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Cancer screening rates are low among Chinese American women, a mostly immigrant minority population. This is possibly because they do not receive cancer screening recommendations from their physicians. The objective of this study was to determine if the rate at which physicians recommend cancer screening to older Chinese American women differs according to the language used during visits.
Data for the cross-sectional study were collected from a telephone survey of older Chinese American women residing in the Washington, DC, area. A total of 507 asymptomatic Chinese American women aged ≥50 who had a regular physician participated in this study. The main outcome was women's self-reported perception of having received a recommendation from their physician for mammography, Pap tests, or colorectal cancer screening in the past 2 years. The main independent variable was the language used during visits (English vs. Chinese). Patient age, educational level, employment status, cultural views, physician specialty, physician gender, and length of relationship with the physician were included in the multiple logistic regression analyses.
Chinese women who communicated with their physicians in English were 1.71 (95% CI 1.00-2.96) and 1.73 (95% CI 1.00-3.00) times more likely to report having received mammography and colorectal cancer screening recommendations, respectively (p<0.05). Physicians in family medicine or general practice were 2.11 (95% CI 1.31-3.40) and 1.70 (95% CI 1.06-2.48) times more likely to recommend cancer screening than those in other specialties.
Chinese American women who conversed with their physicians in Chinese were less likely to perceive receiving cancer screening recommendations. Future research is needed to identify physician-specific knowledge, attitude, and cultural barriers to recommending cancer screening.
Cancer is the number one cause of death among Chinese Americans.1 Breast, cervical, and colorectal cancers are among the most commonly diagnosed cancers in Chinese American women.1 Proven screening technologies are available to detect these three types of cancer at precancerous or early stages, and routine screening for these cancers is recommended by the American Cancer Society (ACS) and the U.S. Preventive Service Task Force (USPSTF).2–4
Although screening for breast, cervical, and colorectal cancers has become more common as a result of successful public health education campaigns,5,6 regular screening rates are still below the Healthy People 2010 objectives,5–7 especially among minority immigrant women.5 For instance, a national survey showed that Asian American and Pacific Islander women, including Chinese Americans, were significantly less likely to have breast and cervical cancer screenings than white women.8 A recent study also indicates that only about 50% of Chinese American women regularly obtain mammography and Pap tests.9 In addition, colorectal cancer screening rates among Chinese Americans were found to be lower than those among non-Hispanic whites.10 Previous research has found that knowledge, attitudes, beliefs, cultural views, socioeconomic status, and healthcare access (e.g., health insurance, time, transportation, and facilities) are associated with variations in cancer screening rates.11–17 Physician recommendation has been found to be one of the most critical factors contributing to women's cancer screening.18–21
Given the low screening rates among Chinese women and the fact that most older Chinese American women are foreign born, it is possible that they experience communication barriers when seeing physicians and that such barriers might interfere with the receipt of screening recommendations. Because of their unfamiliarity with English or English medical terms, older Chinese women prefer to seek care from Chinese-speaking physicians, most of whom are first-generation immigrants.22 Little is known about Chinese American physicians' cancer screening recommendations for older Chinese American women. One study documented that Chinese American physicians reported low rates of recommending cancer screening to their Chinese American patients.23 Their reasons for not recommending cancer screening included perceptions that their patients would not have time, had a low risk of getting cancer, and would not have health insurance to cover screening expenses. To date, no studies have examined physician cancer screening recommendations from the perspective of Chinese American patients or have taken into account patient and physician characteristics that might influence screening recommendations.
In this study, we investigated the role of patient and physician factors in predicting whether older Chinese American women received physician recommendations for breast, cervical, and colorectal cancer screening. We hypothesized that Chinese American women who sought care from physicians who communicated with them in Chinese were less likely to receive cancer screening recommendations. We also examined whether other patient and physician characteristics, such as age and physician specialty, modified physicians' cancer screening recommendations.
Data for this study came from the baseline telephone interview of older Chinese American women prior to their entry into a longitudinal randomized, controlled trial that tested the impact of culturally tailored printed educational materials and telephone counseling on breast, cervical, and colorectal cancer screening rates at 18 months postintervention. Prior to subject recruitment and data collection, this study was approved by the Georgetown University Institutional Review Board.
The study population was Chinese American women residing in the metropolitan Washington, DC, area. Eligibility criteria included being ≥50 years and able to communicate in Chinese (e.g., Mandarin, Cantonese, or Taiwanese) or English. Women who were short-term visitors (i.e., those who planned to stay in the United States for less than a year) were not invited to participate because (1) the longitudinal study involved an 18-month follow-up to assess the use of cancer screening after educational interventions and (2) visitors usually do not receive preventive healthcare in the United States. Women who did not have a regular physician were excluded from the analysis. In addition, women who reported receiving cancer screening because of problems, symptoms, or having cancer or a family history of cancer were excluded from the analysis. Only asymptomatic women who were at average risk for cancer (therefore, would benefit from routine cancer screening at recommended age and interval) and had a regular physician were included in the final sample.
We recruited a convenience sample of participants from several community-based venues, including Chinese churches and schools, senior centers, health fairs, and Chinese organizations' celebration banquets. Typically, leaders of the organizations who endorsed the project would introduce the research team to the congregation or group. The research team then presented a brief overview of the project, including its purpose and methods, the receipt of educational materials about cancer, and the risks and benefits of participation. Women were encouraged to participate so that their views about cancer could contribute to understanding the need for cancer control in Chinese American women. Interested women were asked to provide written consent. Other recruitment strategies included announcements in church bulletins, invitational fliers and announcements distributed to community organization members, and advertisements posted in local Chinese newspapers and grocery stores. Women who contacted the research team as a result of these strategies were asked to mail back a signed consent form. All women who consented received a bottle of a brand-name multivitamin supplement either on site or by mail as a token of appreciation for their participation.
Consenting women were contacted for an hour-long computer-assisted telephone interview (CATI) by trained Chinese American interviewers. Interviewers received one full day of training in the CATI system; their initial interviews were supervised by investigators until they could perform the tasks fluently and handle participants' questions well. Eight people conducted the interviews, including four Mandarin-speaking graduate students, one research assistant fluent in Mandarin and Taiwanese, and three Cantonese-speaking independent contractors. All, except for one student, were women. The majority of the interviews were conducted in Mandarin. Women who did not speak Mandarin were interviewed in their preferred dialects, such as Cantonese and Taiwanese.
The main outcome for this study was the self-reported perception of a physician recommending mammography, Pap tests, or colorectal cancer screening (fecal occult blood test [FOBT], flexible sigmoidoscopy, and colonoscopy). Women were asked if, in the past 2 years, they ever received physician recommendations to obtain these screening tests (yes vs. no). A short description of each screening test was offered during the interview to help women understand the screening tests of interest. The main reason for using a universal interval of the past 2 years for all three types of cancer screening was that mammography, Pap tests, and FOBT were recommended annually, and a duration of 2 years allowed enough time for each participant to need a recommendation or reminder for those screening tests. Although women who had had a recent colonoscopy or sigmoidoscopy might not need a colorectal screening recommendation during the 2-year interval (for the screening intervals were 5 and 10 years for those two tests), we decided against using longer intervals for those two tests to minimize confusion to participants or possible recall bias.
Patient characteristics used for analyses were those showing significant associations with all three cancer recommendations at the bivariate level, including age, educational level, employment status, and cultural views. Household income and health insurance were not considered because the income variable had >30% missing values and >90% of the participants had insurance coverage. Because we only included women having regular physicians for analyses and those seeing regular physicians were mostly insured, health insurance lacked the variability to detect significant associations with outcomes. Age groups were divided between those 50–64 years and those ≥65 years. Because a high proportion of the participants had an educational level of college and above, educational level was categorized as “up to (and including) high school” or “some college and above.” Employment status was coded as yes or no.
Cultural views were assessed by 30 items that were primarily derived from qualitative data from five focus groups consisting of 54 older Chinese American women who were asked about their views of health, illness, cancer, and cancer screening.22 Responses to each item were assessed on a 5-point Likert scale, ranging from strongly agree, agree, neutral, disagree, to strongly disagree. Rotated principal component factor analyses showed that these items measured cultural domains, such as fatalism, self-care, hot-cold balance, use of herbs, Western medicine, medical checkups, and lifestyle, with an internal consistency score (Cronbach's alpha) between 0.82 and 0.39. Fatalism, self-care, use of herbs, and hot-cold balance demonstrated significant concurrent validity, measured by correlation with age on immigration to the United States.9 Sum scores of this cultural scale have been found to be negatively associated with Chinese women's cancer screening practices.9 In this study, the 30-item sum score was divided at the median and categorized as Eastern cultural view or Western cultural view, where the Eastern view represented a more Chinese cultural view, for example, fatalism and self-care, than the Western cultural view.
Patients' self-report of physician and healthcare characteristics included physician specialty, and gender, language used during visits, and length of relationship with the physician. Physician specialty was coded as family medicine or general practitioner and other (about 80% in internal medicine and 9% in obstetrics and gynecology). Language used during visits was coded as English or Chinese. Length of relationship was divided into 3 years or less and longer than 3 years, according to the distribution of responses.
Bivariate relationships between patient and physician characteristics and whether patients received mammography, Pap test, or colorectal cancer screening recommendations in the past 2 years were first examined using chi-square tests. Next, we used logistic regression models to predict the influence of patient and physician-related characteristics for each of the three cancer screening tests among Chinese American women.
Overall, 622 eligible Chinese women expressed interest in participation. Of these, 561 (90%) consented to participate. Of the 561 consenting women, 507 (90%, or 81.5% of the 622 eligible women) completed the interview, and 11% (n=54) declined the interview. The 54 women who dropped out of this study did so because of lack of interest in participation (n=21), ineligibility (n=3), too busy to be interviewed (n=13), feeling uncomfortable talking about cancer (n=5), lost contact (n=5), moving out of the area (n=5), or having physical problems (n=2). The majority of the participants (99%) were immigrants from Asian countries, including 64% from China and 31% from Taiwan. Only 2 participants preferred using English for the interview. The median age at immigration was 45 years (range 12–75). The mean age of the 507 women was 64.5 years (range 50–89 years), and 55% of them were between ages 50 and 64 (Table 1). After excluding women who did not have a regular physician (25% of the sample) or who were symptomatic, the final sample sizes for the breast, cervical, and colorectal cancer screening analyses were 344, 358, and 300, respectively.
About 76% of the sample had a male physician, 56% had physicians in family medicine or general practice, 62% had been seeing their regular physicians for >3 years, and 60% communicated with their physicians in Chinese. Only 63%, 53%, and 51% of the sample reported ever receiving recommendations from their physicians regarding mammography, Pap test, and colorectal cancer screening, respectively.
Bivariate analyses showed that all patient characteristics were strongly associated with a woman's receiving mammography, Pap test, and colorectal cancer screening recommendations from her physician (Table 2). Younger women (aged 50–64), highly educated (college or above) women, employed women, and those holding a Western cultural view were more likely to have received recommendations. Two physician-related factors, physician specialty and language used during visits, consistently predicted recommendations for all three types of cancer screening; physicians in family medicine or general practice or who communicated with patients in English were more likely to recommend cancer screening.
Table 3 shows the final logistic regression models for all three types of screening recommendation. Women who were 50–64 years old were 2.04 (95% CI 1.14 – 3.69), 2.42 (95% CI 1.37 – 4.29), and 1.94 (95% CI 1.05 – 3.60) times more likely to have received mammography, Pap test, and colorectal cancer screening recommendations, respectively, than those who were ≥65 years. A higher educational level was predictive of receiving Pap test recommendation (OR 1.85, 95% CI 1.03 – 3.33). Women who had physicians in family medicine or general practice or who had longer than a 3-year relationship with their physicians were significantly more likely to have received mammography and Pap test recommendations in the past 2 years (OR 2.11, 95% CI 1.31 – 3.40, and 1.80, 95% CI 1.10 – 2.97, for mammography and 1.70, 95% CI 1.06 – 2.48, and 2.15, 95% CI 1.31 – 3.53, for Pap test). Women whose physicians communicated with them in English were 1.71 (95% CI 1.00 – 2.96) and 1.73 (95% CI 1.00 – 3.00) times more likely to have received mammography and colorectal cancer screening recommendations, respectively (p<0.05).
The results of this study demonstrate that among older Chinese American women with regular primary care providers, perceptions of having received a physician's recommendation for cancer screening were far from universal. As predicted, the language used during the visit was related to physicians' cancer screening recommendations. Specifically, Chinese women who reported that their regular physicians communicated with them in Chinese were less likely to have received regular mammography or to have had up-to-date colorectal cancer screening. In addition, physician specialty, length of relationship with the physician, as well as women's age and educational level, influenced women's receipt of cancer screening recommendations from their physicians.
Our finding of a positive association between physicians' communicating in English and patients' receipt of cancer screening recommendations may be explained by several factors. In our study, all physicians who communicated with patients in English only were non-Chinese. On the other hand, physicians speaking Chinese were mostly Chinese immigrants who had received medical degrees from their country of origin. It is possible that Chinese-speaking physicians are less aware of cancer screening guidelines. Alternatively, they may consider their Chinese patients to have a lower cancer risk than the general U.S. population.23 Another possible explanation is that Chinese physicians may not recommend screening because they assume their patients' cultural views (e.g., fatalism and belief in self-care) will lead them to refuse screening. Chinese physicians may also choose not to discuss screening, assuming that Chinese women are reluctant to discuss cancer or discuss body parts, such as breasts and the cervix.22 On the other hand, some women visiting English-speaking physicians may have been accompanied by an interpreter, a variable not included in the survey, which adds to the complexity of the communication process. Future research is needed to determine which of these possible factors explain our results.
The associations between physician specialty and screening recommendations found in our study are inconsistent with earlier studies that found physicians in family and general practice recommended mammography less often than internists did.24 In addition, our data also do not support other studies indicating that female physicians are more prevention oriented and more likely to recommend mammography than male physicians.25–27 Future research needs to explore reasons for these discrepancies, such as the context of practice28 and physicians' beliefs about cancer and cancer screening needs in Chinese Americans29 and prevention orientation.27 Consistent with prior literature,30 our study also indicates that a longer patient-physician relationship is associated with a higher cancer screening recommendation rate among Chinese American women. This may be because physicians had accumulated more knowledge about their patients and their patients had developed a higher degree of trust toward their physicians,30 which made discussion and recommendation of breast and cervical cancer screening easier and more acceptable to older Chinese American women.
The association between older age and fewer cancer screening recommendations is consistent with prior findings that physicians are less likely to recommend cancer screening to older patients,29,31,32 possibly because of competing causes of mortality. We did not find evidence that older patients primarily speak Chinese with their physicians, for our data show that significant proportions of both older and younger patients spoke Chinese with their physicians (about 65% and 67% among women aged 50–64 and ≥65, respectively.) In addition, the influence of language use on screening recommendation did not differ by age; it is also likely the result of differences in communication style between physicians and their younger and older age patients. For instance, it is possible that younger women were more assertive and initiated discussion and requested cancer screening more often than did older women, who were more likely to be passive and modest.33,34 Future qualitative research is needed to confirm this hypothesis and disentangle the dynamic physician-patient communication process.
Several limitations of this study should be taken into account when interpreting the results. First, the study participants were drawn from a convenience sample in a metropolitan area, resulting in a highly educated study sample. Women who did not attend social organizations where recruitment took place or who had a low socioeconomic status possibly were underrepresented. Second, all measures were obtained by participants' self-report, which is subject to reporting bias, social desirability bias, and recall bias. In addition, some important physician variables, such as physician perceived benefits of cancer screening, cultural perspectives, and acculturation level, were not available for analysis, which limited our ability to further explain the findings. Third, the study findings are limited to women who have a regular physician. Fourth, although participants were drawn from the same geographic area, it is likely they visited different physicians over time. It may also be possible that women concurrently visited specialists, such as an obstetrician-gynecologist, who may have been responsible for female cancer screening tests. In addition, the sample is likely to include patients of the same physician. Although physicians may communicate with each of their patients differently, the possible patient contamination and clustering effects may have overestimated study results.
Despite the limitations, our study expands prior research by suggesting that the reason immigrant Chinese women do not receive cancer screening recommendations from their physicians is not largely because of language barriers or communication problems with English-speaking physicians but rather because of the low rate of recommendations from Chinese American physicians. It implies that although physicians play a significant role in offering screening recommendations, they are likely to have knowledge, attitude, or cultural barriers to making such recommendations, especially if they speak the immigrants' native languages. Future research is needed to identify the specific barriers that lead physicians to not recommend cancer screening to their older female Chinese American patients. Public health interventions to improve breast, cervical, and colorectal cancer screening will likely benefit from targeting physicians' barriers and offering educational programs to physicians caring for immigrant patients.
This study was presented at the Society of Behavioral Medicine annual meeting, April 13–16, 2005, Boston, Massachusetts.
This study was supported by funding from the Susan G. Komen Breast Cancer Foundation Population Specific Research grant to W.L. (POP0100855), the National Cancer Institute Career Development award to W.L. (K07 CA90352), U.S. Department of Defense grant to J.H.W. and W.L. (BC010208), and the National Cancer Institute grant to J.S.M. (K05 CA96940).
The authors have no conflicts of interest to report.