Although some data are available for CRC screening rates among Asian Americans and Pacific Islanders,13,22,23
to our knowledge, this is the first study to address CRC screening across different Asian-American ethnic groups in languages other than English. Moreover, this is the first population-based study to examine CRC screening in several different Asian-American ethnic groups rather than aggregating them into a single category. Despite recommendations for regular colon cancer screening for all adults age 50 years and older, rates of screening remain low for all ethnic groups, including non-Latino whites. For all Asian Americans as an aggregated group, the CRC screening rates are lower compared with the rates for non-Latino whites.
Our multivariate regression models suggested that, after accounting for predisposing, enabling, and need variables, there are few ethnic differences in CRC screening rates between Asian Americans and non-Latino whites. However, many Asian Americans are more likely to have many of the predisposing and enabling factors associated with low rates of CRC screening. Asian Americans age 50 years and older tend to be immigrants and to live in households with ≥ 3 individuals. They also tend to have lower educational and income levels and to lack health insurance compared with non-Latino whites. Our findings suggested that we should continue trying to reach individuals who are at risk for not receiving or maintaining CRC screening through increasing access to free screening, increasing enrollment of individuals who are eligible for Medicaid and Medicare, and focusing on immigrant groups. Collaboration with ethnic community organizations and churches to provide individuals with information about CRC screening and the locations of any free screening programs may be a good way to reach immigrant groups. Another way to reach target groups may be through ethnic media campaigns, such as informational commercials, posters, and community campaigns to improve colon health.
We found that most Asian-American groups were 30–50% less likely than whites to be up to date with CRC screening. Whereas some Asian-American groups, such as the Japanese, had a CRC screening rate that was similar the rate among whites, Koreans were less likely to undergo FOBT and Filipinos were less likely to undergo or be up to date with endoscopy compared with non-Latino whites, even after controlling for other predisposing, enabling, and need variables. These findings suggest heterogeneity among different Asian ethnic groups.24,25
Certain lifestyle factors or traditional beliefs, especially among Koreans and Filipinos, may act as significant barriers to receiving and remaining up to date with CRC screening.23,26–28
More important, the underuse of CRC screening among Koreans and Filipinos may be due to linguistic and attitudinal barriers related to hesitancy to discuss health concerns in a nonnative tongue. More work is needed with Koreans and Filipinos to understand which lifestyle behaviors may be acting as barriers to receipt of CRC screening.29
In addition, access is needed to print and media material promoting knowledge of CRC and screening that is sensitive to Korean and Filipino culture. Interventions targeting Koreans and Filipinos can narrow the disparity in CRC screening rates between these groups and non-Latino whites.
Our finding that years in the United States and English language proficiency were collinear suggests that Asian-American immigrants, particularly those who have lived in the United States for < 15 years, are not fluent in English. Asian immigrants should be targeted for outreach efforts, because those who have lived in the United States for < 15 years are approximately half as likely to have ever undergone or to be up to date with CRC screening, suggesting that there may be additional barriers to getting screening even after an individual has health insurance and a usual place of medical care. Indeed, the length of time spent in the United States has been identified as a significant predictor of CRC screening in different Asian-American ethnic groups.13,29,30
There is likely both a lack of familiarity with the importance of obtaining and maintaining CRC screening and a lack of CRC screening information available in specific Asian languages (other than Chinese). There also may be a predisposition for using biomedical procedures as a method of prevention.
This study has highlighted the importance of the clinician’s success in maintaining CRC screening once it is initiated. In fact, being up to date with endoscopy was more significant than being up to date with FOBT. Active efforts focusing on provider recommendation and improving patient-provider communication may help to increase the receipt and maintenance of CRC screening. High levels of psychological distress, including fear and anxiety regarding cancer, often are associated with the avoidance of other types of cancer screening31,32
However, the current study had important limitations. All participants lived in California and, thus, may not be representative of individuals living in other parts of the United States. However, more than half of the Asian-American population lives in three states (California, New York, and Hawaii).33
As with any telephone survey, respondents without a telephone were not included. The CHIS 2001 was weighted to minimize the effects of this characteristic of telephone surveys.19
Data were self-reported, which may have produced bias. There was a potential for under-reporting or over-reporting of screening that occurred; however, there should be no differential bias according to ethnicity in the level of reporting.17
One report of the concordance between patient self-reports and medical records showed that self-reports of CRC screening behavior were accurate irrespective of age, gender, ethnicity, or family history of CRC.34
Despite these limitations, to our knowledge, this is the first study that has examined population based CRC screening rates in several different Asian-American ethnic groups in their own language and that compared their rates with the rates among the non-Latino white population. A major strength of this study is that the survey was administered in Chinese, Korean, and Vietnamese (among other languages), which allowed the participation of considerably larger proportions of these groups.35
In conclusion, further work is needed to examine barriers to CRC screening and to test culturally sensitive interventions aimed at promoting CRC screening, particularly among Koreans and Filipinos. Among all Asian Americans, strategies to increase screening should include familiarizing immigrants about the importance of obtaining and maintaining screening and providing CRC screening information in different Asian languages. Interventions also might include developing and implementing a family-centered care model and increasing the use of qualified translators to discuss CRC and screening.