Abstract
Background
There are few studies on colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, which have lower CRC screening rates than Whites.
Objective
To assess knowledge and beliefs about CRC causes, its prevention and factors associated with CRC screening among three Asian American groups.
Methods
We conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, CA), and Korean (Los Angeles, CA) Americans ages 50–75 sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening.
Results
The sample (N=981) included 78.3% females and 73.8% limited English proficient. Few knew that age (17.7%) or family history (36.3%) were CRC risk factors; 6.2% believed fate caused CRC. Only 46.4% knew screening prevented CRC (Filipino 74.3%, Hmong 10.6%, Korean 55.8%, p<0.001). Two-thirds reported ever having had CRC screening (Filipino 76.0%, Hmong 72.0%, Korean 51.4%, p<0.001) and 48.6% were up-to-date for screening (Filipino 62.2%, Hmong 43.8%, Korean 41.4%, p<0.001). Factors significantly associated with ever screening were being Korean (compared to Filipinos), family history of CRC, having health insurance or a regular place for healthcare, and knowing that fatty diet caused CRC. Believing that fate caused CRC and praying prevented it were negatively associated with ever screening. Factors associated with being up-to-date for CRC screening included U.S. birthplace, family history of CRC, and healthcare access variables.
Conclusions
Knowledge about CRC causes and its prevention among Filipinos, Hmong, and Koreans are low. However, healthcare access, not knowledge or beliefs, were key determinants of CRC screening.
Keywords: Colorectal cancer screening, Asian Americans, Filipino, Hmong, Korean
BACKGROUND
Asian Americans are the fastest growing racial group in the U.S.1,2 Yet, there is a shortage of disaggregated data on their health, which obscures the many differences in health behaviors and outcomes among Asian Americans of various national origins.
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the U.S. and for Asian Americans.3 Although CRC incidence has decreased in the general population, it is rising for Koreans and Filipinos.4,5 CRC screening reduces mortality,6,7 but screening rates among groups such as Chinese (49.2%), Filipinos (46.3%), Koreans (41.3%) and Vietnamese (42.2%) were lower than non-Hispanic whites (61.1%).8 These rates remain below the Healthy People 2020 goal of 70.5%.9
Factors associated with cancer screening and its knowledge among Asian Americans include healthcare access, limited English proficiency (LEP),10 and low health literacy.11,12 Fatalism, a common Asian belief that illness is beyond one’s control, is inversely associated with cancer screening. 13,14 Additionally, many Asian Americans believe that certain foods or herbs can prevent cancer,14 which may affect their decision to get screened.
The purpose of this study was to evaluate factors associated with CRC screening knowledge and behaviors among Filipino, Hmong, and Korean Americans. We postulated that knowledge and beliefs of what causes CRC and how it can be prevented would be associated with knowledge about CRC screening and its receipt.
METHODS
Setting
This study used cross-sectional data collected at baseline from participants in a cluster randomized controlled trial (RCT) testing the efficacy of lay health educator (LHE) outreach in increasing CRC screening among the three targeted groups. Participants included Filipino (n=304) from Honolulu, Hawaii, Hmong (n=329) from Sacramento, CA, and Koreans (n=348) from Los Angeles, CA. Details about recruitment and intervention were reported elsewhere.15,16 The University of California, San Francisco (UCSF) and University of Hawai’i’s Institutional Review Boards approved study procedures.
Participants and Data Collection
Community organizations recruited 83 LHEs: 26 Filipino LHEs by Nursing Advocates and Mentors, Inc.; 29 Hmong LHEs by Hmong Women Heritage Association; and 28 Korean LHEs by Korean Resource Center and local Korean churches. LHEs were recruited through radio, flyers, meetings, and word of mouth. The LHEs were not necessarily members of these community organizations and therefore, the participants were from various types of social networks.
LHE training for recruitment of participants was similar across the sites. Each LHE recruited approximately 12 to 15 participants from the network of people they knew, which may include family members, friends, and people they knew who were clients at the local agency. Eligibility criteria for participants were: age 50 to 75; self-identification as Filipino (in Hawai’i), Hmong (in Sacramento) or Korean (in Los Angeles); speaking a language that the LHE could speak, such as English, Philippine languages (Ilokano and Tagalog), Hmong, or Korean; living and intending to stay in the relevant area for at least 6 months; willing to participate in a study involving nutrition or CRC screening; having no history of CRC or medical problems which would prevent them from attending education sessions; and not having another household member in the study.
Although the survey respondents were recruited to participate in an intervention study, the data analyzed in this report were from the baseline survey, which was conducted before participants received any education about CRC in this project. Participants completed the baseline survey in the language of their choice. The paper-and-pencil surveys were self-administered by the Filipino and Korean participants. Project staff administered the survey verbally to Hmong participants due to the low written literacy in English and Hmong languages in the older Hmong population. Each participant received $20 for completing the survey. Data were collected from August 2012 through January 2015. Since this report is using data from the baseline survey of a RCT, the sample size was calculated to detect an intervention effect, not for the differences in knowledge or beliefs.
Measures
Socio-demographic variables assessed included: age, gender, birthplace, years in the U.S., education, employment, marital status, household income, and spoken English proficiency (“fluent,” “well,” “so-so”, “poorly,” or “not at all”, with LEP defined as the last three categories). Healthcare access and utilization were measured by participants reporting whether they: had health insurance, a regular place of care, a primary care doctor, or an Asian primary care doctor; saw a doctor in the past year or saw a traditional healer in the past 12 months; ever needed a medical interpreter, and if help was at least needed “sometimes,” “often,” or “always” in reading health materials received from doctors or pharmacies. Health status was measured by self-rated health (excellent/very good/good vs. fair/poor) and if there is a family history of CRC.
Participants were given a list of potential causes of CRC or ways to prevent it. Selection of the following items was considered correct knowledge of CRC causes: older age, family history of cancer, inflammatory bowel disease, colon polyps, fatty diet, lack of regular physical activity, alcohol use, and smoking. Similarly, knowledge about CRC prevention was based on selection of the following recommended methods: getting medical tests to find blood or polyps in the colon, taking aspirin, not smoking, exercising regularly, and eating enough fiber and vegetables. We considered selection of unproven causes or prevention methods to be beliefs. Beliefs about CRC causes included: lack of rest, working too hard, negative emotions or unhappiness, stress, toxins in food or water, fate, Heaven’s will, God’s will, and bad karma. Beliefs about CRC prevention included: having regular bowel movements, drinking enough water, not drinking alcohol, taking traditional Asian herbs or cooking herbal soups, seeing a traditional Asian healer, keeping a positive attitude, getting enough rest praying, do nothing, or other.
CRC screening status was assessed through self-report of: 1) ever had a CRC screening test (fecal occult blood test [FOBT], sigmoidoscopy, or colonoscopy) and 2) being up to date (FOBT within past year, sigmoidoscopy within past 5 years, or colonoscopy within past 10 years).
Statistical analysis
Descriptive statistics were computed for all of the measures, including means, standard deviations and percentages. The dependent variables in this analysis were: 1) knowledge that getting medical tests (screening) to find blood or polyps in the colon prevented CRC (yes/no); 2) ever had CRC screening; and 3) being up-to-date for CRC screening. Bivariate and multivariable analyses of the binary outcomes were conducted using generalized linear models. Because participants were recruited by LHEs, generalized estimating equations (GEE) were used to analyze participant responses in bivariate and multivariable analyses. GEE was utilized to account for within-cluster correlation of outcomes between participants recruited by the same LHE. For each multivariable model, the independent variables included socio-demographics, healthcare access and utilization, health status, and knowledge and beliefs about causes and prevention of CRC. We utilized complete case analysis, and there was very little missing data.
RESULTS
Table 1 shows that 65.2% were aged 50 to 64 with 78.3% female, 65.9% married, 96.3% foreign-born with 85.1% having lived in the U.S. more than 10 years. Most Hmong (95.7%) and Korean (92.0%) were LEP while high school graduation rates were 73.7% for Filipinos, 87.1% for Koreans, and 5.2% for Hmong. Only 38.2% of participants reported fair or poor health and 6.3% had a family history of CRC. Most had health insurance (86.1%), regular place for health care (83.3%), primary care doctor (83.4%), and had seen a doctor in the last 12 months (81.6%). Overall, 36.1% reported needing an interpreter during a healthcare visit, and 55.3% reported needing help reading health materials. One-fourth (27.4%) had seen a traditional healer in the last 12 months. Except for length of U.S. residence and marital status, there were significant differences across the 3 ethnic groups for all sociodemographic, health and healthcare variables.
Table 1.
Sociodemographic, Health, and Health Care Characteristics among Filipino, Hmong, and Korean Participants (n=981)
| Total (N=981) | Filipino (N=304) | Hmong (N=329) | Korean (N=348) | |
|---|---|---|---|---|
| % | ||||
| Sociodemographics | ||||
| Age 50–64 years | 65.2* | 57.2 | 73.3 | 64.7 |
| Female | 78.3* | 76.6 | 74.2 | 83.6 |
| Foreign-Born | 96.3* | 90.5 | 98.8 | 99.1 |
| Lived in the U.S. 10 years or more | 85.1 | 85.5 | 82.4 | 87.4 |
| Limited English proficiency | 73.8*** | 29.3 | 95.7 | 92.0 |
| High school graduate or higher educational level | 55.5*** | 73.7 | 5.2 | 87.1 |
| Employed | 35.9*** | 59.5 | 9.1 | 40.5 |
| Married | 65.9 | 64.1 | 64.7 | 68.4 |
| Annual household income | ||||
| Less than $20,000 | 39.1*** | 28.0 | 53.8 | 35.1 |
| $20,000 or more | 37.7 | 54.9 | 4.0 | 54.6 |
| Unknown | 23.1 | 17.1 | 42.3 | 10.3 |
| Health and healthcare | ||||
| Family history of colorectal cancer | 6.3*** | 7.9 | 1.8 | 9.2 |
| Fair or poor self-reported health | 38.2*** | 17.1 | 46.5 | 48.9 |
| Has health insurance | 86.1*** | 94.1 | 95.1 | 70.7 |
| Has regular place for healthcare | 83.3*** | 93.1 | 94.2 | 64.4 |
| Has primary care doctor | 83.4*** | 92.8 | 92.1 | 67.0 |
| Has Asian primary care doctor | 54.8*** | 58.9 | 39.2 | 66.1 |
| Saw a doctor in the last 12 months | 81.6*** | 88.2 | 84.8 | 72.7 |
| Need interpreter for healthcare visit | 36.1*** | 7.6 | 64.4 | 34.2 |
| Need help reading health materials | 55.3*** | 22.2 | 87.7 | 53.7 |
| Saw a traditional healer in last 12 months | 27.4*** | 9.5 | 29.5 | 41.0 |
p<0.05,
p<0.01,
p<0.001 for the comparison between the 3 ethnic groups.
Knowledge and beliefs of CRC risk factors
Table 2 shows the CRC related variables. Few respondents knew about main risk factors of CRC such as getting older (17.7%), having a family history of CRC (36.3%), having colon polyps (34.2%), and having a personal history of inflammatory bowel disease (27.0%).
Table 2.
Colorectal Cancer (CRC) Knowledge, Beliefs, and Behaviors among Filipino, Hmong, and Korean Participants (n=981)
| Total (N=981) | Filipino (N=304) | Hmong (N=329) | Korean (N=348) | |
|---|---|---|---|---|
| % | ||||
| CRC Causes: Knowledge | ||||
| Getting older | 17.7*** | 27.0 | 5.8 | 21.0 |
| Family history of CRC | 36.3*** | 49.3 | 5.5 | 54.0 |
| Colon polyps | 34.2*** | 44.8 | 1.5 | 53.7 |
| Inflammatory bowel disease | 27.0*** | 42.8 | 0.9 | 37.9 |
| Fatty diet | 57.3*** | 62.5 | 21.6 | 86.5 |
| Lack of regular physical activity | 32.6*** | 35.2 | 4.3 | 57.2 |
| Alcohol use | 34.5*** | 38.5 | 13.4 | 50.9 |
| Smoking | 30.8*** | 35.5 | 11.3 | 45.1 |
| CRC Causes: Beliefs | ||||
| Stress | 38.7*** | 41.8 | 6.7 | 66.4 |
| Toxins in food or water | 31.7*** | 45.4 | 12.8 | 37.6 |
| Lack of rest | 14.6*** | 17.8 | 1.2 | 24.4 |
| Working too hard | 17.0*** | 18.1 | 0.6 | 31.6 |
| Negative emotions or unhappiness | 9.7*** | 12.5 | 2.7 | 13.8 |
| Fate, Heaven’s will, or God’s will | 6.2* | 11.2 | 4.3 | 3.7 |
| Bad karma | 1.3 | 2.0 | 0.3 | 1.7 |
| CRC Prevention: Knowledge | ||||
| Get medical tests to find blood or polyps in the colon (screening) | 46.4*** | 74.3 | 10.6 | 55.8 |
| Take aspirin | 2.5* | 3.6 | 0.6 | 3.2 |
| Not smoke | 32.6*** | 37.5 | 9.1 | 50.6 |
| Exercise | 50.7*** | 63.5 | 18.2 | 70.1 |
| Eat enough fiber and vegetables | 64.9*** | 73.7 | 29.8 | 90.5 |
| CRC Prevention: Beliefs | ||||
| Have regular bowel movements | 51.9*** | 72.7 | 3.3 | 79.6 |
| Drink enough water | 49.2*** | 69.7 | 7.6 | 70.7 |
| Not drink alcohol | 33.7*** | 35.5 | 10.6 | 54.0 |
| Get enough rest | 30.6*** | 39.8 | 5.2 | 46.6 |
| Keep a positive attitude | 29.4*** | 33.2 | 4.0 | 50.0 |
| Pray | 25.4*** | 44.7 | 2.7 | 29.9 |
| Take traditional Asian herbs or cook herbal soups | 7.7*** | 17.1 | 6.1 | 0.9 |
| See a traditional Asian healer | 27.4*** | 9.1 | 29.5 | 41.1 |
| Nothing | 1.9* | 1.3 | 4.0 | 0.6 |
| CRC Prevention: Behaviors | ||||
| Ever screened for CRC | 66.0*** | 76.0 | 72.0 | 51.4 |
| Up-to-date for CRC screening | 48.6*** | 62.2 | 43.8 | 41.4 |
p<0.05,
p<0.01,
p<0.001 for the comparison between the 3 ethnic groups.
Hmong were significantly less likely to know about colon polyps (Filipino 44.8%, Hmong 1.5%, Korean 53.7%, p<0.001), and family history of CRC (Filipino 49.3%, Hmong 5.5%, Korean 54.0%, p<0.001) as risk factors. For causes of CRC, 57.3% of participants correctly identified fatty diet, 32.6% lack of physical activity, 34.5% alcohol use, and 30.8% smoking cigarettes.
Prominent beliefs about CRC causes included stress (38.7%) and toxins in food or water (31.7%) while only a few participants chose lack of rest (14.6%), working too hard (17.0%), and negative emotions or unhappiness (9.7%). Very few participants believed that fate (6.2%) or bad karma (1.3%) was a cause of CRC. A majority of Koreans (66.4%) believed that stress caused CRC while only 41.8% of Filipinos and 6.7% of Hmong believed that (p<0.001).
Knowledge and beliefs of CRC prevention methods
When asked about CRC prevention methods, 64.9% correctly identified eating fiber and vegetables and 50.7%, exercising regularly, but only 32.6% knew about not smoking and 2.5%, taking aspirin.
Common beliefs about CRC prevention were having regular bowel movements (51.9%), drinking enough water (49.2%), not drinking alcohol (33.7%), getting enough rest (30.6%), keeping a positive attitude (29.4%), and praying (25.4%). Few (7.7%) believed consuming Asian herbs/soups or seeing a traditional healer (2.7%) prevented CRC. Very few (1.9%) thought that they could do nothing to prevent CRC.
Only 46.4% of respondents knew that CRC screening prevented CRC (Filipino 74.3%, Hmong 10.6%, Korean 55.8% p<0.001). Two-thirds (66.0%) reported ever receiving CRC screening (Filipino 76.0%, Hmong 72.0%, Korean 51.4%, p<0.001) and 48.6%, were up-to-date (Filipino 62.2%, Hmong 43.8%, Korean 41.4%, p<0.001).
Factors associated with CRC screening knowledge and behaviors
Table 3 shows the multivariable models for factors associated with CRC screening knowledge and behaviors. Factors associated with knowing that screening prevented CRC were having completed high school (Odds Ratio [OR]=1.72; 95% confidence interval [CI]:1.06, 2.79), a regular place for health care (OR=2.20; CI:1.16, 4.17), and having an Asian primary care doctor (OR=0.65; CI:0.44, 0.95). Hmong (OR=0.31; CI:0.13, 0.73) and Koreans (OR=0.28; CI:0.14, 0.58) were less likely than Filipinos to know that screening prevented CRC. Knowing that a fatty diet (OR=2.23; CI:1.14, 4.37) was a cause and that exercising can prevent CRC (OR=1.78; CI:1.14, 2.79) were associated with knowledge that screening prevented CRC. Beliefs associated with this outcome included believing in karma as a CRC cause (OR=0.21; CI:0.06, 0.69) and that seeing a traditional healer (OR=3.68; CI:1.26, 10.73), having regular bowel movements (OR=2.82; CI:1.74, 4.57), abstaining from alcohol use (OR= 2.64; CI: 1.38, 5.05), and getting rest (OR=0.54; CI:0.31, 0.94) prevented CRC.
Table 3.
Multivariable models of factors associated with colorectal cancer (CRC) screening knowledge and behaviors among Filipinos, Hmong, and Koreans (N=981)
| Know screening prevents CRC N=955 |
Ever screened for CRC N=955 |
Up-to-date for CRC screening N=955 |
|
|---|---|---|---|
| Odds Ratio (95% Confidence Interval) | |||
| Socio-demographics | |||
| Born in the US (ref. Other) | 0.97 (0.11, 8.70) | 1.56 (0.47, 5.26) | 5.62 (1.40, 22.65) |
| At least high school education (ref. < high school) | 1.72 (1.06, 2.79) | 0.96 (0.59, 1.55) | 0.91 (0.58, 1.43) |
| Ethnicity | |||
| Hmong (ref. Filipino) | 0.31 (0.13, 0.73) | 0.85 (0.41, 1.75) | 0.61 (0.34,1.12) |
| Korean (ref. Filipino) | 0.28 (0.14, 0.58) | 0.42 (0.22, 0.78) | 0.63 (0.37,1.09) |
| Hmong (ref. Korean) | 1.10 (0.49, 2.44) | 2.03 (0.96, 4.27) | 0.97(0.51, 1.86) |
| Health and healthcare factors | |||
| Has family history of colorectal cancer (ref. No) | 0.96 (0.53, 1.72) | 1.78 (1.07, 2.97) | 2.12 (1.24, 3.64) |
| Has health insurance (ref. No) | 0.84 (0.43, 1.62) | 1.76 (1.09, 2.84) | 1.89 (1.10, 3.25) |
| Has a regular place for healthcare (ref. No) | 2.20 (1.16, 4.17) | 2.16 (1.33, 3.51) | 1.88 (1.08, 3.29) |
| Has a primary care doctor (ref. No) | 1.03 (0.50, 2.13) | 1.61 (0.87, 2.98) | 1.93 (1.10, 3.83) |
| Of those who have a primary care doctor, the doctor is Asian (ref. No) | 0.65 (0.44, 0.95) | 0.76 (0.53, 1.10) | 0.78 (0.55, 1.11) |
| Saw a doctor in the last 12 months (ref. No) | 1.33 (0.75, 2.37) | 1.36 (0.83, 2.24) | 2.37 (1.48, 3.79) |
| Knowledge about causes of colorectal cancer | |||
| Fatty diet (ref. No) | 2.23 (1.14, 4.37) | 1.93 (1.24, 3.00) | 1.38 (0.84, 2.27) |
| Beliefs about colorectal cancer causes | |||
| Belief in Karma (ref. No) | 0.21 (0.06, 0.69) | 2.56 (0.33, 20.04) | 2.65 (0.56, 12.60) |
| Fate’s, God’s will (ref. No) | 0.86 (0.40, 1.85) | 0.47 (0.27, 0.84) | 0.60 (0.33, 1.08) |
| Knowledge about colorectal cancer prevention | |||
| Exercising (ref. No) | 1.78 (1.14, 2.79) | 1.00 (0.67, 1.48) | 1.18 (0.83, 1.67) |
| Beliefs about what can prevent colorectal cancer | |||
| Praying (ref. No) | 1.10 (0.66, 1.82) | 0.61 (0.39, 0.93) | 0.76 (0.50, 1.14) |
| Getting rest (ref. No) | 0.54 (0.31, 0.94) | 0.86 (0.60, 1.22) | 0.92 (0.62, 1.38) |
| Seeing a traditional healer (ref. No) | 3.68 (1.26, 10.73) | 0.56 (0.26, 1.20) | 1.01 (0.45, 2.25) |
| Having regular bowel moments (ref. No) | 2.82 (1.74, 4.57) | 1.21 (0.79, 1.83) | 1.10 (0.71, 1.70) |
| Avoid alcohol (ref. No) | 2.64 (1.38, 5.05) | 0.98 (0.59, 1.63) | 1.16 (0.72, 1.88) |
All models also include the following covariates not significant in any model: age, gender, years in the U.S., English proficiency, employment, marital status, income, self-rated health, needing an interpreter, needing help reading health materials, saw a traditional healer in last 12 months, knowledge of some CRC causes (lack of physical activity, alcohol use), believing in some CRC causes (lack of rest, negative emotions, working too hard, stress, toxins), knowledge about some prevention methods (taking aspirin, not smoking, eating fiber), beliefs about some prevention methods (drinking water, taking traditional Asian herbs, keeping a positive attitude, and doing nothing).
Koreans were less likely (OR=0.42; CI:0.22, 0.78) than Filipinos to have ever been screened for CRC. Having a family history of CRC (OR=1.78; CI:1.07, 2.97), a regular place for healthcare (OR=2.16; CI:1.33, 3.51), and health insurance (OR=1.76; CI:1.09, 2.84) were associated with ever screening. The only knowledge item associated with ever screening was knowing that a fatty diet caused CRC (OR=1.93; CI:1.24, 3.00). Those who believed that fate caused CRC (OR=0.47; CI:0.27, 0.84) and that praying prevented CRC (OR=0.61; CI:0.39, 0.93) were less likely to have ever been screened. Factors associated with being up-to-date for CRC screening included U.S. birthplace (OR=5.62; CI:1.40, 22.65), family history of CRC (OR=2.12; CI:1.24, 3.64), having health insurance (OR=1.89; CI:1.10, 3.25), having a regular place for health care (OR=1.88; CI:1.08, 3.29), having a primary care doctor (OR=1.93, CI:1.10, 3.83), and having seen a doctor in the last 12 months (OR=2.37; CI:1.48, 3.79). No knowledge or belief was associated with being up-to-date.
DISCUSSION
To our knowledge, this is the first study to evaluate CRC knowledge and beliefs among Hmong Americans, and one of only a few studies among Filipino and Korean Americans.17–19 The findings demonstrated that knowledge about CRC causes and prevention among all 3 groups were low, with Hmong having very low levels of knowledge. Both Hmong and Koreans were less likely than Filipinos to know that CRC screening can prevent CRC while Koreans were less likely than Filipinos to have ever been screened. The participants had a wide range of beliefs about CRC causes and prevention. Surprisingly, few held fatalistic beliefs, which were primarily associated with CRC knowledge and less so with CRC screening. The most important factors associated with CRC screening receipt were U.S. birthplace, family history of CRC, and healthcare access.
Filipino, Hmong, and Korean Americans all had low levels of knowledge about CRC. The very low levels of knowledge about CRC causes and prevention among the Hmong may be due to low educational attainment and LEP. Exposure to biomedical care culture is relatively recent for this group, who were traditionally farmers in Southeast Asia.20,21 In addition, the Hmong also had low levels of health literacy, which is not surprising since many older Hmong cannot read the Hmong language, as it has only been recently been put into written form.22 Our findings for all 3 groups reinforce the need for more culturally and linguistically appropriate materials about CRC and its prevention.
Compared to Filipinos, Hmong and Koreans had lower levels of knowledge about CRC screening. While that may have been expected for the Hmong, it was unexpected for Korean Americans in this sample, who had equivalent or higher levels of education and income compared to the Filipinos. Korean Americans were also less likely than Filipinos to have ever been screened for CRC in the multivariable models, even after adjusting for covariates such as LEP, health literacy, healthcare access, and knowledge and beliefs about CRC causes and prevention, indicating that there may be unmeasured factors that should be explored in future research.
Those who believed that seeing a traditional healer, having regular bowel movements, and avoiding alcohol were ways to prevent CRC were also more likely to know about CRC screening. It is possible that Asian Americans with a preventive orientation may look for help from a variety of sources including self-care, traditional medicine, and biomedical approaches.13 Having various beliefs indicate that participants are interested in preventing CRC. One implication for interventions is that there may not be a need to discourage people from having beliefs about CRC prevention if they are not harmful as long as they are also taught about the proven methods.23
Contrary to common perceptions and other papers about Asian health beliefs,24,25 most participants in this study did not hold fatalistic beliefs about CRC. This was particularly surprising for Hmong Americans, given that Hmong culture tends to revolve around shamanism and have a mistrust of Western medicine.24,26 However, the few participants who believed that fate or God’s will caused CRC and those who thought praying prevented CRC were less likely to have ever been screened for it. Interventions to increase CRC screening in these populations need to address these beliefs in culturally sensitive ways.
Respondents who were born in the U.S. were five times more likely than immigrants to be up-to-date with CRC screening, a finding found in other studies that suggest greater familiarity with the U.S. healthcare system.8,27,28 Those with a family history of CRC were appropriately more likely to have had screening and be up-to-date.
The most striking finding was that knowledge and belief had minimal effect on CRC screening status. More notably, access to healthcare had a strong impact on screening behavior. Participants who had health insurance and a regular place of care were more likely to have had CRC screening and be up-to-date for screening, while those who had a regular doctor or saw their doctor in the last 12 months were more likely to be up-to-date. In order to improve CRC screening rates among Filipino, Hmong, and Korean American populations, improving access to healthcare through systematic interventions may be more effective than attempting to change their beliefs.29 These interventions may include increasing health insurance coverage through the Affordable Care Act and ensuring that these patients have regular visits with their primary care providers.
There are several limitations to this study including self-reports of CRC screening, the validity of which have not been well studied in these populations, and since this is a cross-sectional study, causality cannot be inferred. Each ethnic group was selected from a different geographic area, so differences between groups may be due to unmeasured geographically determined confounders. The samples have lower levels of education and more females, foreign-born, and limited English proficient speakers than the U.S. Census data for all age groups for each population. However, the findings may be generalizable to older Filipino, Hmong, and Korean immigrants living in urban areas. The strengths of the study include the samples of 3 understudied and underserved Asian American populations, use of in-language surveys, and the comparison across multiple Asian American groups.
Conclusion
Our findings show that there are many prevalent beliefs about CRC among Filipino, Hmong, and Korean Americans. Notably, with the exception of fatalism, most are not negatively associated with knowledge about CRC screening or screening behaviors. The key determinants of CRC screening are not knowledge or beliefs about CRC causes and prevention but healthcare access. Our study illustrates the importance of being patient-centered and culturally sensitive in the promotion of CRC screening among these populations as well as to the need for healthcare access to maintain good health in these underserved populations.
Acknowledgments
Funding source: This study was supported by a grant from the National Cancer Institute (U54CA153499). The opinions expressed reflect those of the authors and are not necessarily those of the NCI.
We gratefully acknowledge the contributions of Angela Jo, MD, Hy Lam, May Chee Lo, Penny Lo, MJ Sung, Ching Wong, and the LHEs to the recruitment and data collection efforts.
Footnotes
Conflicts of Disclosure: The authors made no disclosures.
Author’s Contributions:
Conceptualization, writing-original draft, and writing–review and editing: Mi T. Tran Writing-original draft: Matthew Jeong, Vickie Vuong Nguyen, Michael Thanh Sharp, Filmer Yu, Edgar Yu
Development and execution of the concept; writing–review and editing: Elisa Tong, Marjorie Kagawa Singer, Charlene Cuaresma, Angela Sy.
Conceptualization, methodology, writing-original draft, and writing–review and editing: Janice Y. Tsoh, Ginny Gildengorin, Susan LeRoy Stewart, Tung T. Nguyen
References
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