Heterogeneous Demographic and Cultural Profiles of Chinese American Patients Nonadherent to Colorectal Cancer Screening: A Latent Class Analysis
Strong, Carol PhD; Ji, Cheng Shuang PhD; Liang, Wenchi PhD; Ma, Grace PhD; Brown, Roger PhD; Wang, Judy Huei-yu PhD
Author Affiliations: Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Strong); Cancer Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC (Drs Ji, Liang, and Wang); Department of Public Health and Center for Asian Health, Temple University, Philadelphia, Pennsylvania (Dr Ma); and School of Nursing, University of Wisconsin–Madison (Dr Brown).
Funding for this study was provided by National Cancer Institute grants R01 CA121023. The National Cancer Institute had no further role in study design, data collection, analysis, interpretation, the writing of the report, or in the decision to submit the paper for publication.
The authors have no conflicts of interest to disclose.
Correspondence: Judy Huei-Yu Wang, PhD, Cancer Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center; Suite 4100, 3300 Whitehaven St, NW, Washington, DC 20007 (firstname.lastname@example.org).
Accepted for publication December 21, 2012.
Background: Colorectal cancer (CRC) is one of the leading causes of cancer death in Chinese Americans, but their CRC screening rates remain low.
Objective: We examined subgroups of Chinese American patients nonadherent to CRC screening guidelines to better inform clinical practices to effectively promote screening.
Methods: Using latent class analysis of data from 327 participants recruited from 18 primary care clinics, we classified nonadherent patients based on sociodemographics, screening barriers, and attitudinal and clinical factors for CRC screening.
Results: The best-fitting latent class analysis model described 3 distinctive classes: Western healthcare class (36%), Eastern healthcare class (18%), and mixed healthcare class (46%). Western healthcare class patients were highly educated, with average US residency of 20 years, a high level of English proficiency, the least Eastern cultural views of care, and the greatest exposure to physician recommendations, but reported having no time for screenings. Eastern healthcare class patients were highly educated seniors and recent immigrants with the least CRC knowledge and the most Eastern cultural views. Mixed healthcare class patients had low level of education, resided in the United States for 20 years, and half had sought services of their physicians for at least 3 years, but their knowledge and cultural views were similar to those of Eastern healthcare class patients.
Conclusions: Nonadherent Chinese American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of nonadherent patients.
Implications for Practice: Training primary care physicians to recognize patients’ different demographic characteristics and healthcare beliefs may facilitate physicians’ communication with patients to overcome their barriers and improve screening behaviors.
Colorectal cancer (CRC) is the second most common cancer type and 1 of the top 3 leading causes of cancer death among Chinese Americans.1 Various CRC screening methods are proven effective in early detection of CRC, such as fecal occult blood test (FOBT) and colonoscopy.2–4 Yet the CRC screening rates among Chinese Americans are lower than those among non-Hispanic white Americans5–7 and are heterogeneously presented in the subgroups of Chinese Americans. For example, recent literature showed that about 54% of Chinese Americans adhered to CRC screening guidelines,6 whereas other research indicated that only 40% of less-acculturated Chinese Americans used recommended CRC screening tests.8
A few studies have examined predictive factors for the utilization of CRC screening in Chinese Americans.8–13 As in other ethnic groups,14,15 Chinese Americans’ low utilization of CRC screening is significantly related to the lack of physician recommendation13,16 and health insurance,8,12 recent immigrant status or low-acculturation level,10,13,16 and low perceived susceptibility of CRC and cancer worry.10,13 In addition, previous studies found that Chinese American traditional views of healthcare (eg, preferring primary prevention methods, such as diet over medical checkups) predicted their CRC screening behavior.9,17
Chinese Americans are one of the fastest growing populations in the United States.18 It is notable that the majority of Chinese Americans are foreign born (∼70%),18 and more than half have limited English proficiency.19 A previous study showed that the incidence of colon cancer among Chinese Americans was higher than that reported in mainland China,20 suggesting that Chinese who migrated to the United States might have increased risk for developing CRC.21 Therefore, it is important to increase Chinese Americans’ awareness of CRC risk and screening behavior. There is limited knowledge about the homogeneity of Chinese Americans who are nonadherent to recommended CRC screening guidelines. Research indicates that identifying the subtypes of patients is advantageous for healthcare providers to tailor their communication with patients by focusing on their particular needs and barriers and consequently promote their health-seeking behaviors.22–24
To increase Chinese Americans’ participation in CRC screening, it is important to understand whether there are different demographic, clinical, and psychosocial characteristics associated with their nonadherence to the US Preventive Services Task Force (USPSTF) CRC screening guidelines. In the guidelines, average-risk patients aged 50 to 75 years should have either (1) annual high-sensitivity FOBT, or (2) sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years, or (3) screening colonoscopy at intervals of 10 years.25 Thus, average-risk patients who have not had 1 of the 3 CRC screening tests in the recommended intervals are known as nonadherent. For this purpose, we utilize baseline data from an ongoing physician-based CRC intervention trial that enrolled Chinese Americans nonadherent to the above USPSTF guidelines from Chinese-speaking primary care physician’s offices to classify the subtypes of nonadherent Chinese American patients and provide clinical implications for promoting their adherence to CRC screening. This study was not designed to test health behavior models, but included constructs related to Chinese American patients’ CRC screening behavior, such as knowledge, attitudes (ie, barriers and cancer worry), and beliefs (ie, cultural views) at baseline in addition to their clinical access factors (ie, physicians’ recommendations and length of relationship) to understand their nonadherent behaviors and to inform the content of our physician-based CRC intervention.
Sample and Procedures
This physician-based randomized controlled trial has been approved by Georgetown University and Temple University institutional review boards. We enrolled Chinese American primary care physicians and their Chinese American patients from the metropolitan Washington, DC; New York; and Philadelphia areas. All participating physicians, who were bilingual and able to speak Chinese (ie, Mandarin and/or Cantonese) and English languages, were randomized into either an intervention arm or a control arm. Physicians in the intervention arm received Chinese-language educational materials (describing cognitive, cultural, and attitudinal factors contributing to explain Chinese American patients’ CRC screening behavior) and 2 rounds of in-office educational training (using standardized patients to train physicians how to speak with patients about their barriers to CRC screening). In contrast, physicians in the control arm practiced usual care without any educational training and materials. Participating patients would take 2 telephone interviews: (1) baseline assessment and (2) follow-up interview 1 year after the completion of baseline interviews. For this analysis, we only used the baseline assessment, which was independent of the randomization procedure.
Criteria for physicians participating in this study included (1) being able to communicate with their patients in Chinese (ie, Mandarin and Cantonese); (2) having more than 75 Chinese patients older than 50 years old; and (3) practicing primary care, family medicine, or geriatrics. We identified 109 potentially eligible Chinese American primary care physicians in the study areas (40 in DC and 69 in Pennsylvania and New York) through different resources including Chinese American physician directories, yellow pages, local newspaper advertisements, existing Asian Community Cancer networks (National Cancer Institute funded, principal investigator: G.M.), and the American Medical Association master file. Their Chinese ethnicity was identified by their last name on the list. Bilingual research staff were hired to recruit physicians and their patients. From October 2008 to December 2011, we were able to contact 62 physicians. Among them, 25 physicians consented to participate in the study (a 40% response rate), 25 refused, and 12 had too small practices to achieve the accrual goal. Each physician office was expected to enroll at least 24 Chinese American patients, but some offices enrolled fewer than 24 patients for various reasons. Patients from 18 of the 25 physicians were included for our analysis because the other 7 physicians were newly enrolled and in the process of enrolling patients for participation.
Eligible patients (1) were aged 50 to 75 years, (2) were active patients of participating physicians, who had visited the physicians at least once in the past 2 years from the enrollment point, (3) had no personal or family history of CRC, and (4) were nonadherent to the USPSTF CRC screening guidelines for persons at average risk who have not had a FOBT for more than 1 year, or a sigmoidoscopy for more than 5 years, or a colonoscopy for more than 10 years, including those who had never screened.25 Patients were enrolled according to the following procedures. First, research staff used patients’ first and last names to identify potential age-appropriate Chinese American patients from the physician’s database or billing records, and then they randomly selected patients from the potentials to generate a calling list for this study. Second, our research staff called potential patients to invite their participation and screen their eligibility. Currently, 327 of 671 eligible patients (49%) from the 18 physicians consented to participate in this study and have completed baseline assessment via telephone.
Sociodemographics include gender, age, years of residency in the United States, English proficiency, employment (yes vs no), and education (college or higher vs high school or lower). English proficiency was assessed by asking about the patients’ ability to speak, read, and write in English on a 5-point scale (α = .99).26 Higher scores suggest better proficiency.
Clinical care factors included whether they received physician recommendation for CRC screening in the past 2 years (yes vs no), length of patient-physician relationship (≥3 vs <3 years), prior CRC screening (ever vs never screened), and whether they had any kind of health insurance coverage (yes vs no).
Patients’ knowledge of CRC screening was assessed by asking (1) at which age average-risk adults should start CRC screening and (2) the different time intervals for CRC screening modalities including FOBT, sigmoidoscopy, and colonoscopy. A correct answer to each question earned 1 point. The total score of CRC screening knowledge were summed and divided into 2 groups: “high” (≥2 points) and “low” (0 or 1 point).
Chinese cultural views of cancer and health were assessed by 20 items from the previously validated Cultural Views of Health Care scale in Chinese American populations (α = .82).27,28 Examples of questions included asking about their fatalistic beliefs about cancer, healthcare, self-care, and traditional Chinese medicine. Patients responded to each item with a range of options from 1 = strongly agree to 5 = strongly disagree. High standardized mean scores on cultural views indicate a more Eastern view of care, whereas low scores reflect a more Western view of care.
Attitudinal factors include worry about developing CRC and barriers to CRC screening. Cancer worry was assessed by 1 item (“Overall, how worried are you that you might get colorectal cancer someday?”), which has been used in our previous research in Chinese Americans.17 Patients responded to the item with choices from 1 = very worried to 4 = not worried. The answers were dichotomized into worried (including “somewhat worried,” “worried,” and “very worried”) versus not worried at all.
Barriers to CRC screening were inquired with a list of reasons presented for interviewers to choose. Multiple responses were an option, but we used only the top 3 commonly cited reasons for analysis. They are (1) no symptoms, (2) no time, and (3) access barriers (including at least 1 of language barrier, no physician recommendation, no transportation, or no health insurance coverage). Patients answered yes or no for each of the barriers separately.
Latent class analysis (LCA) was conducted to profile differences in measured variables among nonadherent Chinese American patients. Latent class analysis is a method widely used to detect homogeneity in a potentially heterogeneous group by evaluating associations among responses to a set of indicators. The LCA is based on an assumption that people differ in their behaviors as a result of some observable latent trait.29 We used Mplus version 7 to conduct LCA and the following assessments to determine the number of classes.30
To determine the number of classes, we used various information criteria such as AIC (Akaike’s information criterion), BIC (Bayesian information criterion), and CAIC (consistent AIC). Participants were assigned to latent classes according to their maximal posterior probabilities. The smaller the BIC, AIC, and CAIC, the better the model fits the data.31 We further compared the improvement of fit between neighboring models (k class vs k-1 class) by the Lo-Mendell-Rubin likelihood ratio test (LRT) and the Vuong-Lo-Mendell-Rubin LRT. We reported the P values of these tests to verify whether the improvement of fit was significant.32
After classes were identified, multilevel regression analyses were conducted for pairwise comparisons. Because the patients were nested under physicians, a multilevel contrast analysis was conducted to model this within physician dependency assessing the differences in mean values of the continuous variables and in proportional values of the categorical variables across the classes. A combination of multilevel logit and continuous models was used to obtain the SEs and 95% confidence intervals.
The characteristics of the overall sample are presented in Table 1. In general, the mean age of the study sample was 59 (SD, 7.41) years, and on average, years staying in the United States are about 19 (SD, 9.34) years. Approximately 53% of the sample were female, 51% were college graduates or greater, and 59% were employed. The majority of our sample had health insurance coverage (87%). About 42% of the patients reported having received physician recommendation for CRC screening, and 47% have been seeing a current physician for more than 3 years. However, 90% of our participants had never had CRC screening.
Results from the LCA showed that the 3-class model had the lowest values of BIC and CAIC and a fairly low AIC value, indicating the best goodness of fit to the data (Table 2). Results from both LRTs confirmed that the 3-class model has significant improvement of fit to data compared with the 2-class model. Furthermore, the results of the Vuong-Lo-Mendell-Rubin LRT and Lo-Mendell-Rubin LRT indicated that the 4-class model did not improve the model fit compared with the 3-class model. Given that the results of both LRTs agreed on the choice of a 3-class model and that it had better values of BIC and CAIC, the 3-class model solution was warranted to address the goodness of fit to our data.
We compared differences in demographics, clinical access factors, knowledge, cultural beliefs, and attitudinal factors among the 3 classes after adjusting SEs. We presented the mean scores and percentage distribution of variables for each class in Table 3 and described the significance of pairwise comparisons between classes in Table 4. As shown in Table 3, patients in class 1 (36% of the sample) had the youngest age (mean, 53 [SD, 2.55] years), the longest residency in the United States (mean, 20.25 [SD, 11.05] years), and highest level of English proficiency (mean, 3.01 [SD, 0.68]) among the 3 classes. Approximately 91% of them were college-educated and full-time employed. Most of them (60%) had sought services of their physicians for over 3 years, similar to the rate of receiving their physician’s recommendation for CRC screening (59%) in contrast to approximately one-third of patients in the other 2 classes reporting the receipt of physician recommendation. Furthermore, as shown in Table 4, patients in class 1 had the highest level of CRC screening knowledge among the 3 classes and the lowest Chinese cultural views of cancer and health (both P < .05). Although they were more likely to worry about developing CRC (P < .01) than the other 2 classes, more patients in class 1 reported that time was a salient barrier to obtaining timely CRC screening (P < .001) in contrast to patients in the other 2 classes whose key barriers were attributed to having no symptoms and encountering access barriers to screening such as lack of transportation, insurance coverage, and English ability (P < .05). In short, patients in class 1 were more likely to associate with Western primary care and were less likely to face language and cultural barriers to healthcare access. They were labeled as the Western healthcare class (WHC).
In contrast, patients in class 2 (18% of the sample) were distinguished as the Eastern healthcare class (EHC). Their average age was 71 (SD, 2.65) years. Ninety-eight percent of them were unemployed or retired (Table 3). These patients had an average US residency of 12 (SD, 5.93) years, much shorter than the other 2 classes who had lived in the United States for about 20 years on average (P < .001; Table 4). They had lowest level of English proficiency than the other 2 classes (P < .001). Only 26% of them had sought services of their primary care physicians over 3 years, and only 29% received physician recommendations for screening (P < .001). They had lower knowledge about CRC screening and expressed less cancer worry relative to the WHC group (percentage differences = 0.11 and 0.21, respectively, both P < .05). These patients had the highest score on Chinese cultural views of cancer and health among the 3 classes (mean difference = −0.43 to the WHC, P < .01). About 70% of them attributed their nonadherence to having no symptoms. Apparently, those in the EHC were more inclined to a traditional way of care.
The third class (46% of the sample) was named the mixed healthcare class (MHC). The average age of MHC was 59 (SD, 5.56) years, and the length of residency in the United States was about 20 (SD, 6.12) years (Table 3). Although they had similar age and length of years in the United States to the WHC, they had much lower level of education and employment status (P < .001) and were less likely to receive physician recommendation for CRC screening (34%) than the WHC (percentage difference = 25%, P < .001; Table 4). Patients in MHC did utilize Western care as more than 50% of them reported seeing their current primary care physician for at least 3 years. However, despite their relatively long residency in the United States and relationship with physicians, those in the MHC were not significantly different from those in the EHC in knowledge, Chinese cultural views of cancer and health, worry about developing CRC, and perceived barriers. These results differentially characterized the MHC from the WHC and EHC.
The results of this study suggest that Chinese American patients who were nonadherent to CRC screening were differentiated in their demographics, cultural views of cancer and health, and attitudes toward CRC screening. They were generally characterized by 3 patterns: WHC, MHC, and EHC. The WHC is distinct in their high socioeconomic status and less traditional views of healthcare, perhaps resulting from their high English ability and long US residency that have led to greater exposure to Western healthcare resources. Compared with those in the WHC, those in the MHC who also had resided in the United States over 20 years but had poor English ability were significantly less likely to receive recommendation from physicians and hold Western views of healthcare. Surprisingly, the MHC’s attitudes and barriers to CRC screening were similar to those of the EHC who had much shorter length of stay in the United States and relationship with physicians than the WHC and MHC.
People in WHC were more likely to receive screening advice (59%) and have longer visits with a physician; however, they do not adhere to their physician’s recommendation for CRC screening. In addition, 40% of this class did not receive physician recommendation. It could be that people in WHC have insufficient knowledge about CRC and screening. Although this group had higher screening knowledge and was more worried about developing CRC than the other 2 groups, this group’s average knowledge scores were actually low, and more than 50% of them reported lacking symptoms as a reason for being nonadherent. Along with their high employment rate, the WHC was significantly more likely to report being too busy to have a CRC test. It can be understood that when people are busy with work and lack accurate knowledge about CRC, they are less likely to make time for CRC screening. Adherence to clinical recommendations may be improved by enhancing patient-physician communication in order to influence patients’ decision making and outweigh the benefit of screening over the inconvenience of screening. Research showed that patients who have received thorough information about CRC screening were motivated to discuss CRC screening with their provider and those who were counseled about their barriers were able to participate in CRC screening.33 Some research reported that physicians often did not discuss the full varieties of CRC screening options or emphasize the importance of adherence when making recommendations.34,35 How Chinese-speaking physicians provide recommendations and communicate with their Chinese-speaking patients is understudied. While our patients have shown poor knowledge and low adherence to physician recommendation, it is suggested that providers may stress the benefits of early detection to assist patients in the WHC to weigh the pros and cons of CRC screening and provide options for timesaving methods, such as take-home FOBTs.
It is notable that people in the MHC are similar to those in the WHC at their age level, length of seeing physicians, and US residency; however, the former was significantly less likely to receive a CRC screening recommendation from their physician. Nevertheless, even though those in the MHC were more acculturated than those in the EHC, by measure of residency in the United States and English proficiency used as proxies, their CRC knowledge level, Chinese cultural views of cancer and health, and barriers to CRC screening were similar to those of the EHC. This is deviant from the typical notion that the longer an immigrant stays in the United States, the more likely he/she is acculturated to the mainstream lifestyle including healthcare practices.36,37 Our data show that the length of US residency is not linearly related to patients’ receipt of CRC screening information and recommendations in a sample of nonadherent patients. Perhaps, the lower educational level and poor English proficiency among people in the MHC make them less capable of accessing the mainstream healthcare resources. This reflects a need to develop linguistically and culturally appropriate programs for these less acculturated and less educated patients about CRC and evidence-based screening modalities for early detection. Research has shown that a multicomponent and culturally tailored intervention program distributed in a clinical setting, which included Chinese-language educational videos and brochures, has facilitated Chinese Americans’ use of FOBT.38 It is unknown why physicians are less likely to recommend CRC screening to patients in the MHC. Further investigation of Chinese-speaking patient-physician communication during medical encounters will be needed.
Multiple reasons could contribute to explaining the nonadherence to CRC screening guidelines in the EHC. Eastern healthcare class is an elderly population that has resided in the United States for fewer years and holds more traditional views of self-care. Their poorer level of English proficiency might have limited their learning and understanding about preventive cancer screening in the United States. Previous studies found that Chinese immigrants with traditional views of care were more likely to have decreased screening adherence.17,39 This is probably due to their misconceptions about CRC and screening.17 For instance, despite the fact that the risk of developing CRC increases with age, our senior patients reported less worry about getting CRC, and 70% of them attributed their nonadherence to the lack of symptoms. Patients in the EHC who were seeing Chinese-speaking physicians reported the lowest likelihood of receiving physician recommendation (29%) for screening. Previous studies in other ethnicities have shown that physicians are less likely to recommend CRC screening for the very elderly due to consideration of the potential benefits and harm given the patients’ physical health status.40,41 Although USPSTF does not recommend routine screening for asymptomatic adults older than 75 years,25 the average age of the EHC is about 71 years old, and most of them should still be screened. It is possible that those senior Chinese American patients see physicians for other chronic diseases, making any recommendation for CRC screening less focused. We need future studies to examine whether having major concerns for other diseases interferes with physicians’ cancer screening recommendation agenda and consequently makes physicians less likely to recommend CRC screening for patients. On the other hand, it may be explained by low awareness and knowledge among our senior patients. As a result, they are least likely to initiate communication with physicians about CRC screening and see the necessity of regular screening.
Our study has a few limitations. First, the study sample was elder Chinese American patients collected via Chinese American primary care physicians in metropolitan DC, Philadelphia, and New York areas. Our findings will not be generalizable to other Chinese American immigrants residing in other areas and those who do not go to Chinese American physicians for medical advice. Second, our study examined various sociodemographics, clinical factors, beliefs, and attitudes toward CRC screening to classify homogenous subtypes in this population, but there may be more factors that contribute to nonadherent behaviors that we can further consider in future studies, such as trust in physicians and the utilization of traditional Chinese medicine practices or the availability of a Chinese-speaking gastroenterologist.
This is the first study to identify subgroups of Chinese American patients who were nonadherent to CRC screening guidelines. These findings extend previous literature and demonstrate that there are different sociodemographic and behavioral factors to account for nonadherent screening behaviors of older Chinese immigrants. Training primary care physicians to understand that there are distinctive heterogeneous subgroups among nonadherent patients and recognize patients’ different demographic characteristics (ie, socioeconomic status, years in the United States) and healthcare beliefs (eg, cancer screening) during encounters may facilitate physicians’ communication with patients to overcome their barriers and consequently promote their screening behaviors. In addition, culturally and linguistically appropriate educational materials will be needed to educate immigrant patients and assist them to communicate with physicians or vice versa. Our findings recommend that future intervention programs tailored to address specific screening beliefs and barriers for subtypes of Chinese should be essential in effectively improving CRC screening for nonadherent Chinese immigrants.
The authors thank all the participants in the study, including patients, physicians, and clinical staff, for the support.
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Chinese Americans; Colorectal cancer screening; Cultural view of healthcare; Latent class analysis
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