526457
research-article2014
TCNXXX10.1177/1043659614526457Journal of Transcultural NursingLee et al.
Article
Breast Cancer Screening Behaviors Among Korean American Immigrant Women: Findings From the Health Belief Model
Journal of Transcultural Nursing 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614526457 tcn.sagepub.com
Hee Yun Lee, PhD, LCSW1, Mia Ju Stange, MA2, and Jasjit S. Ahluwalia, MD, MPH, MS3
Abstract This study examined the utilization of clinical breast examinations (CBEs) and mammograms among Korean American immigrant women and investigated how the six constructs of Health Belief Model (HBM) are associated with the receipt of breast cancer screening. Using a quota sampling strategy, 202 Korean American immigrant women were recruited in metropolitan areas in the northeastern United States. Approximately 64% of the participants reported having had at least one CBE in their lifetime, and about 81% of the sample had undergone at least one mammogram in their lifetime. Women who perceived themselves to be susceptible to breast cancer were more likely to have undergone a CBE, and women who had lower barriers to screening or demonstrated a higher level of confidence were more likely than their counterparts to undergo a mammogram. Findings suggest that HBM constructs such as susceptibility, barriers, and confidence should be considered when designing interventions aimed at promoting breast cancer screening. Keywords breast cancer screening, mammogram, clinical breast exam, Korean American immigrant women, Health Belief Model, cancer screening disparity Breast cancer is the most common cancer among American women (Centers for Disease Control and Prevention [CDC], 2013a). In 2013, the numbers of new cases and deaths for breast cancer were estimated to be 232,340 and 39,620, respectively (American Cancer Society [ACS], 2013). Although non-Latina White and African American women have the highest incidence and mortality rates for breast cancer in the United States, these rates have decreased significantly every year. The opposite trends hold true for some other ethnic minority groups, specifically Asian Americans and Pacific Islanders (CDC, 2013b). For instance, Deapen, Liu, Perkins, Bernstein, and Ross (2002) found breast cancer incidence rates for most Asian American ethnic groups to be on the rise. Fejerman and Ziv (2008) found that although Asian American women have lower breast cancer incidence per capita than do non-Latina White women, they have higher mortality rates. The significant breast cancer burden among Asian Americans and Pacific Islanders women appears to come from low rates of breast cancer screening. The ACS (2009) recommends that women aged 20 years and older have a clinical breast examination (CBE) at least once every three years and begin annual mammography at the age of 40 years. However, Goel et al. (2003) found that foreign-born individuals report
less cancer screening than do their counterparts born in the United States and that screening rates among ethnic minority women are lower than among non-Latina White women. According to the ACS (2009), Asian American women are the least likely of all American women to have had a mammogram within the last 2 years. Breast cancer specifically poses a significant burden to Korean American immigrant women, who report one of lowest breast cancer screening rates in the United States. Studies conducted among Korean American women revealed that only 58% (Han, Williams, & Harrison, 2000) to 70% (Ma, Shive, Wang, & Tan, 2009) had undergone a mammogram and 67% a CBE (Han et al., 2000) at least once in their lifetime. A more recent study by Lee, Ju, Vang, and Lundquist (2010) found Korean American women reporting the lowest rate of mammography in the past two years (57.1%). 1
University of Minnesota, Twin Cities, St. Paul, MN, USA Free University of Amsterdam, Amsterdam, Netherlands 3 University of Minnesota Medical School, Minneapolis, MN, USA 2
Corresponding Author: Hee Yun Lee, PhD, School of Social Work, University of Minnesota, Twin Cities, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN 55108, USA. Email: [email protected]
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Many studies have investigated determinants associated with Asian American women’s utilization of breast cancer screening. Such studies have reported that sociodemographic variables are strong predictors for screening. Many studies have reported that Asian American women who are younger, married, employed, and have a higher household income and education level are more likely to have had breast cancer screening (Liang et al., 2009; Wong-Kim & Wang, 2006). Moreover, health insurance and physician recommendations have been identified as the most important reinforcing factors for cancer screening (Liang, Yuan, Mandelblatt, & Pasick, 2004). Studies taking health accessibility factors into account have identified several barriers to breast cancer screening for Asian American Women. These include the financial costs of screening, the absence of health insurance, and lack of screening recommendations from physicians (Chen, 2009; Tang, Solomon, & McCracken, 2000; Wu, Hsieh, & West, 2008, 2009). Several studies have also determined that lack of English language literacy has been found to be a barrier for breast cancer screening (Lee, Kim, & Han, 2009; Wu et al., 2008). Conversely, Yu, Kim, Chen, and Brintnall (2001) found that Chinese American women who spoke English fluently were more likely to have knowledge of CBE, breast self-exam (BSE), and mammograms and to use these screening mechanisms. Several other studies have shown that Asian American women who had resided longer in the United States, had fluency in English, and who demonstrated greater awareness and practice of BSE were more likely to have regular and recent mammograms (Liang et al., 2009; Wong-Kim & Wang, 2006; Wu et al., 2009; Wu & Ronis, 2009). Similarly, a study conducted by Tang et al. (2000) found that acculturation predicted the initiation of breast cancer screening. The Health Belief Model (HBM; Rosenstock, 1966; Rosenstock, Strecher, & Becker, 1988) theoretically guided this study. This theory states that an individual’s health service utilization is primarily due to six factors: (a) Susceptibility, (b) Severity, (c) Benefits, (d) Barriers, (e) Cues to action, and (f) Self-efficacy. Although the HBM has been widely adopted to explain cancer screening compliance, it has only recently been used to predict breast cancer screening behaviors among Asian American immigrant women. For example, Han et al. (2000) found that Korean American women who had never had a CBE had significantly lower knowledge of and higher perceived barriers to the exam than did those who had previously undergone the exam. Other recent research using the HBM with Korean American women found that perceived breast cancer susceptibility and perceived benefits were significantly correlated with mammogram use (Lee et al., 2009). Moreover, studies have found that Asian women seem to perceive little susceptibility to breast cancer due to the misconception that breast cancer is a non-Latina White, Western disease (Kwok, Sullivan, & Cant 2006; Park, Hur, Kim, & Song, 2007). Similarly, a study
conducted by Wu and Ronis (2009) found that the higher the misconceptions and the less knowledge Asian American women had about breast cancer, the less likely they were to have had a mammogram. Unique and differing health beliefs and behaviors regarding breast cancer screening clearly exist within the Asian American population. There is an urgent need for studies not merely to consider Asian Americans as an aggregate but also to examine the unique subgroup differences within that broad designation. Korean American immigrant women appear to differ from other Asian American women in terms of screening behaviors, for example, and may therefore experience different barriers and facilitators to breast cancer screening. Little is known, however, about Korean American immigrant women’s breast cancer screening behavior, despite the fact that this group has disproportionally suffered from breast cancer mortality. The current study aims to better understand breast cancer screening behaviors among Korean American immigrant women by use of the HBM.
Method Research Design and Sampling We conducted a cross-sectional survey of 202 Korean American women between the ages of 20 and 90 years. These women were recruited in 2009 from two Korean senior centers and two Korean ethnic churches in a large urban metropolitan area in northeastern United States. A quota sampling strategy (Judd, Smith, & Kidder, 1991; Neuman, 1994) was used to ensure that numbers of women who are eligible for the CBE were adequately represented in the sample; CBEs are recommended every three years for women ages 20 years and older and yearly for women ages 40 years and older (ACS, 2009). For this purpose, a quota was set to ensure the inclusion of 20 to 30 women in each of the four age categories: 20 to 29, 30 to 39, 40 to 49, and 50 to 59. Likewise, the quota strategy determined recruitment of 80 to 120 Korean American women below the age of 60 years, plus a similar number of participants above the 60-year mark. Research staff approached potential participants at the aforementioned multiple sampling sites to reduce sampling bias inherent in nonprobability sampling.
Data Collection Two data collection methods were employed: all the Korean American immigrant women aged 20 to 59 years (n = 101) completed a self-administered questionnaire in Korean, whereas all the women aged 60 years and older (n = 101) participated in face-to-face interviews in Korean. The decision to conduct face-to-face interviews with participants in the older age bracket was informed by pilot interviews with three older Korean immigrant women; information gained suggested that this older demographic may lack the knowledge in
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Lee et al. terminologies associated with cancer screening necessary to understand the self-administered questionnaire. The use of face-to-face interviews enabled the researchers to include older adults in the study and to collect accurate data from them. The interviews were conducted at two senior centers located in large urban metropolitan areas in the northeastern United States. To recruit participants, flyers were posted in the public areas—such as lunch and recreational rooms—of these senior centers. A number of study informational presentations were conducted describing the purpose of the research, eligibility criteria, the types of questions to be asked, confidentiality, anonymity of participation, the duration of the interview, and the voluntary nature of participation. Willing participants were then interviewed by one of four bilingual interviewers, each of whom had work experience with older adults and had received interview training. The interviews averaged about one hour in length. A total of 108 Korean American women aged 60 years and older were interviewed; seven of these were incomplete, leading to inclusion of 101 interviews in the analysis. The younger cohort, aged 20 to 59 years, completed selfadministered surveys at two Korean ethnic churches. Similar recruitment procedures to those used for the older women were applied. Flyers were posted in the public areas and several public presentations concerning the study were offered. A total of 105 Korean American women in the younger age bracket participated in this research, all of whom returned the questionnaires. Four questionnaires were excluded from the analysis, however, due to the high proportion of missing data. The procedure of the research project was approved by the institutional review board (IRB Code Number: 0806S35441). All the subjects who participated in the study received US $5 for study participation.
Instruments Dependent Variables. There were two dependent variables: receipt of a CBE in the participant’s lifetime and receipt of a mammogram at least once in the woman’s lifetime. “Lifetime” was used as the time frame, rather than the “past two years,” to identify which HBM constructs are actually correlated with Korean women’s receipt of CBE or mammogram at any point in their lives. Control Variables. These consisted of sociodemographic characteristics (age, marital status, employment, and years of education), the immigration factor (years in the United States), and the health accessibility factor (having a primary physician). Independent Variables. The 40-item HBM constructs (Champion, 1993) were used as the independent variables to measure barriers, susceptibility, seriousness, confidence, benefits,
and motivation. Responses to each item were scored using a 4-point Likert-type scale, ranging from “strongly disagree” to “strongly agree,” with higher averaged scores indicating a greater endorsement of the construct. A back-translation method was used to develop the Korean version of the HBM constructs among Korean American women. The final translated HBM instrument was compared with Champion’s HBM Scale-Korean (CHBMS-K; Lee, Kim, & Song, 2002), a validated Korean version of HBM instrument among Korean women in Korea, and necessary editing was conducted for further clarification of wording. Finally, a pilot interview was conducted with three older and two younger Korean women, whose input and feedback were integrated to finalize the translated questionnaire. Prior to data analysis, a reliability analysis was conducted on the HBM questions. The items “Breast cancer is a hopeless disease” and “I have a lot to gain by doing clinical breast exams” were deleted, which led to a higher reliability for the seriousness (raising Cronbach’s alpha from .83 to .87) and benefits (raising Cronbach’s alpha from .63 to .68) constructs, respectively. According to factor analysis, the seriousness scale could be divided into a cancer anxiety scale and a life in danger scale, and these scales were found to be highly reliable (Cronbach’s α = .75 and .86, respectively). With regard to the confidence construct, the item “I can recognize normal and abnormal changes in my breasts” loaded low on multiple factors; deletion of this item raised Cronbach’s alpha from .76 to .80 for this construct. The barriers and susceptibility items were found to be highly reliable (Cronbach’s α = .83 and .85, respectively), whereas Cronbach’s alpha of the motivation scale (.58) was quite low, suggesting caution in interpreting the current study’s findings in this area.
Data Analysis Univariate analysis was used to identify sociodemographic, immigration, and health care access characteristics of the sample and screening rates by age and time frame. Subsequently, hierarchical logistic regression analysis was conducted to determine the association between HBM constructs (barriers, susceptibility, seriousness, confidence, benefits, and motivation) and the receipt of CBE or a mammogram, while controlling sociodemographic characteristics (age, marital status, employment, and years of education), the immigration factor (years in the United States), and the health accessibility factor (having a primary physician). All analyses were conducted using SPSS 20.0, and a .05 significance level was used for identifying statistically significant factors.
Results The Sample’s Sociodemographic Characteristics Sociodemographic, immigration, and health care access information is presented in Table 1. Subjects were between
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Table 1. Sociodemographic Characteristics of the Study Sample (n = 202). Variable
Frequency
Age (M = 55.02, SD = 18.47) 20-29 30-39 40-49 50-59 60 and older Education (M = 13.26, SD = 3.91) Elementary and middle High school College Graduate school Marital status Never married Married Widowed, divorced, or separated Employment Yes No Monthly household income $1,499 or less $1,500-2,999 $3,000-4,499 $4,500 or more Years in the United States (M = 16.60, SD = 11.23) Less than 10 years 10-20 Years 21 years or more Heath insurance Yes No Primary physician Yes No
24 29 20 28 101 33 64 85 16 48 96 56
75 126 109 52 12 18
61 60 70 143 58 129 71
Percentagea (%) 11.9 14.3 9.9 13.9 50.0 16.7 31.7 42.1 7.9 23.8 47.5 28 37.7 62.3 57.1 27.2 6.3 9.4 31.9 31.4 36.6 70.8 28.7 63.9 35.1
a. Some of the variables’ total percentage do not equal to 100% due to missing values.
the ages of 20 and 90 years, with a mean age of 55 (SD = 18.47). About half of the women reported having at least some college education (50%) and currently married (47.5%).
Breast Cancer Screening Rates As can be seen in Table 2, 62.9% of the participants had at least one previous CBE, and 81.2% of the women aged 40 years or older indicated having had a mammogram. Examining these rates by age, the results show that only 34% of the participants aged 20 to 39 years reported ever having had a CBE, as compared with 68.8% in the age group 40 to 49 years and 75.2% of the women aged 60 years or older. The
results for ever having had a mammogram were 77.1% for those aged 40 to 59 years and 83.2% for those aged 60 years and older. With regard to the time frame in which screening had occurred, most of the CBEs were recent: 28.3% of those aged 20 to 39 years, 56.2% of those aged 40 to 59 years, and 64.4% of those aged 60 years and older reported having had a CBE within the previous two years. Examining the time frame outcomes for mammography showed similar findings: 45.9% for those aged 40 to 59 years and 62.4% for those 60 years and older had had a mammogram in the past two years.
Hierarchical Logistic Regression We conducted a set of hierarchical logistic regression analyses to examine which HBM constructs predicted utilization of a CBE or mammogram (Model 4), after controlling for sociodemographic characteristics (age, marital status, employment, education; Model 1), immigration (years lived in the United States; Model 2), and health accessibility factors (having a primary physician; Model 3). Having health insurance was not used as one of the controlling variables because it was highly correlated with having a primary physician (r = .687). Table 3 presents the results from the logistic regression for CBE, and Table 4 depicts results for mammograms. For CBEs, the first logistic regression analysis examined sociodemographic variables. This revealed that age (odds ratio [OR] = 1.04, p = .003) and marital status (OR = 3.78, p = .001) significantly predicted CBE utilization, suggesting that women who were older and married had a greater likelihood of having received this exam. In the second logistic regression analysis, the immigration factor (in terms of years in the United States) was entered. Marital status (OR = 3.50, p = .002) still significantly predicted one’s receipt of a CBE, whereas age no longer did so. Adding the health accessibility variable—that of having a primary physician (Model 3)—did not change the model. In the final analysis, six HBM constructs were entered (Model 4). Marital status (OR = 4.38, p = .001) still predicted CBE use, and the susceptibility factor of the HBM became significant (OR = 1.85, p = .038). The odds of having a CBE were greater for married women who perceived themselves to be particularly susceptible to breast cancer. For mammogram usage, the first model—which involved entering sociodemographic variables into the regression analysis—was not significant. When the immigration factor was entered into the second model, employment status (OR = 0.18, p = .03), age (OR = 0.92, p = .008), and years in the United States (OR =1.10, p = .003) were significant in predicting mammogram use. The odds of having a mammogram were increasingly greater for women who were younger, unemployed, and had resided longer in the United States. In the third model of analysis, the variable pertaining to one’s naming of a primary physician became a significant predictor (OR = 4.06, p = .048) for mammogram use, whereas age (OR = 0.90, p = .002), employment status (OR = 0.16,
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Lee et al. Table 2. Breast Cancer Screening Rates by Age and Time Frame. Age CBE (n = 202) Ever Within 1 year Within 2 years Within 3 years Mammogram (n = 149) Ever Within 1 year Within 2 years Within 3 years
20-39 (n = 53)
40-59 (n = 48)
60 and older (n = 101)
18 (34.0%) 11 (20.8%) 4 (7.5%) 1 (1.9%)
33 (68.8%) 17 (35.4%) 10 (20.8%) 6 (12.5%)
76 (75.2%) 42 (41.6%) 23 (22.8%) 9 (8.9%)
— — — —
37 (77.1%) 13 (27.1%) 9 (18.8%) 8 (16.7%)
84 (83.2%) 39 (38.6%) 24 (23.8%) 12 (11.9%)
Total (n = 202) 127 (62.9%) 70 (34.7%) 37 (18.3%) 16 (7.9%) 121 (81.2%) 52 (25.7%) 33 (16.3%) 20 (9.9%)
Note. CBE = complete breast examination.
Table 3. Hierarchical Logistic Regression for Receipt of Clinical Breast Exam at least Once in Lifetime (n = 168). Model 1a Predictors Sociodemographics Age Married/partnered (ref = Not married) Employed (ref = Not employed) Years of education Immigration Years in the United States Health accessibility Having primary physician (ref = No) HBM constructs Barriers Susceptibility Life in danger Cancer anxiety Confidence Benefits Motivation χ2 (n) −2 log likelihood Pseudo R2
Model 2b
Model 3c
SE
OR
SE
OR
SE
OR
.01 .39 .42 .06
1.04** 3.78** 1.38 1.03
.02 .4 .42 .06
1.02 3.5** 1.32 1.02
.02 .4 .42 .06
1.02 3.44** 1.32 1.03
.02
1.0
.02
1.04
.46
1.11
χ2(4) = 34.85*** 184.14 .19
χ2(5) = 37.96*** 181.03 .20
χ2(6) = 38.02*** 180.98 .20
Model 4d SE
OR
1.02 4.38** 1.45 .98 .02 1.05 .49 .79 .41 .49 .3 1.85* .33 1.46 .34 .84 .31 1.36 .35 1.16 .38 1.25 χ2(13) = 48.53*** 170.46 .25 .02 .43 .46 .07
Note. SE = standard error; OR = odd ratio; HBM = Health Belief Model. a. Logistic regression with sociodemographic characteristics. b. Logistic regression with sociodemographic characteristics + immigration factors. c. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors. d. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors + HBM constructs. *p < .05. **p < .01. ***p < .001.
p = .023), and years in the United States (OR = 1.09, p = .012) remained significant. Finally, when HBM constructs were entered (Model 4), only years in the United States remained significant (OR = 1.11, p = .021), whereas barriers (OR = 0.07, p = .026) and confidence (OR = 6.12, p = .018) became significant predictors of mammogram screening. The odds of having a mammogram were increasingly greater as confidence to carry out the necessary screening behaviors increased and barriers to conducting screening decreased.
The final model for mammogram use explained 31.8% of the variance on whether participants had ever utilized this screening method.
Discussion and Conclusions This study investigated the utilization of the CBE and mammogram among underserved Korean American immigrant women and the association of Champion’s six HBM constructs with the
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Table 4. Hierarchical Logistic Regression for Receipt of Mammogram at least Once in Lifetime (n = 139). Model 1a Predictors Sociodemographics Age Married/partnered (ref = Not married) Employed (ref = Not employed) Years of education Immigration Years in the United States Health accessibility Having primary physician (ref = No) HBM constructs Barriers Susceptibility Life in danger Cancer anxiety Confidence Benefits Motivation χ2 (n) −2 log likelihood Pseudo R2
Model 2b
Model 3c
SE
OR
SE
OR
SE
OR
.03 .58 .72 .08
.95 .69 .21* .95
.03 .63 .78 .09
.92** .48 .18* .92
.03 .68 .8 .09
.9** .37 .16* .92
.03
1.09*
.71
4.06*
.03
χ2(4) = 7.59 93.53 .06
1.1**
χ2(5) = 17.62** 83.51 .14
χ2(6) = 21.61** 79.52 .17
Model 4d SE
OR
.92 .43 .23 .86 .05 1.11* .97 .93 1.2 .07* .72 .56 .67 .77 .84 3.29 .76 6.12* 1.05 4.26 .98 6.54 χ2(13) = 45.58*** 55.55 .32 .05 .84 1.05 .11
Note. SE = standard error; OR = odd ratio; HBM = Health Belief Model. a. Logistic regression with sociodemographic characteristics. b. Logistic regression with sociodemographic characteristics + immigration factors. c. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors. d. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors + HBM constructs. *p < .05. **p < .01. ***p < .001.
receipt of breast cancer screening. Approximately 64% of the participants reported having had a CBE in their lifetime and 53% had done so within the past year, a finding similar to that of other studies (Han et al., 2000; Maxwell, Bastini, & Warda, 2000). In our study, about 81% of those 40 years and older reported ever having had a mammogram, with 42% of these occurring within the past two years. This rate is slightly higher than found in previous studies for lifetime mammogram use among Korean American women. Ma et al. (2009) reported that about 70% of their study participants had received at least one mammogram in their lifetime. Other researchers reported ever-screened rates of between 58% and 50% for mammograms (Han et al., 2000; Lee et al., 2009; Maxwell et al., 2000). The higher mammography rate in the current study was particularly apparent for those aged 60 years and older (83.2%), as compared with the younger cohort (77.1%). This finding may originate from the fact that most of the older Korean American immigrant women in this study had health insurance provided through Medicare and/ or Medicaid programs, which enabled them to receive regular health check-ups that were likely to include a mammogram. However, mammogram use in the past two years was extremely low (42%), as compared with the goal of Healthy
People 2020, which aims to have 81.1% of women aged 50 years or older having undergone a mammogram in the past two years (U.S. Department of Health and Human Services, 2010). The current study’s findings support the HBM that a person’s health service utilization depends on six HBM factors. Our finding clearly indicates that different HBM constructs have different predictive values as to one’s utilization of CBE and mammography as breast cancer screening methods. Regarding CBE use, women who perceived themselves to be susceptible to breast cancer were more likely to undergo this screening method. This study’s emphasis on the CBE adds new information to existing knowledge by demonstrating that the likelihood of having a CBE increases as one’s sense of susceptibility increases. Previous researchers using the HBM in their studies have not examined CBE as factor in measuring screening adherence. The current study’s findings concerning mammogram use revealed that the odds of having a mammogram increased when women had lower barriers to screening and greater confidence in screening. Studies using the HBM have shown that women who have never had a mammogram report significantly higher perceived barriers to mammography (Han et al., 2000) and have lower adherence scores (Wu & Ronis,
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Lee et al. 2009). The current study demonstrates that confidence in one’s ability to take action is critical. Although marital status and years in the United States were not the focus of the study, multivariate analysis revealed the critical role of these factors in undergoing breast cancer screening. First, women who were married were more likely to undergo a CBE. This finding receives support from other studies. Goodwin, Visintainer, Facelle, and Falvo (2006) found marital status to be a significant predictor of CBE. Second, participants in the current study who had lived longer in the United States tended to use mammography, a result in line with previous findings. Researchers have found, for example that Asian American women who have resided in the United States for greater lengths of time are at more advanced stages of mammography adoption (Wu et al., 2009) and are more likely to report recent mammograms (Wu & Ronis, 2009).
Limitations The current study has several limitations. Since quota sampling was used, the sampling approach was convenient and purposive. Women who participated could differ systematically from those who chose not to participate; therefore, we cannot assume this sample to be broadly representative. Moreover, women who did not attend the Korean churches or frequent the Korean senior centers used by the study were not represented in this sample, limiting the generalizability of the findings. This research is also restricted by the use of self-reports and face-to-face interviews, although the interview method enabled inclusion of older adults in the study. The responses may be subject to social desirability or desirability response bias, in which participants answer in a manner viewed favorably by others or the researcher. This could explain the slightly higher mammogram rate found in this study, specifically for older Korean women. Furthermore, we used the back-translation method to translate scales that were developed in English into Korean. Although we made every effort to develop reliable scales in the Korean language, there might be inaccuracy in the process of translation and accommodating the cultural nuance. Finally, as a result of the crosssectional design, causal relationships between factors and screening behaviors cannot be determined. Thus, future work is necessary to establish cause-and-effect relationships by, for example, conducting a longitudinal study.
Implications for Research and Practice Despite these limitations, this study indicates that the HBMinformed and tailored interventions targeting Korean American immigrant women, particularly the unmarried, are urgently needed. Such interventions would likely raise confidence in the importance and utility of screening and dismantle perceived barriers to screening. Future studies should extend information found in this study and develop and
evaluate intervention strategies to improve breast cancer screening behavior among underserved Korean American immigrant women. Findings from this study have several important implications for research and clinical practice. Programs targeted to promote Korean American women’s breast cancer screening should address preventive education, particularly providing information about the CBE. When developing educational interventions, relevant health beliefs should be considered. Efforts to decrease barriers and increase both one’s sense of susceptibility and confidence appear to be particularly promising for Korean American immigrant women, given that these factors predicted mammogram use in this study. Programs designed to improve breast cancer screening should also focus on the role of the health care provider. Primary physicians may be in the best position to provide information about and address potential barriers to cancer screening among minority immigrant women. Yu et al.’s (2001) research supports this in that women in their study indicated receiving their most useful information about how to prevent illness and improve health from their primary doctors. The results of our study indicated that women who had lived a shorter time in the United States were less likely to have had a mammogram. These women may experience barriers such as inability to communicate in English (Lee et al., 2009; Wu et al., 2008) or lack of familial support (Han et al., 2000), given that family may still reside in their home country. This suggests that immigration factors—such as length of residence in the United States and where Korean immigrants spend time—should be considered when designing outreach programs. Acknowledgments The authors thank the Korean American immigrant women who participated in this study. This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by a grant from the Minnesota Agricultural Experiment Station (MIN-55-01).
References American Cancer Society. (2009). Cancer prevention & early detection facts & figures 2009. Atlanta, GA: Author. American Cancer Society. (2013). Cancer facts & figures 2013. Retrieved from http://www.cancer.org/acs/groups/content/@epi demiologysurveilance/documents/document/acspc-036845.pdf Champion, V. L. (1993). Instrument refinement for breast cancer screening behaviors. Nursing Research, 42, 139-143.
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Chen, W. T. (2009). Predictors of breast examination practices of Chinese immigrants. Cancer Nursing, 66, 191-200. Centers for Disease Control and Prevention. (2013a). Breast cancer. Retrieved from http://www.cdc.gov/cancer/breast/ Centers for Disease Control and Prevention. (2013b). Breast cancer rates by race and ethnicity. Retrieved from http://www.cdc .gov/cancer/breast/statistics/race.htm Deapen, D., Liu, L., Perkins, C., Bernstein, L., & Ross, R. K. (2002). Rapidly rising breast cancer incidence rates among Asian-American women. International Journal of Cancer, 99, 747-750. Fejerman, L., & Ziv, E. (2008). Population differences in breast cancer severity. Pharmacogenomics, 9, 323-333. Goel, M. S., Wee, C. C., McCarthy, E. P., Davis, R. B., Ngo-Metzger, Q., & Phillips, R. S. (2003). Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care. Journal of General Internal Medicine, 18, 1028-1035. Goodwin, S. S., Visintainer, P. F., Facelle, J., & Falvo, C. E. (2006). Breast cancer screening in Rockland County, New York: A survey of attitudes and behaviors. Ethnicity & Disease, 16, 428-434. Han, Y., Williams, R. D., & Harrison, R. A. (2000). Breast cancer screening knowledge, attitudes, and practices among Korean American women. Oncology Nurse Forum, 27, 1585-1591. Judd, C. M., Smith, E. R., & Kidder, L. H. (1991). Research methods in social relations. Fort Worth, TX: Holt, Rinehart & Winston. Kwok, C., Sullivan, G., & Cant, R. (2006). The role of culture in breast health practices among Chinese-Australian women. Patient Education and Counselling, 64, 268-276. Lee, E. H., Kim, J. S., & Song, M. S. (2002). Translation and validation of Champion’s Health Belief Model Scale with Korean women. Cancer Nursing, 25, 391-395. Lee, H., Kim, J., & Han, H. R. (2009). Do cultural factors predict mammography behaviour among Korean immigrants in the USA? Journal of Advanced Nursing, 65, 2574-2584. Lee, H. Y., Ju, E. S., Vang, P. D., & Lundquist, M. (2010). Breast and cervical cancer screening disparity among subgroups of Asian American women: Does race/ethnicity matter? Journal of Women’s Health, 19, 1877-1884. Liang, W., Wang, J., Chen, M. Y., Feng, S., Yi, B., & Mandelblatt, J. S. (2009). Cultural views, language ability, and mammography use in Chinese American women. Health Education & Behavior, 36, 1012-1025.
Liang, W., Yuan, E., Mandelblatt, J. S., & Pasick, R. J. (2004). How do Chinese women view health and cancer screening? Results from focus groups and implications for interventions. Ethnicity & Health, 9, 283-304. Ma, G. X., Shive, S. E., Wang, M. Q., & Tan, Y. (2009). Cancer screening behaviors and barriers in Asian Americans. American Journal of Health Behavior, 33, 650-660. Maxwell, A. E., Bastini, R., & Warda, U. S. (2000). Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States. American Journal of Preventive Medicine, 18, 62-68. Neuman, L. (1994). Social research methods: Qualitative and quantitative approaches. Boston, MA: Allyn & Bacon. Park, S. P., Hur, H. K., Kim, G., & Song, H. Y. (2007). Knowledge, barriers, and facilitators of Korean women and their spouses in the contemplation stage of breast self-examination. Cancer Nursing, 30(1), 78-84. Rosenstock, I. M. (1966). Why people use health services. Milbank Memorial Fund Quarterly, 44(3), 94-127. Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15, 175-183. Tang, T. S., Solomon, L. J., & McCracken, L. M. (2000). Cultural barriers to mammography, clinical breast exam, and breast self-exam among Chinese-American women 60 and older. Preventive Medicine, 31, 575-583. U.S. Department of Health and Human Services. (2010). Healthy People 2020: Cancer objectives. Washington, DC: Author. Wong-Kim, E., & Wang, C. C. (2006). Breast self-examination among Chinese immigrant women. Health Education & Behavior, 33, 580-590. Wu, T. Y., Hsieh, H. F., & West, B. T. (2008). Demographics and perceptions of barriers toward breast cancer screening among Asian-American women. Women & Health, 48, 261-281. Wu, T. Y., Hsieh, H. F., & West, B. T. (2009). Stages of mammography adoption in Asian American women. Health Education Research, 24, 748-759. Wu, T. Y., & Ronis, D. (2009). Correlates of recent and regular mammography screening among Asian-American women. Journal of Advanced Nursing, 65, 2434-2446. Yu, E. S. H., Kim, K. K. K., Chen, E. H., & Brintnall, R. A. (2001). Breast and cervical cancer screening among Chinese American women. Cancer Practice, 9(2), 81-91.
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research-article2014
TCNXXX10.1177/1043659614526457Journal of Transcultural NursingLee et al.
Article
Breast Cancer Screening Behaviors Among Korean American Immigrant Women: Findings From the Health Belief Model
Journal of Transcultural Nursing 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614526457 tcn.sagepub.com
Hee Yun Lee, PhD, LCSW1, Mia Ju Stange, MA2, and Jasjit S. Ahluwalia, MD, MPH, MS3
Abstract This study examined the utilization of clinical breast examinations (CBEs) and mammograms among Korean American immigrant women and investigated how the six constructs of Health Belief Model (HBM) are associated with the receipt of breast cancer screening. Using a quota sampling strategy, 202 Korean American immigrant women were recruited in metropolitan areas in the northeastern United States. Approximately 64% of the participants reported having had at least one CBE in their lifetime, and about 81% of the sample had undergone at least one mammogram in their lifetime. Women who perceived themselves to be susceptible to breast cancer were more likely to have undergone a CBE, and women who had lower barriers to screening or demonstrated a higher level of confidence were more likely than their counterparts to undergo a mammogram. Findings suggest that HBM constructs such as susceptibility, barriers, and confidence should be considered when designing interventions aimed at promoting breast cancer screening. Keywords breast cancer screening, mammogram, clinical breast exam, Korean American immigrant women, Health Belief Model, cancer screening disparity Breast cancer is the most common cancer among American women (Centers for Disease Control and Prevention [CDC], 2013a). In 2013, the numbers of new cases and deaths for breast cancer were estimated to be 232,340 and 39,620, respectively (American Cancer Society [ACS], 2013). Although non-Latina White and African American women have the highest incidence and mortality rates for breast cancer in the United States, these rates have decreased significantly every year. The opposite trends hold true for some other ethnic minority groups, specifically Asian Americans and Pacific Islanders (CDC, 2013b). For instance, Deapen, Liu, Perkins, Bernstein, and Ross (2002) found breast cancer incidence rates for most Asian American ethnic groups to be on the rise. Fejerman and Ziv (2008) found that although Asian American women have lower breast cancer incidence per capita than do non-Latina White women, they have higher mortality rates. The significant breast cancer burden among Asian Americans and Pacific Islanders women appears to come from low rates of breast cancer screening. The ACS (2009) recommends that women aged 20 years and older have a clinical breast examination (CBE) at least once every three years and begin annual mammography at the age of 40 years. However, Goel et al. (2003) found that foreign-born individuals report
less cancer screening than do their counterparts born in the United States and that screening rates among ethnic minority women are lower than among non-Latina White women. According to the ACS (2009), Asian American women are the least likely of all American women to have had a mammogram within the last 2 years. Breast cancer specifically poses a significant burden to Korean American immigrant women, who report one of lowest breast cancer screening rates in the United States. Studies conducted among Korean American women revealed that only 58% (Han, Williams, & Harrison, 2000) to 70% (Ma, Shive, Wang, & Tan, 2009) had undergone a mammogram and 67% a CBE (Han et al., 2000) at least once in their lifetime. A more recent study by Lee, Ju, Vang, and Lundquist (2010) found Korean American women reporting the lowest rate of mammography in the past two years (57.1%). 1
University of Minnesota, Twin Cities, St. Paul, MN, USA Free University of Amsterdam, Amsterdam, Netherlands 3 University of Minnesota Medical School, Minneapolis, MN, USA 2
Corresponding Author: Hee Yun Lee, PhD, School of Social Work, University of Minnesota, Twin Cities, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN 55108, USA. Email: [email protected]
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Many studies have investigated determinants associated with Asian American women’s utilization of breast cancer screening. Such studies have reported that sociodemographic variables are strong predictors for screening. Many studies have reported that Asian American women who are younger, married, employed, and have a higher household income and education level are more likely to have had breast cancer screening (Liang et al., 2009; Wong-Kim & Wang, 2006). Moreover, health insurance and physician recommendations have been identified as the most important reinforcing factors for cancer screening (Liang, Yuan, Mandelblatt, & Pasick, 2004). Studies taking health accessibility factors into account have identified several barriers to breast cancer screening for Asian American Women. These include the financial costs of screening, the absence of health insurance, and lack of screening recommendations from physicians (Chen, 2009; Tang, Solomon, & McCracken, 2000; Wu, Hsieh, & West, 2008, 2009). Several studies have also determined that lack of English language literacy has been found to be a barrier for breast cancer screening (Lee, Kim, & Han, 2009; Wu et al., 2008). Conversely, Yu, Kim, Chen, and Brintnall (2001) found that Chinese American women who spoke English fluently were more likely to have knowledge of CBE, breast self-exam (BSE), and mammograms and to use these screening mechanisms. Several other studies have shown that Asian American women who had resided longer in the United States, had fluency in English, and who demonstrated greater awareness and practice of BSE were more likely to have regular and recent mammograms (Liang et al., 2009; Wong-Kim & Wang, 2006; Wu et al., 2009; Wu & Ronis, 2009). Similarly, a study conducted by Tang et al. (2000) found that acculturation predicted the initiation of breast cancer screening. The Health Belief Model (HBM; Rosenstock, 1966; Rosenstock, Strecher, & Becker, 1988) theoretically guided this study. This theory states that an individual’s health service utilization is primarily due to six factors: (a) Susceptibility, (b) Severity, (c) Benefits, (d) Barriers, (e) Cues to action, and (f) Self-efficacy. Although the HBM has been widely adopted to explain cancer screening compliance, it has only recently been used to predict breast cancer screening behaviors among Asian American immigrant women. For example, Han et al. (2000) found that Korean American women who had never had a CBE had significantly lower knowledge of and higher perceived barriers to the exam than did those who had previously undergone the exam. Other recent research using the HBM with Korean American women found that perceived breast cancer susceptibility and perceived benefits were significantly correlated with mammogram use (Lee et al., 2009). Moreover, studies have found that Asian women seem to perceive little susceptibility to breast cancer due to the misconception that breast cancer is a non-Latina White, Western disease (Kwok, Sullivan, & Cant 2006; Park, Hur, Kim, & Song, 2007). Similarly, a study
conducted by Wu and Ronis (2009) found that the higher the misconceptions and the less knowledge Asian American women had about breast cancer, the less likely they were to have had a mammogram. Unique and differing health beliefs and behaviors regarding breast cancer screening clearly exist within the Asian American population. There is an urgent need for studies not merely to consider Asian Americans as an aggregate but also to examine the unique subgroup differences within that broad designation. Korean American immigrant women appear to differ from other Asian American women in terms of screening behaviors, for example, and may therefore experience different barriers and facilitators to breast cancer screening. Little is known, however, about Korean American immigrant women’s breast cancer screening behavior, despite the fact that this group has disproportionally suffered from breast cancer mortality. The current study aims to better understand breast cancer screening behaviors among Korean American immigrant women by use of the HBM.
Method Research Design and Sampling We conducted a cross-sectional survey of 202 Korean American women between the ages of 20 and 90 years. These women were recruited in 2009 from two Korean senior centers and two Korean ethnic churches in a large urban metropolitan area in northeastern United States. A quota sampling strategy (Judd, Smith, & Kidder, 1991; Neuman, 1994) was used to ensure that numbers of women who are eligible for the CBE were adequately represented in the sample; CBEs are recommended every three years for women ages 20 years and older and yearly for women ages 40 years and older (ACS, 2009). For this purpose, a quota was set to ensure the inclusion of 20 to 30 women in each of the four age categories: 20 to 29, 30 to 39, 40 to 49, and 50 to 59. Likewise, the quota strategy determined recruitment of 80 to 120 Korean American women below the age of 60 years, plus a similar number of participants above the 60-year mark. Research staff approached potential participants at the aforementioned multiple sampling sites to reduce sampling bias inherent in nonprobability sampling.
Data Collection Two data collection methods were employed: all the Korean American immigrant women aged 20 to 59 years (n = 101) completed a self-administered questionnaire in Korean, whereas all the women aged 60 years and older (n = 101) participated in face-to-face interviews in Korean. The decision to conduct face-to-face interviews with participants in the older age bracket was informed by pilot interviews with three older Korean immigrant women; information gained suggested that this older demographic may lack the knowledge in
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Lee et al. terminologies associated with cancer screening necessary to understand the self-administered questionnaire. The use of face-to-face interviews enabled the researchers to include older adults in the study and to collect accurate data from them. The interviews were conducted at two senior centers located in large urban metropolitan areas in the northeastern United States. To recruit participants, flyers were posted in the public areas—such as lunch and recreational rooms—of these senior centers. A number of study informational presentations were conducted describing the purpose of the research, eligibility criteria, the types of questions to be asked, confidentiality, anonymity of participation, the duration of the interview, and the voluntary nature of participation. Willing participants were then interviewed by one of four bilingual interviewers, each of whom had work experience with older adults and had received interview training. The interviews averaged about one hour in length. A total of 108 Korean American women aged 60 years and older were interviewed; seven of these were incomplete, leading to inclusion of 101 interviews in the analysis. The younger cohort, aged 20 to 59 years, completed selfadministered surveys at two Korean ethnic churches. Similar recruitment procedures to those used for the older women were applied. Flyers were posted in the public areas and several public presentations concerning the study were offered. A total of 105 Korean American women in the younger age bracket participated in this research, all of whom returned the questionnaires. Four questionnaires were excluded from the analysis, however, due to the high proportion of missing data. The procedure of the research project was approved by the institutional review board (IRB Code Number: 0806S35441). All the subjects who participated in the study received US $5 for study participation.
Instruments Dependent Variables. There were two dependent variables: receipt of a CBE in the participant’s lifetime and receipt of a mammogram at least once in the woman’s lifetime. “Lifetime” was used as the time frame, rather than the “past two years,” to identify which HBM constructs are actually correlated with Korean women’s receipt of CBE or mammogram at any point in their lives. Control Variables. These consisted of sociodemographic characteristics (age, marital status, employment, and years of education), the immigration factor (years in the United States), and the health accessibility factor (having a primary physician). Independent Variables. The 40-item HBM constructs (Champion, 1993) were used as the independent variables to measure barriers, susceptibility, seriousness, confidence, benefits,
and motivation. Responses to each item were scored using a 4-point Likert-type scale, ranging from “strongly disagree” to “strongly agree,” with higher averaged scores indicating a greater endorsement of the construct. A back-translation method was used to develop the Korean version of the HBM constructs among Korean American women. The final translated HBM instrument was compared with Champion’s HBM Scale-Korean (CHBMS-K; Lee, Kim, & Song, 2002), a validated Korean version of HBM instrument among Korean women in Korea, and necessary editing was conducted for further clarification of wording. Finally, a pilot interview was conducted with three older and two younger Korean women, whose input and feedback were integrated to finalize the translated questionnaire. Prior to data analysis, a reliability analysis was conducted on the HBM questions. The items “Breast cancer is a hopeless disease” and “I have a lot to gain by doing clinical breast exams” were deleted, which led to a higher reliability for the seriousness (raising Cronbach’s alpha from .83 to .87) and benefits (raising Cronbach’s alpha from .63 to .68) constructs, respectively. According to factor analysis, the seriousness scale could be divided into a cancer anxiety scale and a life in danger scale, and these scales were found to be highly reliable (Cronbach’s α = .75 and .86, respectively). With regard to the confidence construct, the item “I can recognize normal and abnormal changes in my breasts” loaded low on multiple factors; deletion of this item raised Cronbach’s alpha from .76 to .80 for this construct. The barriers and susceptibility items were found to be highly reliable (Cronbach’s α = .83 and .85, respectively), whereas Cronbach’s alpha of the motivation scale (.58) was quite low, suggesting caution in interpreting the current study’s findings in this area.
Data Analysis Univariate analysis was used to identify sociodemographic, immigration, and health care access characteristics of the sample and screening rates by age and time frame. Subsequently, hierarchical logistic regression analysis was conducted to determine the association between HBM constructs (barriers, susceptibility, seriousness, confidence, benefits, and motivation) and the receipt of CBE or a mammogram, while controlling sociodemographic characteristics (age, marital status, employment, and years of education), the immigration factor (years in the United States), and the health accessibility factor (having a primary physician). All analyses were conducted using SPSS 20.0, and a .05 significance level was used for identifying statistically significant factors.
Results The Sample’s Sociodemographic Characteristics Sociodemographic, immigration, and health care access information is presented in Table 1. Subjects were between
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Table 1. Sociodemographic Characteristics of the Study Sample (n = 202). Variable
Frequency
Age (M = 55.02, SD = 18.47) 20-29 30-39 40-49 50-59 60 and older Education (M = 13.26, SD = 3.91) Elementary and middle High school College Graduate school Marital status Never married Married Widowed, divorced, or separated Employment Yes No Monthly household income $1,499 or less $1,500-2,999 $3,000-4,499 $4,500 or more Years in the United States (M = 16.60, SD = 11.23) Less than 10 years 10-20 Years 21 years or more Heath insurance Yes No Primary physician Yes No
24 29 20 28 101 33 64 85 16 48 96 56
75 126 109 52 12 18
61 60 70 143 58 129 71
Percentagea (%) 11.9 14.3 9.9 13.9 50.0 16.7 31.7 42.1 7.9 23.8 47.5 28 37.7 62.3 57.1 27.2 6.3 9.4 31.9 31.4 36.6 70.8 28.7 63.9 35.1
a. Some of the variables’ total percentage do not equal to 100% due to missing values.
the ages of 20 and 90 years, with a mean age of 55 (SD = 18.47). About half of the women reported having at least some college education (50%) and currently married (47.5%).
Breast Cancer Screening Rates As can be seen in Table 2, 62.9% of the participants had at least one previous CBE, and 81.2% of the women aged 40 years or older indicated having had a mammogram. Examining these rates by age, the results show that only 34% of the participants aged 20 to 39 years reported ever having had a CBE, as compared with 68.8% in the age group 40 to 49 years and 75.2% of the women aged 60 years or older. The
results for ever having had a mammogram were 77.1% for those aged 40 to 59 years and 83.2% for those aged 60 years and older. With regard to the time frame in which screening had occurred, most of the CBEs were recent: 28.3% of those aged 20 to 39 years, 56.2% of those aged 40 to 59 years, and 64.4% of those aged 60 years and older reported having had a CBE within the previous two years. Examining the time frame outcomes for mammography showed similar findings: 45.9% for those aged 40 to 59 years and 62.4% for those 60 years and older had had a mammogram in the past two years.
Hierarchical Logistic Regression We conducted a set of hierarchical logistic regression analyses to examine which HBM constructs predicted utilization of a CBE or mammogram (Model 4), after controlling for sociodemographic characteristics (age, marital status, employment, education; Model 1), immigration (years lived in the United States; Model 2), and health accessibility factors (having a primary physician; Model 3). Having health insurance was not used as one of the controlling variables because it was highly correlated with having a primary physician (r = .687). Table 3 presents the results from the logistic regression for CBE, and Table 4 depicts results for mammograms. For CBEs, the first logistic regression analysis examined sociodemographic variables. This revealed that age (odds ratio [OR] = 1.04, p = .003) and marital status (OR = 3.78, p = .001) significantly predicted CBE utilization, suggesting that women who were older and married had a greater likelihood of having received this exam. In the second logistic regression analysis, the immigration factor (in terms of years in the United States) was entered. Marital status (OR = 3.50, p = .002) still significantly predicted one’s receipt of a CBE, whereas age no longer did so. Adding the health accessibility variable—that of having a primary physician (Model 3)—did not change the model. In the final analysis, six HBM constructs were entered (Model 4). Marital status (OR = 4.38, p = .001) still predicted CBE use, and the susceptibility factor of the HBM became significant (OR = 1.85, p = .038). The odds of having a CBE were greater for married women who perceived themselves to be particularly susceptible to breast cancer. For mammogram usage, the first model—which involved entering sociodemographic variables into the regression analysis—was not significant. When the immigration factor was entered into the second model, employment status (OR = 0.18, p = .03), age (OR = 0.92, p = .008), and years in the United States (OR =1.10, p = .003) were significant in predicting mammogram use. The odds of having a mammogram were increasingly greater for women who were younger, unemployed, and had resided longer in the United States. In the third model of analysis, the variable pertaining to one’s naming of a primary physician became a significant predictor (OR = 4.06, p = .048) for mammogram use, whereas age (OR = 0.90, p = .002), employment status (OR = 0.16,
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Lee et al. Table 2. Breast Cancer Screening Rates by Age and Time Frame. Age CBE (n = 202) Ever Within 1 year Within 2 years Within 3 years Mammogram (n = 149) Ever Within 1 year Within 2 years Within 3 years
20-39 (n = 53)
40-59 (n = 48)
60 and older (n = 101)
18 (34.0%) 11 (20.8%) 4 (7.5%) 1 (1.9%)
33 (68.8%) 17 (35.4%) 10 (20.8%) 6 (12.5%)
76 (75.2%) 42 (41.6%) 23 (22.8%) 9 (8.9%)
— — — —
37 (77.1%) 13 (27.1%) 9 (18.8%) 8 (16.7%)
84 (83.2%) 39 (38.6%) 24 (23.8%) 12 (11.9%)
Total (n = 202) 127 (62.9%) 70 (34.7%) 37 (18.3%) 16 (7.9%) 121 (81.2%) 52 (25.7%) 33 (16.3%) 20 (9.9%)
Note. CBE = complete breast examination.
Table 3. Hierarchical Logistic Regression for Receipt of Clinical Breast Exam at least Once in Lifetime (n = 168). Model 1a Predictors Sociodemographics Age Married/partnered (ref = Not married) Employed (ref = Not employed) Years of education Immigration Years in the United States Health accessibility Having primary physician (ref = No) HBM constructs Barriers Susceptibility Life in danger Cancer anxiety Confidence Benefits Motivation χ2 (n) −2 log likelihood Pseudo R2
Model 2b
Model 3c
SE
OR
SE
OR
SE
OR
.01 .39 .42 .06
1.04** 3.78** 1.38 1.03
.02 .4 .42 .06
1.02 3.5** 1.32 1.02
.02 .4 .42 .06
1.02 3.44** 1.32 1.03
.02
1.0
.02
1.04
.46
1.11
χ2(4) = 34.85*** 184.14 .19
χ2(5) = 37.96*** 181.03 .20
χ2(6) = 38.02*** 180.98 .20
Model 4d SE
OR
1.02 4.38** 1.45 .98 .02 1.05 .49 .79 .41 .49 .3 1.85* .33 1.46 .34 .84 .31 1.36 .35 1.16 .38 1.25 χ2(13) = 48.53*** 170.46 .25 .02 .43 .46 .07
Note. SE = standard error; OR = odd ratio; HBM = Health Belief Model. a. Logistic regression with sociodemographic characteristics. b. Logistic regression with sociodemographic characteristics + immigration factors. c. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors. d. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors + HBM constructs. *p < .05. **p < .01. ***p < .001.
p = .023), and years in the United States (OR = 1.09, p = .012) remained significant. Finally, when HBM constructs were entered (Model 4), only years in the United States remained significant (OR = 1.11, p = .021), whereas barriers (OR = 0.07, p = .026) and confidence (OR = 6.12, p = .018) became significant predictors of mammogram screening. The odds of having a mammogram were increasingly greater as confidence to carry out the necessary screening behaviors increased and barriers to conducting screening decreased.
The final model for mammogram use explained 31.8% of the variance on whether participants had ever utilized this screening method.
Discussion and Conclusions This study investigated the utilization of the CBE and mammogram among underserved Korean American immigrant women and the association of Champion’s six HBM constructs with the
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Table 4. Hierarchical Logistic Regression for Receipt of Mammogram at least Once in Lifetime (n = 139). Model 1a Predictors Sociodemographics Age Married/partnered (ref = Not married) Employed (ref = Not employed) Years of education Immigration Years in the United States Health accessibility Having primary physician (ref = No) HBM constructs Barriers Susceptibility Life in danger Cancer anxiety Confidence Benefits Motivation χ2 (n) −2 log likelihood Pseudo R2
Model 2b
Model 3c
SE
OR
SE
OR
SE
OR
.03 .58 .72 .08
.95 .69 .21* .95
.03 .63 .78 .09
.92** .48 .18* .92
.03 .68 .8 .09
.9** .37 .16* .92
.03
1.09*
.71
4.06*
.03
χ2(4) = 7.59 93.53 .06
1.1**
χ2(5) = 17.62** 83.51 .14
χ2(6) = 21.61** 79.52 .17
Model 4d SE
OR
.92 .43 .23 .86 .05 1.11* .97 .93 1.2 .07* .72 .56 .67 .77 .84 3.29 .76 6.12* 1.05 4.26 .98 6.54 χ2(13) = 45.58*** 55.55 .32 .05 .84 1.05 .11
Note. SE = standard error; OR = odd ratio; HBM = Health Belief Model. a. Logistic regression with sociodemographic characteristics. b. Logistic regression with sociodemographic characteristics + immigration factors. c. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors. d. Logistic regression with sociodemographic characteristics + immigration factors + health accessibility factors + HBM constructs. *p < .05. **p < .01. ***p < .001.
receipt of breast cancer screening. Approximately 64% of the participants reported having had a CBE in their lifetime and 53% had done so within the past year, a finding similar to that of other studies (Han et al., 2000; Maxwell, Bastini, & Warda, 2000). In our study, about 81% of those 40 years and older reported ever having had a mammogram, with 42% of these occurring within the past two years. This rate is slightly higher than found in previous studies for lifetime mammogram use among Korean American women. Ma et al. (2009) reported that about 70% of their study participants had received at least one mammogram in their lifetime. Other researchers reported ever-screened rates of between 58% and 50% for mammograms (Han et al., 2000; Lee et al., 2009; Maxwell et al., 2000). The higher mammography rate in the current study was particularly apparent for those aged 60 years and older (83.2%), as compared with the younger cohort (77.1%). This finding may originate from the fact that most of the older Korean American immigrant women in this study had health insurance provided through Medicare and/ or Medicaid programs, which enabled them to receive regular health check-ups that were likely to include a mammogram. However, mammogram use in the past two years was extremely low (42%), as compared with the goal of Healthy
People 2020, which aims to have 81.1% of women aged 50 years or older having undergone a mammogram in the past two years (U.S. Department of Health and Human Services, 2010). The current study’s findings support the HBM that a person’s health service utilization depends on six HBM factors. Our finding clearly indicates that different HBM constructs have different predictive values as to one’s utilization of CBE and mammography as breast cancer screening methods. Regarding CBE use, women who perceived themselves to be susceptible to breast cancer were more likely to undergo this screening method. This study’s emphasis on the CBE adds new information to existing knowledge by demonstrating that the likelihood of having a CBE increases as one’s sense of susceptibility increases. Previous researchers using the HBM in their studies have not examined CBE as factor in measuring screening adherence. The current study’s findings concerning mammogram use revealed that the odds of having a mammogram increased when women had lower barriers to screening and greater confidence in screening. Studies using the HBM have shown that women who have never had a mammogram report significantly higher perceived barriers to mammography (Han et al., 2000) and have lower adherence scores (Wu & Ronis,
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Lee et al. 2009). The current study demonstrates that confidence in one’s ability to take action is critical. Although marital status and years in the United States were not the focus of the study, multivariate analysis revealed the critical role of these factors in undergoing breast cancer screening. First, women who were married were more likely to undergo a CBE. This finding receives support from other studies. Goodwin, Visintainer, Facelle, and Falvo (2006) found marital status to be a significant predictor of CBE. Second, participants in the current study who had lived longer in the United States tended to use mammography, a result in line with previous findings. Researchers have found, for example that Asian American women who have resided in the United States for greater lengths of time are at more advanced stages of mammography adoption (Wu et al., 2009) and are more likely to report recent mammograms (Wu & Ronis, 2009).
Limitations The current study has several limitations. Since quota sampling was used, the sampling approach was convenient and purposive. Women who participated could differ systematically from those who chose not to participate; therefore, we cannot assume this sample to be broadly representative. Moreover, women who did not attend the Korean churches or frequent the Korean senior centers used by the study were not represented in this sample, limiting the generalizability of the findings. This research is also restricted by the use of self-reports and face-to-face interviews, although the interview method enabled inclusion of older adults in the study. The responses may be subject to social desirability or desirability response bias, in which participants answer in a manner viewed favorably by others or the researcher. This could explain the slightly higher mammogram rate found in this study, specifically for older Korean women. Furthermore, we used the back-translation method to translate scales that were developed in English into Korean. Although we made every effort to develop reliable scales in the Korean language, there might be inaccuracy in the process of translation and accommodating the cultural nuance. Finally, as a result of the crosssectional design, causal relationships between factors and screening behaviors cannot be determined. Thus, future work is necessary to establish cause-and-effect relationships by, for example, conducting a longitudinal study.
Implications for Research and Practice Despite these limitations, this study indicates that the HBMinformed and tailored interventions targeting Korean American immigrant women, particularly the unmarried, are urgently needed. Such interventions would likely raise confidence in the importance and utility of screening and dismantle perceived barriers to screening. Future studies should extend information found in this study and develop and
evaluate intervention strategies to improve breast cancer screening behavior among underserved Korean American immigrant women. Findings from this study have several important implications for research and clinical practice. Programs targeted to promote Korean American women’s breast cancer screening should address preventive education, particularly providing information about the CBE. When developing educational interventions, relevant health beliefs should be considered. Efforts to decrease barriers and increase both one’s sense of susceptibility and confidence appear to be particularly promising for Korean American immigrant women, given that these factors predicted mammogram use in this study. Programs designed to improve breast cancer screening should also focus on the role of the health care provider. Primary physicians may be in the best position to provide information about and address potential barriers to cancer screening among minority immigrant women. Yu et al.’s (2001) research supports this in that women in their study indicated receiving their most useful information about how to prevent illness and improve health from their primary doctors. The results of our study indicated that women who had lived a shorter time in the United States were less likely to have had a mammogram. These women may experience barriers such as inability to communicate in English (Lee et al., 2009; Wu et al., 2008) or lack of familial support (Han et al., 2000), given that family may still reside in their home country. This suggests that immigration factors—such as length of residence in the United States and where Korean immigrants spend time—should be considered when designing outreach programs. Acknowledgments The authors thank the Korean American immigrant women who participated in this study. This article was accepted under the editorship of Marty Douglas, PhD, RN, FAAN.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by a grant from the Minnesota Agricultural Experiment Station (MIN-55-01).
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