23 (1.23–4.01)a | 2.05 (1.08–3.88)c |
|
| |||
| Knowledge of CRC Screening and Guidelines | |||
|
| |||
| Get medical tests to find blood or polyps in the colon can prevent CRC (Ref: No/incorrect) | NA | NA | 2.03 (0.99–4.13) |
|
| |||
| CRC screening guideline knowledge (Ref: knew none of the guidelines) Knew one or more guidelines | NA | NA | 2.38 (1.32–4.28)a |
Abbreviations: Ref, reference group; AOR, adjusted odds ratios; 95% CI, 95% confidence interval; CRC, colorectal cancer; NA, not applicable.
All models accounted for clustering of participants by lay health educators and were adjusted by age, sex, education, employment status, English proficiency and use of medical interpreters, which were not associated with CRC screening intention in the multivariable models (p>0.05). Significant AORs (p<0.05) are bolded and denoted with a p-value.
p<0.01
p=0.01
p=0.02
p=0.04
DISCUSSION
In this sample of Filipino, Hmong and Korean Americans who reported non-adherence to CRC screening, 73% reported no intention to get screened within 6 months. More than half did not know CRC screening as a CRC prevention method or any CRC screening guidelines.
In multivariable analyses, we found that knowing at least one CRC screening guideline doubled the odds of screening intention but knowing that CRC screening is a CRC prevention method was not associated with intention. Prior studies assessed CRC knowledge by measuring awareness of CRC, names of screening tests, CRC risks, and CRC symptoms, which yielded mixed findings regarding the association of knowledge with intention or screening adherence.17–19 Educational interventions with Filipinos20, Hmong8 and Koreans9 are effective in increasing guideline knowledge and in CRC screening,8,20 with knowledge mediated the intervention effects on screening receipt among Hmong and Filipinos.8,20 Our findings confirm the importance of increasing knowledge of CRC screening guidelines, a highly modifiable factor, as part of any strategy to promote CRC screening among non-adherent Asian Americans.
In addition to knowledge of screening guidelines, perceived needs as measured by participants’ worry about getting CRC or perceiving a high chance of getting it were associated with higher screening intention. This is consistent with other studies showing associations between perceived severity or susceptibility for CRC and screening adherence.17,18
This study also found that some healthcare factors are associated with higher screening intention. Those who have an Asian healthcare provider, compared to those with no provider, were more likely intend to get screening. Ethnically concordant providers may have better insights and understanding of cultural and contextual factors relevant for patients’ screening adherence. Both physicians’ recommendation of CRC screening and prior CRC screening, as found in prior studies17,18 were positively associated with CRC screening uptake.
In contrast to population data showing low CRC screening adherence among individuals with low income,3 we found no difference between low versus higher income in screening intention. Participants with undisclosed income, however, had lower odds of screening intention. This warrants further investigation as this group might experience different barriers to intention or adherence.
The difference in screening intention between Hmong and Koreans was explained by guideline knowledge since model 3 showed no difference between the two groups in screening intention when guideline knowledge was included. However, even after adjusting for sociodemographics, healthcare factors, perceived needs, and knowledge, Hmong remained less likely to intend to get screening compared to Filipinos. Cultural beliefs in cancer or prevention among Hmong, which remain understudied, could be plausible explanations for lack of screening intention or behaviors. Because preventive health care may be a new concept to Hmong older adults, they may view that screening or seeking preventive healthcare is unnecessary without experiencing health symptoms.21 Nonetheless, this topic deserves additional research. Of note, while these Hmong participants reported the highest rates of prior CRC screening, they had the lowest screening intention. This finding underscores the need to emphasize the importance of regular CRC screening per guideline recommendations.
Limitations
The study sample consisted of primarily immigrants who were enrolled in an educational intervention trial. In addition, most had utilized healthcare services within past year. Thus the findings may not be generalizable to other Filipino, Hmong and Korean Americans or other Asian American immigrants. The cross-sectional nature of the data did not allow inference of causation of identified factors leading to changes of intentions; the findings are not conclusive as to which factors motivate or lead to screening intention.
Conclusions
CRC screening intention among non-adherent Filipino, Hmong, and Korean Americans was low; only one in four intending to get CRC screening within six months. Knowing at least one CRC screening guideline recommendation doubled the odds of intending to get screened. Interventions aiming to increase knowledge of CRC screening guidelines and perceived needs of screening may be effective strategies for increasing CRC screening intention, and subsequent receipt, among non-adherent Asian Americans.
Acknowledgments
Our gratitude for the contributions of Moon S. Chen, Jr, PhD, Angela M. Jo, MD, Min J. Sung, Majorie Kagawa-Singer, PhD, RN, MN, Charlene Cuaresma, MPH, Penny Lo, May Chee Lo, Ching Wong, and Hy Lam in the parent randomized controlled trial study design, survey instrument development, recruitment, and data collection. We would like to thank Asian American Network for Cancer Awareness, Research and Training (AANCART) interns Vickie Nguyen, Kristine Phung, Mimi Tran, Matthew Jeong, and Filmer Yu for their assistance on the project. We also appreciate the efforts of our lay health educators in recruiting participants.
Funding Support: Supported in part by grants from the National Cancer Institute (Asian American Network for Cancer Awareness, Research and Training: U54CA153499, and R01CA138778). The opinions expressed in this article reflect those of the authors and are not necessarily those of the National Cancer Institute.
CONFLICT OF INTEREST DISCOSURES
All authors received grant support from National Cancer Institute during the conduct of the study. In addition, Dr. Angela Sy received grants from National Institutes of Health for work performed outside of the current study.
Footnotes
Author Contributions:
Janice Y. Tsoh: Conceptualization, methodology, supervision, formal analysis, writing-original draft, review and editing. Elisa K. Tong: Conceptualization, project administration, and writing-review and editing draft. Angela U. Sy: Conceptualization, project administration, and writing-review and editing draft. Susan Stewart: Methodology, validation, supervision, formal analysis, and writing-review and editing. Ginny Gildengorin: Methodology, validation, formal analysis, and writing-review and editing. Tung T. Nguyen: Conceptualization, writing-review and editing draft, supervision, and funding acquisition.
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