Colorectal Cancer Beliefs, Knowledge, and Screening Among Filipino, Hmong, and Korean Americans

Transcription

1 Original Article Colorectal Cancer Beliefs, Knowledge, and Screening Among Filipino, Hmong, and Korean Americans Mi T. Tran, BA 1 ; Matthew B. Jeong, BS 1 ; Vickie V. Nguyen, BA 1 ; Michael T. Sharp, BA 1 ; Edgar P. Yu, BS 1 ; Filmer Yu, BA 1 ; Elisa K. Tong, MD 2 ; Marjorie Kagawa-Singer, PhD 3 ; Charlene F. Cuaresma, MPH 4 ; Angela U. Sy, DrPH 4 ; Janice Y. Tsoh, PhD 5 ; Ginny L. Gildengorin, PhD 1 ; Susan L. Stewart, PhD 6 ; and Tung T. Nguyen, MD 1 BACKGROUND: To the authors knowledge, there are few studies to date regarding colorectal cancer (CRC) beliefs, knowledge, and screening among multiple Asian American populations, who are reported to have lower CRC screening rates compared with white individuals. The current study was performed to assess knowledge and beliefs regarding the causes of CRC, its prevention, and factors associated with CRC screening among 3 Asian American groups. METHODS: The authors conducted an in-language survey with Filipino (Honolulu, Hawaii), Hmong (Sacramento, California), and Korean (Los Angeles, California) Americans aged 50 to 75 years who were sampled through social networks. Bivariate and multivariable analyses were conducted to assess factors associated with CRC screening. RESULTS: The sample of 981 participants was 78.3% female and 73.8% reported limited proficiency in English. Few of the participants were aware that age (17.7%) or family history (36.3%) were risk factors for CRC; 6.2% believed fate caused CRC. Only 46.4% of participants knew that screening prevented CRC (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; P<.001). Approximately two-thirds of participants reported ever having undergone CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; P<.001) and 48.6% were up to date for screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; P<.001). Factors found to be significantly associated with ever screening were being Korean (compared with Filipino), having a family history of CRC, having health insurance or a regular source of health care, and knowing that a fatty diet caused CRC. Believing that fate caused CRC and that praying prevented it were found to be negatively associated with ever screening. Factors associated with being up to date for CRC screening included being born in the United States, having a family history of CRC, and having access to health care. CONCLUSIONS: Knowledge regarding the causes of CRC and its prevention among Filipino, Hmong, and Korean individuals is low. However, health care access, not knowledge or beliefs, was found to be a key determinant of CRC screening. Cancer 2018;124: VC 2018 American Cancer Society. KEYWORDS: Asian Americans, colorectal cancer screening, Filipino, Hmong, Korean. INTRODUCTION Asian Americans are the fastest growing racial group in the United States. 1,2 Nevertheless, there is a shortage of disaggregated data regarding 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 death in the United States and for Asian Americans. 3 Although the incidence of CRC 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%), Filipino (46.3%), Korean (41.3%) and Vietnamese (42.2%) individuals were lower than that for non-hispanic white individuals (61.1%). 8 These rates remain below the Healthy People 2020 goal of 70.5%. 9 Corresponding author: Tung T. Nguyen, MD, Division of General Internal Medicine, University of California at San Francisco Medical Center, Box 0320, San Francisco, CA 94143; Tung.Nguyen@ucsf.edu. 1 Division of General Internal Medicine, University of California at San Francisco, San Francisco, California; 2 Department of General Internal Medicine, University of California at Davis, Davis, California; 3 Department of Community Health Sciences, Los Angeles Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California; 4 Department of Public Health, University of Hawai i at Manoa, Honolulu, Hawaii; 5 Department of Psychiatry, University of California at San Francisco, San Francisco, California; 6 Department of Public Health Sciences, University of California at Davis, Davis, California We gratefully acknowledge the contributions of Angela M. Jo, MD; Hy Lam; May Chee Lo; Penny Lo; M.J. Sung; Ching Wong; and the lay health educators to the recruitment and data collection efforts. The articles in this Supplement were presented at the National Center on Reducing Asian American Cancer Health Disparities (also known as the Asian American Network for Cancer Awareness, Research, and Training AANCART ) meeting held in August The organizational entities that comprise AANCART included the University of California, Davis Comprehensive Cancer Center (Lead); University of California, San Francisco; University of California, Los Angeles; University of Hawaii; Chinese Community Health Organization; and Hmong Women s Heritage Association. This supplement was funded in part through a cooperative agreement grant funded by the National Cancer Institute s Center to Reduce Cancer Health Disparities under grant 3U54 CA The views in this Supplement are those of the authors and do not necessarily reflect the opinions of the American Cancer Society, John Wiley & Sons, Inc., or the National Cancer Institute. DOI: /cncr.31216, Received: August 28, 2017, Revised: November 22, 2017; Accepted: December 13, 2017, Published online March 22, 2018 in Wiley Online Library (wileyonlinelibrary.com) 1552 Cancer April 1, 2018

2 CRC Beliefs/Tran et al Factors associated with cancer screening and its knowledge among Asian Americans include health care access, limited English proficiency (LEP), 10 and low health literacy. 11,12 Fatalism, a common Asian belief that illness is beyond one s control, has been reported to be inversely associated with cancer screening. 13,14 In addition, many Asian Americans believe that certain foods or herbs can prevent cancer, 14 which may affect their decision to undergo screening. The purpose of the current study was to evaluate factors associated with CRC screening knowledge and behaviors among Filipino, Hmong, and Korean American individuals. We postulated that knowledge and beliefs regarding what causes CRC and how it can be prevented would be associated with knowledge concerning CRC screening and its receipt. MATERIALS AND METHODS Setting The current study used cross-sectional data collected at baseline from participants in a cluster randomized controlled trial testing the efficacy of lay health educator (LHE) outreach in increasing CRC screening among the 3 targeted groups. Participants included Filipino participants (304 participants) from Honolulu, Hawaii; Hmong participants (329 participants) from Sacramento, California; and Korean participants (348 participants) from Los Angeles, California. Details regarding recruitment and intervention were reported elsewhere. 15,16 The institutional review boards of the University of California at San Francisco and the University of Hawai i approved study procedures. Participants and Data Collection Community organizations recruited 83 LHEs: 26 Filipino LHEs were recruited by Nursing Advocates and Mentors Inc (Waipahu, Hawaii); 29 Hmong LHEs were recruited by the Hmong Women Heritage Association (Sacramento, California); and 28 Korean LHEs were recruited by the Korean Resource Center (Los Angeles, California) and local Korean churches. LHEs were recruited through radio advertisements, 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 the recruitment of participants was similar across the sites. Each LHE recruited approximately 12 to 15 participants from the network of individuals they knew, which may have included family members, friends, and people they knew who were clients at the local agency. Eligibility criteria for participants were age 50 to 75 years; self-identification as Filipino (in Hawaii), Hmong (in Sacramento), or Korean (in Los Angeles); speaking a language that the LHE could speak, such as English, Ilokano and Tagalog (languages of the Philippines), Hmong, or Korean; living and intending to stay in the relevant area for at least 6 months; willingness to participate in a study involving nutrition or CRC screening; having no history of CRC or medical problems that would prevent the participant from attending education sessions; and not having another household member taking part in the study. Although the survey respondents were recruited to participateinaninterventionstudy,thedataanalyzedin the current 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-andpencil 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 among the older Hmong population. Each participant received $20 for completing the survey. Data were collected from August 2012 through January Because this report used data from the baseline survey of a randomized controlled trial, the sample size was calculated to detect an intervention effect, not for the differences in knowledge or beliefs. Measures Sociodemographic variables assessed included age, sex, birthplace, years in the United States, 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 3 categories). Health care access and use were measured by participants reporting whether they had health insurance, a regular source of care, a primary care physician, or an Asian primary care physician; saw a physician within the past year or saw a traditional healer within the past 12 months; and ever needed a medical interpreter, and if help was at least needed sometimes, often, or always in reading health materials received from physicians or pharmacies. Health status was measured by self-rated health (excellent/very good/good vs. fair/poor) and if there was 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 regarding CRC prevention was based on the selection of the following Cancer April 1,

3 Original Article TABLE 1. Sociodemographic, Health, and Health Care Characteristics Among Filipino, Hmong, and Korean Participants (N 5 981) Characteristic Total, % N Filipino, % N Hmong, % N Korean, % N Sociodemographics Age y 65.2 a Female 78.3 a Foreign-born 96.3 a Lived in the United States 10 y Limited English proficiency 73.8 b High school graduate 55.5 b Employed 35.9 b Married Annual household income <$20, b $20, Unknown Health and health care Family history of CRC 6.3 b Fair or poor self-reported health 38.2 b Has health insurance 86.1 b Has regular source of health care 83.3 b Has primary care physician 83.4 b Has Asian primary care physician 54.8 b Saw a physician within the past 12 mo 81.6 b Need interpreter for health care visit 36.1 b Need help reading health materials 55.3 b Saw a traditional healer within past 12 mo 27.4 b Abbreviation: CRC, colorectal cancer. a P<.05 for the comparison between the 3 ethnic groups. b P<.001 for the comparison between the 3 ethnic groups. recommended methods: undergoing medical tests to find blood or polyps in the colon, taking aspirin, not smoking, exercising regularly, and eating enough fiber and vegetables. We considered the selection of unproven causes or prevention methods to be beliefs. Beliefs regarding 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 regarding CRC prevention included having regular bowel movements, drinking enough water, not drinking alcohol, taking traditionalasianherbsorcookingherbalsoups,seeingatraditional Asian healer, keeping a positive attitude, getting enough rest, praying, doing nothing, or other. CRC screening status was assessed through selfreport of: 1) ever having had a CRC screening test (fecal occult blood test, sigmoidoscopy, or colonoscopy); and 2) being up to date with screening (fecal occult blood test within the past year, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years). Statistical Analysis Descriptive statistics were computed for all of the measures, including means, standard deviations, and percentages. The dependent variables in the current study analysis were: 1) knowledge that undergoing medical tests (screening) to find blood or polyps in the colon prevented CRC (yes/no); 2) ever undergone 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 were used to analyze participant responses in bivariate and multivariable analyses. Generalized estimating equations were used to account for within-cluster correlation of outcomes between participants recruited by the same LHE. For each multivariable model, the independent variables included sociodemographics, health care access and use, health status, and knowledge and beliefs regarding the causes and prevention of CRC. We used complete case analysis, and there were very few missing data. RESULTS Table 1 shows that 65.2% of participants were aged 50 to 64 years with 78.3% being female, 65.9% married, and 96.3% foreign-born, with 85.1% having lived in the United States for >10 years. The majority of Hmong (95.7%) and Korean (92.0%) respondents had LEP, whereas high school graduation rates were 73.7% for 1554 Cancer April 1, 2018

4 CRC Beliefs/Tran et al TABLE 2. CRC Knowledge, Beliefs, and Behaviors Among Filipino, Hmong, and Korean Participants (N 5 981) Total, % N Filipino, % N Hmong, % N Korean, % N % CRC causes: knowledge Getting older 17.7 a Family history of CRC 36.3 a Colon polyps 34.2 a Inflammatory bowel disease 27.0 a Fatty diet 57.3 a Lack of regular physical activity 32.6 a Alcohol use 34.5 a Smoking 30.8 a CRC causes: beliefs Stress 38.7 a Toxins in food or water 31.7 a Lack of rest 14.6 a Working too hard 17.0 a Negative emotions or unhappiness 9.7 a Fate, Heaven s or God s will 6.2 b Bad karma CRC prevention: knowledge Get medical tests to find blood or polyps in the colon (screening) 46.4 a Take aspirin 2.5 b Do not smoke 32.6 a Exercise 50.7 a Eat enough fiber and vegetables 64.9 a CRC prevention: beliefs Have regular bowel movements 51.9 a Drink enough water 49.2 a Do not drink alcohol 33.7 a Get enough rest 30.6 a Keep a positive attitude 29.4 a Pray 25.4 a Take traditional Asian herbs or cook herbal soups 7.7 a See a traditional Asian healer 27.4 a Nothing 1.9 b CRC prevention: behaviors Ever screened for CRC 66.0 a Up to date for CRC screening 48.6 a Abbreviation: CRC, colorectal cancer. a P<.001 for the comparison between the 3 ethnic groups. b P<.05 for the comparison between the 3 ethnic groups. 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. The majority of participants had health insurance (86.1%), a regular source of health care (83.3%), and a primary care physician (83.4%), and had seen a physician within the past 12 months (81.6%). Overall, 36.1% of participants reported needing an interpreter during a health care visit, and 55.3% reported needing help reading health materials. Approximately one-fourth of participants (27.4%) had seen a traditional healer within the past 12 months. Except for length of US residence and marital status, there were significant differences noted across the 3 ethnic groups for all sociodemographic, health, and health care variables. Knowledge and Beliefs Regarding CRC Risk Factors Table 2 shows the CRC-related variables. Few respondents knew about the main risk factors for 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%). Hmong were significantly less likely to know about colon polyps (44.8% of Filipino, 1.5% of Hmong, and 53.7% of Korean participants; P<.001) and a family history of CRC (49.3% of Filipino, 5.5% of Hmong, and 54.0% of Korean participants; P<.001) as risk factors. For causes of CRC, 57.3% of participants correctly identified fatty diet, 32.6% correctly identified lack of physical Cancer April 1,

5 Original Article activity, 34.5% correctly identified alcohol use, and 30.8% correctly identified smoking cigarettes. Prominent beliefs regarding causes of CRC included stress (38.7%) and toxins in food or water (31.7%), whereas 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 whereas only 41.8% of Filipinos and 6.7% of Hmong did (P<.001). Knowledge and Beliefs Regarding CRC Prevention Methods When asked about CRC prevention methods, 64.9% of participants correctly identified eating fiber and vegetables and 50.7% correctly identified exercising regularly, but only 32.6% knew about not smoking and 2.5% were aware of taking aspirin. Common beliefs regarding 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 participants (7.7%) believed consuming Asian herbs/soups or seeing a traditional healer (27.4%) 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 (74.3% of Filipino, 10.6% of Hmong, and 55.8% of Korean participants; P<.001). Approximately two-thirds (66.0%) reported ever receiving CRC screening (76.0% of Filipino, 72.0% of Hmong, and 51.4% of Korean participants; P<.001) and 48.6% were up to date with CRC screening (62.2% of Filipino, 43.8% of Hmong, and 41.4% of Korean participants; P<.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 [95% CI], ), having a source of health care (OR, 2.20; 95% CI, ), and having an Asian primary care physician (OR, 0.65; 95% CI, ). Hmong (OR, 0.31; 95% CI, ) and Korean (OR, 0.28; 95% CI, ) participants were less likely than Filipinos to know that screening prevented CRC. Knowing that a fatty diet was a cause (OR, 2.23; 95% CI, ) and that exercising can prevent CRC (OR, 1.78; 95% CI, ) were associated with knowledge that screening prevented CRC. Beliefs associated with this outcome included believing in karma as a cause of CRC (OR, 0.21; 95% CI, ) and that seeing a traditional healer (OR, 3.68; 95% CI, ), having regular bowel movements (OR, 2.82; 95% CI, ), abstaining from alcohol (OR, 2.64; 95% CI, ), and getting rest (OR, 0.54; 95% CI, ) prevented CRC. Korean participants were less likely (OR, 0.42; 95% CI, ) than Filipinos to have ever been screened for CRC. Having a family history of CRC (OR, 1.78; 95% CI, ), a regular source of health care (OR, 2.16; 95% CI, ), and health insurance (OR, 1.76; 95% CI, ) were found to be associated with ever screening. The only knowledge item found to be associated with ever screening was knowing that a fatty diet caused CRC (OR, 1.93; 95% CI, ). Those who believed that fate caused CRC (OR, 0.47; 95% CI, ) and that praying prevented CRC (OR, 0.61; 95% CI, ) were less likely to have ever been screened. Factors associated with being up to date for CRC screening included US birthplace (OR, 5.62; 95% CI, ), a family history of CRC (OR, 2.12; 95% CI, ), having health insurance (OR, 1.89; 95% CI, ), having a regular source of health care (OR, 1.88; 95% CI, ), having a primary care physician (OR, 1.93, 95% CI, ), and having seen a physician within the past 12 months (OR, 2.37; 95% CI, ). No knowledge or belief was associated with being up to date with CRC screening. DISCUSSION To our knowledge, this is the first study to date to evaluate CRC knowledge and beliefs among Hmong Americans, and one of only a few studies among Filipino and Korean Americans The current study findings demonstrate that knowledge about CRC causes and prevention among all 3 groups was low, with Hmong individuals having very low levels of knowledge. Both Hmong and Korean participants were less likely than Filipinos to know that CRC screening can prevent CRC, whereas Koreans were less likely than Filipinos to have ever been screened. The participants had a wide range of beliefs regarding CRC causes and prevention. Surprisingly, few held fatalistic beliefs, which primarily were associated with CRC knowledge and less so with CRC screening. The most important factors found to be associated with receipt of CRC screening 1556 Cancer April 1, 2018

6 CRC Beliefs/Tran et al TABLE 3. Multivariable Models of Factors Associated With CRC Screening Knowledge and Behaviors Among Filipino, Hmong, and Korean Participants (N 5 955) Know Screening Prevents CRC OR (95% CI) N Ever Screened for CRC OR (95% CI) N Up to Date for CRC Screening OR (95% CI) N Sociodemographics Born in the United States (referent: other) 0.97 ( ) 1.56 ( ) 5.62 ( ) High school education (referent: <high school) 1.72 ( ) 0.96 ( ) 0.91 ( ) Ethnicity Hmong (referent: Filipino) 0.31 ( ) 0.85 ( ) 0.61 ( ) Korean (referent: Filipino) 0.28 ( ) 0.42 ( ) 0.63 ( ) Hmong (referent: Korean) 1.10 ( ) 2.03 ( ) 0.97 ( ) Health and health care factors Has family history of CRC (referent: no) 0.96 ( ) 1.78 ( ) 2.12 ( ) Has health insurance (referent: no) 0.84 ( ) 1.76 ( ) 1.89 ( ) Has a regular source of health care (referent: no) 2.20 ( ) 2.16 ( ) 1.88 ( ) Has a primary care physician (referent: no) 1.03 ( ) 1.61 ( ) 1.93 ( ) Of those who have a primary care physician, 0.65 ( ) 0.76 ( ) 0.78 ( ) the physician is Asian (referent: no) Saw a physician within the past 12 mo (referent: no) 1.33 ( ) 1.36 ( ) 2.37 ( ) Knowledge regarding causes of CRC Fatty diet (referent: no) 2.23 ( ) 1.93 ( ) 1.38 ( ) Beliefs regarding CRC causes Belief in karma (referent: no) 0.21 ( ) 2.56 ( ) 2.65 ( ) Fate or God s will (referent: no) 0.86 ( ) 0.47 ( ) 0.60 ( ) Knowledge concerning CRC prevention Exercising (referent: no) 1.78 ( ) 1.00 ( ) 1.18 ( ) Beliefs regarding what can prevent CRC Praying (referent: no) 1.10 ( ) 0.61 ( ) 0.76 ( ) Getting rest (referent: no) 0.54 ( ) 0.86 ( ) 0.92 ( ) Seeing a traditional healer (referent: no) 3.68 ( ) 0.56 ( ) 1.01 ( ) Having regular bowel moments (referent: no) 2.82 ( ) 1.21 ( ) 1.10 ( ) Avoid alcohol (referent: no) 2.64 ( ) 0.98 ( ) 1.16 ( ) Abbreviations: 95% CI, 95% confidence interval; CRC, colorectal cancer; OR, odds ratio. All models also included the following covariates that were not found to be significant in any model: age, sex, years in the United States, English proficiency, employment, marital status, income, self-rated health, needing an interpreter, needing help reading health materials, saw a traditional healer within the past 12 months, knowledge of some CRC causes (lack of physical activity and alcohol use), beliefs regarding some CRC causes (lack of rest, negative emotions, working too hard, stress, and toxins), knowledge regarding some prevention methods (taking aspirin, not smoking, and eating fiber), and beliefs regarding some prevention methods (drinking water, taking traditional Asian herbs, keeping a positive attitude, and doing nothing). were US birthplace, a family history of CRC, and health care access. Filipino, Hmong, and Korean Americans all had low levels of knowledge regarding CRC. The very low levels of knowledge concerning 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 traditionally were farmers in Southeast Asia. 20,21 In addition, the Hmong also had low levels of health literacy, which is not surprising because many older Hmong cannot read the Hmong language because it has only recently been put into written form. 22 The current study findings for all 3 groups reinforce the need for more culturally and linguistically appropriate materials regarding CRC and its prevention. Compared with Filipinos, Hmong and Korean participants had lower levels of knowledge regarding CRC screening. Although 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 with Filipino participants. In the multivariable models, Korean Americans also were found to be less likely than Filipino participants to ever have been screened for CRC, even after adjusting for covariates such as LEP, health literacy, health care access, and knowledge and beliefs regarding 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 also were 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 indicates that participants are interested in preventing Cancer April 1,

7 Original Article CRC. One implication for interventions is that there may not be a need to discourage people from holding beliefs regarding CRC prevention if they are not harmful, provided these individuals also are taught about the proven methods. 23 Contrary to common perceptions and other articles concerning health beliefs among Asian individuals, 24,25 the majority of participants in the current study did not hold fatalistic beliefs regarding CRC. This was particularly surprising for Hmong Americans, given that Hmong culture tends to revolve around shamanism and to 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 the disease. Interventions to increase CRC screening in these populations need to address these beliefs in culturally sensitive ways. Respondents who were born in the United States were 5 times more likely than immigrants to be up to date with CRC screening, a finding found in other studies and one that suggests greater familiarity with the US health care system. 8,27,28 Those individuals with a family history of CRC were appropriately more likely to have undergone screening and be up to date. The most striking finding was that knowledge and belief appeared to have a minimal effect on CRC screening status. More notably, access to health care was found to have a strong impact on screening behavior. Participants who had health insurance and a regular source of care were more likely to have received CRC screening and be up to date for screening, whereas those who had a regular physician or saw their physician within the past 12 months were more likely to be up to date with screening. To improve CRC screening rates among Filipino, Hmong, and Korean American populations, improving access to health care through systematic interventions may be more effective than attempting to change the beliefs of these individuals. 29 These interventions may include increasing health insurance coverage through the Patient Protection and Affordable Care Act and ensuring that these patients have regular visits with their primary care providers. There are several limitations to the current study, including self-reports of CRC screening, the validity of which have to our knowledge not been well studied in these populations. In addition, because this was a crosssectional study, causality could not be concluded. Each ethnic group was selected from a different geographic area, and therefore differences between groups may be due to unmeasured geographically determined confounders. The samples had individuals with lower levels of education and more female participants, foreignborn participants, and participants with LEP than the US 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 current 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. Conclusions The findings of the current study demonstrate that there are many prevalent beliefs regarding CRC among Filipino, Hmong, and Korean Americans. It is interesting to note that, with the exception of fatalism, the majority of these beliefs are not negatively associated with knowledge regarding CRC screening or screening behaviors. The key determinants of CRC screening are not knowledge or beliefs concerning CRC causes and prevention but rather health care access. The results of the current study illustrate the importance of being patient-centered and culturally sensitive in the promotion of CRC screening among these populations, as well as the need for health care access to maintain good health in these underserved individuals. FUNDING SUPPORT Supported by a grant from the National Cancer Institute (U54CA153499) through the Center to Reduce Cancer Health Disparities. CONFLICT OF INTEREST DISCLOSURES Elisa K. Tong received a grant from the American Cancer Society (RSGT CPPB) for work performed as part of the current study. Marjorie Kagawa-Singer received a grant from the National Cancer Institute (U01 CA114640) for work performed as part of the current study. Angela U. Sy and Ginny L. Gildengorin received grant funding payment for the research reported in the current study from the National Institutes of Health. Janice Y. Tsoh received a grant from the National Cancer Institute (R01CA138778) for work performed as part of the current study. AUTHOR CONTRIBUTIONS Conceptualization, writing-original draft, and writing review and editing: Mi T. Tran. Writing-original draft: Matthew B. Jeong, Vickie V. Nguyen, Michael T. Sharp, Edgar P. Yu, and Filmer Yu. Development and execution of the concept and writing review and editing: Elisa K. Tong, Marjorie Kagawa-Singer, Charlene F. Cuaresma, and Angela U. Sy. Conceptualization, methodology, writing-original draft, and writing review and editing: Janice Y. Tsoh, Ginny L. Gildengorin, Susan L. Stewart, and Tung T. Nguyen Cancer April 1, 2018

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