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212 JOGNN © 2007, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses Objective: To explore knowledge and beliefs (perceived risk factors, susceptibility, benefits, com- mon barriers, and cultural barriers) in relation to mammography screening practices among Chinese American women. Design: A descriptive study guided by the Health Belief Model. Setting: Metropolitan area in the northwestern United States. Participants: One hundred Chinese immigrant women, 40 years or older. Main Outcome Measures: The percentage of Chinese American women ages 40 and older who ever received a mammogram and who received a mammogram within the past year. Results: Although 86% of the respondents re- ported that they had once had a mammogram, only 48.5% had a mammogram within the past year. The strongest factor associated with having a mammo- gram within the past year was having an immediate family member diagnosed with breast cancer, fol- lowed by having insurance that covered a mammo- gram and lower perceived barriers to obtaining a mammogram. Respondents had low knowledge of breast cancer and mammography screening guide- lines. They also perceived low susceptibility to breast cancer. Conclusions: Nurses may influence the mam- mogram rates among Chinese American women by providing health education to family members of pa- tients with breast cancer, reducing perceived barriers to mammogram, and seeking alternative payment mechanisms for patients who do not have insurance coverage for mammogram. JOGNN, 36, 212-221; 2007. DOI: 10.1111/J.1552-6909.2007.00141.x Keywords: breast cancer beliefs—Chinese American immigrant women—Health Belief Model— mammography screening Accepted: January 2007 Cancer continues to be the leading cause of death for Asian American women in the United States, with breast cancer (BC) the most commonly diagnosed. Although the overall incidence of BC is lower among Asian American women than White women (American Cancer Society [ACS], 2006), the change in incidence is rising faster among Asian American women (2.1% vs. 0.9%) (ACS, 2003). In addition, Asian-born women were found to have a larger tumor size (> 1 cm) at diagnosis than White women or U.S.-born Asian women. This variation is believed to result from underutilization of BC screening among Asian female immigrants (Hedeen, White, & Taylor, 1999). BC is the most commonly diagnosed cancer among Asian American women in the United States. The Asian American population is the fastest growing racial population in the United States (U.S. Census Bureau, 2000). In 2000, it was reported that CLINICAL RESEARCH Breast Cancer Beliefs and Mammography Screening Practices Among Chinese American Immigrants Frances Lee-Lin, Usha Menon, Marjorie Pett, Lillian Nail, Sharon Lee, and Kathi Mooney

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Page 1: Breast Cancer Beliefs and Mammography Screening Practices Among Chinese American Immigrants

212 JOGNN © 2007, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

Objective : To explore knowledge and beliefs (perceived risk factors, susceptibility, benefi ts, com-mon barriers, and cultural barriers) in relation to mammography screening practices among Chinese American women.

Design : A descriptive study guided by the Health Belief Model.

Setting : Metropolitan area in the northwestern United States.

Participants : One hundred Chinese immigrant women, 40 years or older.

Main Outcome Measures : The percentage of Chinese American women ages 40 and older who ever received a mammogram and who received a mammogram within the past year.

Results : Although 86% of the respondents re-ported that they had once had a mammogram, only 48.5% had a mammogram within the past year. The strongest factor associated with having a mammo-gram within the past year was having an immediate family member diagnosed with breast cancer, fol-lowed by having insurance that covered a mammo-gram and lower perceived barriers to obtaining a mammogram. Respondents had low knowledge of breast cancer and mammography screening guide-lines. They also perceived low susceptibility to breast cancer.

Conclusions : Nurses may infl uence the mam-mogram rates among Chinese American women by providing health education to family members of pa-tients with breast cancer, reducing perceived barriers to mammogram, and seeking alternative payment mechanisms for patients who do not have insurance

coverage for mammogram. JOGNN , 36, 212-221; 2007. DOI: 10.1111/J.1552-6909.2007.00141.x

Keywords : breast cancer beliefs — Chinese American immigrant women — Health Belief Model — mammography screening

Accepted: January 2007

Cancer continues to be the leading cause of death for Asian American women in the United States, with breast cancer (BC) the most commonly diagnosed. Although the overall incidence of BC is lower among Asian American women than White women (American Cancer Society [ACS], 2006), the change in incidence is rising faster among Asian American women (2.1% vs. 0.9%) (ACS, 2003 ). In addition, Asian-born women were found to have a larger tumor size (> 1 cm) at diagnosis than White women or U.S.-born Asian women. This variation is believed to result from underutilization of BC screening among Asian female immigrants ( Hedeen, White, & Taylor, 1999 ).

BC is the most commonly diagnosed cancer among Asian American women in

the United States.

The Asian American population is the fastest growing racial population in the United States (U.S. Census Bureau, 2000). In 2000, it was reported that

CLINICAL RESEARCH

Breast Cancer Beliefs and Mammography Screening Practices Among Chinese American Immigrants Frances Lee-Lin, Usha Menon, Marjorie Pett, Lillian Nail, Sharon Lee , and Kathi Mooney

Page 2: Breast Cancer Beliefs and Mammography Screening Practices Among Chinese American Immigrants

May/June 2007 JOGNN 213

4.2% of the total U.S. population self-reported as Asians, a 72% increase from 1990. In comparison, the total popu-lation of the United States grew only 13% from 1990 to 2000 (U.S. Census Bureau, 2000). The Asian American population is expected to double to 8% of the U.S. popu-lation by the year 2050 ( U.S. Census Bureau, 2004a ). Al-though there is a tendency to classify all Asian Americans and Pacifi c Islanders into one large racial/ethnic cluster, Asian Americans represent more than 25 separate ethnici-ties (Intercultural Cancer Council [ICC] — Asian Ameri-cans & Cancer, 2004; National Cancer Institute, 2004 ). Each subgroup is unique and differs from the others in language, culture, and health beliefs. Among the different Asian American subgroups, the Chinese Americans are the largest (ICC — Asian Americans & Cancer).

Over the past 40 years, randomized clinical trials have demonstrated substantially reduced mortality rates from BC among women who participate in screening mammography ( Feig, 2002 ). However, the practice of screening mammog-raphy among Chinese American women (CAW) is limited.

The purpose of this descriptive study was to explore the relationships of sociodemographic characteristics, knowledge, and beliefs about BC and mammography to the self-reported practice of mammography screening among Chinese female immigrants residing in a metro-politan city in the United States. The specifi c research aims were to (a) describe the sociodemographic characteristics, knowledge, beliefs, and mammography screening prac-tices of immigrant CAW ages 40 and older and (b) iden-tify which of the above factors are predictive of mammography screening.

Review of Literature

Asian American women have the lowest mammogra-phy screening rates among ethnic groups in the United States. Several studies have shown that the rate of mam-mography screening in the past 1 to 2 years in the United States is highest in Whites (70%-80%) and Blacks (70%-72%), somewhat lower in Hispanics (61%-65%), and lowest in Asian American women (36%-67%, depending on the subgroup) ( Centers for Disease Control & Preven-tion, 2006; Chen, Diamant, Pourat, & Kagawa-Singer, 2005; Hiatt et al., 1996 ).

Lee-Lin and Menon (2005) reviewed the current re-search on BC screening practices among CAW. Rates of CAW who have ever had a mammogram (MMG) ranged from 63% to 74% with the exception of a Chinatown sample (12%). Rates of at least one MMG in the past 2 years ranged from 53% to 61% for CAW (Lee-Lin & Menon; Yu & Wu, 2005 ). The screening rates are well below the 70% target rate set by the Healthy People 2010 (2004) .

Sociodemographic characteristics, knowledge, and be-liefs that have been demonstrated to facilitate mammogra-

phy adherence among CAW include fl uency in English, higher education, insurance coverage, usual source of health care, recommendations by health care providers (HCPs), owning a home, received prenatal/family plan-ning services, as well as belief in early detection, accultura-tion, and knowledge of cancer warning signs, MMG, and breast self examination ( Lee-Lin & Menon, 2005; Tang, Solomon, & McCracken, 2000; Tu et al., 2003; Yu, Kim, Chen, & Brintnall, 2001; Yu, Seetoo, Tsai, & Sun, 1998 ).

Methods

Study Design and Sample The target population in this descriptive study was

foreign-born Chinese American immigrants 40 years or older in the urban and surrounding areas of a northwest metropolitan city. One hundred CAW were recruited from Asian community centers and churches. The participants completed a self-administered questionnaire that mea-sured BC beliefs and screening knowledge, mammography practices, and their sociodemographic backgrounds.

The participants were a convenience sample of 100 CAW. Eligibility criteria included being a foreign-born Chinese woman, 40 years or above, no history of BC, and able to understand or read English or Chinese.

Measures The Health Belief Model (HBM) was used as the con-

ceptual framework for this study because of its focus on people ’ s perceptions about illness and their beliefs about preventative action. Sociodemographic characteristics, knowledge, and beliefs of BC and MMG screening were measured by one questionnaire. The concepts of knowl-edge and beliefs were derived from the HBM, which in-cluded knowledge, perceived risk factors, susceptibility, benefi ts, common barriers, and cultural barriers. Items about knowledge and beliefs of BC and mammography screening were drawn from Champion ’ s Breast Health Survey (primarily on White women), with items focused on cultural aspects taken from Tang et al. ’ s (2000) Wom-en ’ s Health Survey (focused on CAW 60 years and older) and Taylor et al. ’ s Women ’ s Health Project Questionnaire (focused on Asian women). Items of each scale were evalu-ated and validated with a review of literature, content and cultural experts, and pretested with 10 CAW. Only those items that reached a complete (100%) agreement between all reviewers were retained. All scales had a Cronbach ’ s alpha above 0.70.

Knowledge about BC causes and treatment and mam-mography screening recommendations was assessed by 11 items. Responses were multiple choices; each correct an-swer received a score of 1 for a possible range of 0 to 11.

Perceived risk factor beliefs for BC were measured by 10 items asking respondents to indicate if they thought

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214 JOGNN Volume 36, Number 3

a specifi c factor (e.g., breast feeding, history of BC, stress, environment) increased or decreased an individual ’ s risk for developing BC or if they were not sure. Responses were categorical; the responses were reported by frequency counts and percentages.

Four other beliefs (perceived susceptibility, perceived benefi ts, perceived common barriers, and perceived cul-tural barriers) were measured on Likert-type scales with responses from strongly disagree (1) to strongly agree (5). Perceived susceptibility was measured by three items. Per-ceived benefi ts were measured by seven items. Perceived common barriers were assessed with 21 items. Perceived cultural barriers (crisis orientation, modesty, lack of fam-ily support, and use of Eastern medicine) to cancer screen-ing were assessed with 16 items.

Mammography Practices . The date of the last MMG screening test was self-reported. Two questions assessed having had an MMG at least once and adherence to MMG guidelines. The adherence to guidelines (yearly MMG af-ter age 40 as recommended by the ACS) was determined by frequency counts of women who had completed their last MMG “ less than/just about 1 year ago. ”

Translation . The questionnaire was translated into Chinese using the “ modifi ed ” committee approach to translation ( Schous-Glusberg, 2004; U.S. Census Bureau, 2004b ). The translation team consisted of three bilingual translators. Each translated a portion of the questionnaire with the fi nal version determined by group verbal consen-sus. This approach has been found to produce more ac-curate text translations than translation of a single person or back translation by a pair of individuals.

Procedures Study procedures were approved by the institutional re-

view board. Participants were approached at community meetings and gatherings of Asian community centers and Chinese community churches. The study was explained to eligible women who were told that the study was about women and health screening behaviors, that their partici-pation would be voluntary and confi dential, and that they would receive a “ small gift ” for their time. The specifi c amount of money ($10) was not explicitly stated as it is not culturally appropriate to discuss monetary reimburse-ment in public. Those who volunteered were asked to re-main after the meeting to complete a 20- to 30-minute, self-administered questionnaire in a group setting. The fi rst author was present at the site and available to answer questions.

Statistical Power and Data Analysis Based on a review of the odds ratios (OR) reported in

the literature for CAW, it was determined that an OR of 2.0 would be meaningful. The signifi cant OR for the sociodemographic and cancer belief and knowledge variables ranged from 2.20 to 14.01 for MMG screen-

ing ( Tang et al., 2000; Yu et al., 1998, 2001 ). To have an 80% chance, or power ( Cohen, 1988 ) of detecting this effect size, a sample of 90 participants would be required. Accounting for a potential of up to 10% of participants with missing data, a sample of 100 was used.

Data analysis was conducted using the Statistical Pack-age for Social Sciences (SPSS Version 11.5, Chicago, IL). First, descriptive frequencies were run for all variables. Next, in order to determine which variable to enter the fi -nal logistic regression model, bivariate analyses were con-ducted with each independent variable (knowledge, beliefs, and sociodemographic characteristics) and the outcome variables (MMG practices). Continuous variables such as age, years lived in the United States were analyzed with binominal logistic regression and categorical variables such as do you have a regular provider or insurance were analyzed by chi square. In keeping with the exploratory nature of this research, variables associated at p ≤ .1 were included in the fi nal logistic regression analysis. Stepwise forward and backward logistic regression analyses were conducted for each outcome variable and selected statisti-cally signifi cant independent variables. The results were the same with each approach.

Results

Sociodemographic Characteristics The sociodemographic characteristics of the study par-

ticipants are presented in Table 1. The mean age of the participants was 56.5 years (range 40-91 years). The mean age of these women when they immigrated to the United States was 39 years (range 9-70 years). The average length of residence in the United States was 17.5 years, ranging from 1 month to 43 years. Fifty-four percent of the par-ticipants immigrated from mainland China.

Seventy-two percent of the respondents were currently married. Forty-eight percent of the respondents (48%) had a college or graduate school degree and 18% of the respondents reported having had no formal education or only an elementary education. Of those who reported their income (23% did not), 47% reported that their an-nual household incomes were less than $30,000 and 26% reported that their incomes were greater than $100,000.

Of the 100 participants, 93% of the respondents in this sample chose to complete the questionnaire in Chinese. Thirty-nine percent of women reported their ability to speak English as poor or not at all. Seventy-seven percent reported that they had a regular HCP. Eighty-four percent reported that they usually understood what the HCP said to them and thought that the HCP usually understood them (83%). The women who did not speak English well stated that they had interpreters to help them communicate

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May/June 2007 JOGNN 215

Variable N or % M SD

Age 56.5 13.4

Age moved to the United States 38.8 15.5

How many years lived in the United States 17.5 10.6

Married 72

Single/never been married 6

Separated 6

Divorced 4

Widow 12

Education

Elementary and less 18

Some middle school 6

Some high school 15

Some college 13

Graduated from college 30

Graduate school 18

Employment

Full time 24

Part time 18

Not employed 58

Annual household income

Less than 15,000 27

15,000-30,000 20

30,001-50,000 9

50,001-75,000 8

75,001-100,000 10

100,001-150,000 22

How well do you speak English

Not at all 16

Poorly 23

Average 43

Well 14

Fluently 3

Have a regular HCP 77

Gender of your regular HCP

Male 40

Female 57

Ethnicity of your regular HCP

Asian 22

Non-Asian 76

Understand what HCP says 84

HCP understands what you say 83

Told you to have an MMG 76

Health care insurance 87

MMG coverage 88

Know anyone with breast cancer 72

Immediate family had breast cancer 9

Note. HCP, health care provider; MMG, mammogram. a Because N = 100, sample size and percent are similar.

TABLE 1 Sociodemographic and Health Care Information (N = 100 ) a

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216 JOGNN Volume 36, Number 3

with the HCP. Seventy-eight percent of the women also stated that in the past year or two, their HCP had told them to have an MMG. Thirteen percent of the participants did not have health insurance. Seventy-two percent knew someone with BC and 9% reported that they had an imme-diate family member who had been diagnosed with BC.

Knowledge Table 2 summarizes the responses about knowledge of

BC and mammography screening, perceived susceptibility to BC, benefi ts of early detection, and barriers to mam-mography and cancer screening.

The mean score on the knowledge scale was 4.64 ( SD = 2.16). In other words, participants answered 5 of 11 ques-tions correctly on average. Seventy-two percent knew hav-ing a close relative with BC or having previous BC (60%) would increase a woman ’ s risk of having BC. Twenty-six percent of the women knew that being overweight was a BC risk factor. Seventy-three percent believed that women with BC almost always have to have their breast removed. Ten percent recognized that when breast lumps are discov-ered, most do not turn out to be cancer. Thirty-six percent of these women knew that BC risk increases with age. Sixty-seven percent recognized that women of their age should have annual MMGs. Two percent reported that a MMG was necessary when symptoms occur.

Breast Cancer Beliefs In regard to perceived risk factors , the respondents be-

lieved that having a family history of BC (88%), stress

(82%), environment (64%), and being 50 years or older (58%) could contribute to their risks of having BC. They also reported that breastfeeding (64%) and having a posi-tive mental attitude (55%) would decrease their risks of having BC.

For perceived susceptibility, the mean score was 7.13 ( SD = 2.22, range 3-13, maximum = 15). The mean score for perceived benefi ts in detecting and treating BC early was 8.24 ( SD = 1.03, range 4-10, maximum = 10). The mean score for understanding the importance of obtaining an MMG was 19.93 ( SD = 3.19, range 6-25, maximum = 25).

The mean for the perceived barrier score (barriers to detecting and treating BC early) was 11.14 ( SD = 2.89, range 4-17, maximum = 20), while the mean perceived barrier score to obtaining an MMG was 37.53 ( SD = 10.24, range 17-70, maximum = 85).

For the specifi c cultural barriers, higher scores of mod-esty, family support, and use of Eastern medicine indicated a stronger presence of the components. The data indicated a high degree of modesty ( M = 13.93, SD = 3.62, range 6-24, maximum = 25) and family support ( M = 11.76, SD = 3.03, range 5-18, maximum = 20), and an average score of use of Eastern medicine ( M = 8.70, SD = 2.40, range 3-15, maximum = 15). For the crisis orientation cultural barrier, a higher score indicated a lower degree of crisis orientation and a higher degree of prevention orientation. The result indicated a low crisis orientation ( M = 15.56, SD = 1.91, range 11-20, maximum = 20) among the respondents.

Scale N No. of Items Maximum Possible Score Range Scale ± SD Mean

Knowledge Knowledge 97 11 11 0-10 4.64 ± 2.16 Perceived susceptibility Perceived BC susceptibility 98 3 15 3-13 7.13 ± 2.22 Perceived benefi ts Perceived BC benefi ts 100 2 10 4-10 8.24 ± 1.03 Perceived MMG benefi ts 98 5 25 6-25 19.93 ± 3.19 Perceived barriers Perceived BC barriers 94 4 20 4-17 11.14 ± 2.89 Perceived MMG barriers 93 17 85 17-70 37.53 ± 10.24 General cultural barriers Crisis orientation 72 4 20 11-20 15.56 ± 1.91 Modesty 67 5 25 6-24 13.93 ± 3.62 Family support 97 4 20 5-18 11.76 ± 3.03 Use of Eastern medicine 99 3 15 3-15 8.70 ± 2.40

Note. BC, breast cancer; MMG, mammogram.

TABLE 2 Summary of Knowledge, Perceived Susceptibility, Barriers, and Benefi ts of Breast Cancer and Mammogram

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May/June 2007 JOGNN 217

Mammography Practices Eighty-six percent of the participants reported that they

had once undergone an MMG. However, only 48.5% re-ported that their last MMG was less than or just about 1 year ago.

Factors Predictive of MMG Screening Ever Having Had an MMG . The following factors

were positively related ( p < .10) to ever having had an MMG: longer time in the United States, having a regular HCP, being told by the provider to have an MMG, health care insurance coverage of MMG screening, and reporting household income on the questionnaire (vs. missing data) (see Table 3).

Of 77% who had a regular HCP, 89.6% had had an MMG. Of the 77.6% who stated that their provider had told them to have an MMG, 92.1% had had an MMG. Of the 92% who reported having health care insurance that covered their MMG, 89.6% reported they had had an MMG. Of the 86% who had had an MMG, 81.4% re-ported their household income on the questionnaire.

Final logistic regression analyses indicated that having health insurance covering MMG and household income not reported in the survey were predictive of ever having had an MMG ( Table 4). Women with health insurance coverage of MMG service were approximately six times more likely to have ever had an MMG than those women who did not have this coverage (OR = 5.59, confi dence interval [CI] = 1.85-16.89). Those women who did not report their annual household income were less likely than those who did to ever have had an MMG (OR = 0.24, CI = 0.08-0.72) (see Table 4 ).

MMG Within the Past Year . Perceived common barri-ers ( B = − 0.07, p = .01), perceived benefi t score ( B = − 0.42, p = .05), and use of Eastern medicine ( B = − 0.22, p = .02) were all negatively associated with having had an MMG

in the past year. The top six perceived MMG barriers in this group were having trouble remembering to get an MMG ( M = 2.87, SD = 1.20, range 1-5); believing or experiencing that having an MMG is painful ( M = 2.55, SD = 1.14); worrying about being exposed to the x-ray ( M = 2.48, SD = 1.05); believing that compared with other health problems, having an MMG is not important ( M = 2.46, SD = 1.20); feeling that they did not have time to get an MMG ( M = 2.33, SD = 1.11); and not speaking English well ( M = 2.30, SD =1.13).

The two categorical variables associated ( p < .10) with having an MMG in the past year (see Table 3 ) were being told by the provider to have an MMG and health care in-surance coverage of MMG screening. Of the 77.3% who stated that their provider had told them to have an MMG, 57.3% have had an MMG in the past year. Of the 88.2% who reported having health care insurance covering MMG, 56% reported having had an MMG in the past year.

Table 4 also presents the odds of having had an MMG within the past year. Perceived benefi ts to detecting and treating BC early, perceived barriers to having an MMG, having insurance coverage of MMG, and having an imme-diate family member with BC were predictive of having had an MMG in the past year ( p < .10). Women with higher perceived MMG barriers were less likely to have had an MMG in the past year than those with lower perceived MMG barriers (OR = 0.94, CI = 0.90-0.99). Surprisingly, women with higher perceived benefi ts were also less likely to have had an MMG in the past year than those with lower perceived BC benefi ts (OR = 0.47, CI = 0.30-0.74). Women with health insurance coverage of MMG service were three times more likely to have had an MMG within the past year than those women who did not have the cov-erage (OR = 3.21, CI = 1.13-9.11). In addition, women who had an immediate family member with BC were fi ve

Variable

Ever Had MG (Y/N) MMG in Past Year (Y/N)

� 2 p* � 2 p*

Have a regular HCP (Y/N) 3.62 .06 NS HCP told you to have MMG (Y/N) 5.96 .02 8.15 .001 Insurance covers MMG (Y/N) 9.61 .001 6.70 .01 Born in China (China/others) NS 2.85 .09 Income (reported/missing) 6.70 .01 NS Education (elementary or less/middle school or higher) NS 2.02 .08 Immediate family has BC (Y/N) NS 3.29 .07

Note. HCP, health care provider; BC, Breast cancer; Y/N, yes/no; MMG, mammogram; NS, not signifi cant, p > .10. * Variables with p < .1 were included in multivariate analyses.

TABLE 3 Bivariate Analyses for Sociodemographics and Mammography Use

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218 JOGNN Volume 36, Number 3

times more likely to have had an MMG in the past year than those women who did not have an immediate family member with BC (OR = 5.31, CI = 1.09-25.84).

Only 48.5% of participants reported that their last mammogram was within

the past year.

Discussion

Sociodemographic Characteristics The socioeconomic characteristics of the sample were

quite diverse, including women who were highly educated and with high family household incomes, and women with limited education and low income. The results also suggest that the respondents were relatively older immigrants who had lived in the United States for a fairly long period of time. Even though the average length of residence in the United States for the sample was approximately 18 years, the majority of the women were still more comfortable with the Chinese language. This suggests that this group of respondents had a strong Chinese cultural affi liation. Sur-prisingly, while this study shows that length of residence in the United States was a strong predictor for ever having had an MMG, this factor was not related to having had an MMG within the past year. This may be due to lack of the

annual mammography screening knowledge in this group of Chinese women.

The fi ndings that duration of residence in the United States, having recommendation from HCP, and having health care insurance coverage of MMG are signifi cantly ( p < .05) associated with ever having had an MMG are consistent with previous studies ( Tang et al., 2000; Tu et al., 2003; Yu et al., 2001 ). However, educational level and income level were not signifi cantly related to the utili-zation of mammography screening in this study. This may be due to the generally higher level of education among participants in this study. For income level, it may be due to the fact that a large portion of women (23%) did not report their annual household income. Women who did report their household income were more likely to have ever had an MMG ( p = .01). This may suggest that women who are more open with their personal information may also be more open to having an MMG. Perhaps those women who did report had higher incomes and may also have had insurance coverage.

Similarly to ever having had an MMG, having a recom-mendation from an HCP and having health care insurance that covers an MMG are signifi cantly ( p < .05) associated with having an MMG in the past year. These results were consistent with previous studies ( Tang et al., 2000; Tu et al., 2003; Yu et al., 1998 ). Having insurance that covers an MMG signifi cantly predicted higher odds of having had an MMG in the past year. With consistent fi ndings that insurance coverage predicts a higher likelihood of having MMG screening, funding is needed to provide ac-cess to MMG for uninsured women and to evaluate the effectiveness of such programs.

In this study, women who have an immediate family member diagnosed with cancer were signifi cantly more

Independent Variable B SE Odds Ratio

(90% Confi dence Interval)

Ever had an MMG Insurance covers MMG 1.72 0.67 5.59 (1.85-16.89) Income not reported − 1.45 0.68 0.24 (0.08-0.72) Constant 1.34 0.55 MMG within past year BC benefi ts − 0.76 0.28 0.47 (0.30-0.74) MMG barriers − 0.06 0.03 0.94 (0.90-0.99) Insurance covers MMG 1.17 0.63 3.21 (1.13-9.11) Immediate family with BC 1.67 0.96 5.31 (1.09-25.84) Constant 7.50 2.71

Note. BC, breast cancer; MMG, mammogram.

TABLE 4 Factors Associated With Having Had an MMG

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May/June 2007 JOGNN 219

likely to have had an MMG in the past year. To our knowledge, this variable has not been reported in previous studies of Asian participants as an infl uencing factor. However, Kerlikowske et al. (2000) reported that the rela-tive risk for BC is approximately two times higher in women who have a fi rst-degree relative with a history of cancer than in women who do not. Women with a family history of BC are somewhat more compliant with MMG screening. The rates of BC detection are higher in women with a family history of BC ( Kerlikowske et al., 2000 ).

Knowledge In general, this group of CAW had low knowledge

scores about BC and about MMG screening recommenda-tions. However, the knowledge score did not directly af-fect their MMG screening behavior. This fi nding is consistent with Yu and Wu ’ s (2005) fi ndings that increas-ing knowledge alone might not be an effective approach in promoting MMG screening in CAW. The fi ndings under-score the need to explore other related factors impacting MMG use.

Breast Cancer Beliefs The fi ndings of this sample of CAW were similar in be-

liefs to those reported in Champion ’ s (1994) study; how-ever, the Chinese respondents in this study had a signifi cant lower perceived susceptibility score (item M 2.37 vs. 2.54, p = .003) than the participants in Champion ’ s study (pre-dominantly White and middle class) for developing BC. The participants in this study recognized the high per-ceived benefi ts and demonstrated an understanding of the importance of obtaining mammography that was refl ected in high perceived benefi t score. Most respondents had a slightly higher than average common barrier score (barri-ers in detecting and treating BC early) but a low barrier score to obtaining an MMG. When comparing cultural barrier scores with Tang et al. ’ s (2000), the Chinese re-spondents in this study had a similar mean score of utiliza-tion of Eastern medicine (2.89 vs. 2.93, p = .62), a signifi cantly higher modesty mean score (2.82 vs. 2.65, p = .01), and were signifi cantly higher in prevention orien-tation (4.02 vs. 1.71, p < .001) and family support (2.95 vs. 2.65, p < .001).

Unexpectedly, perceived benefi ts to detecting and treat-ing BC early signifi cantly predicted lower odds of having had an MMG in the past year. This may be due to low variance in responses and limited breadth of items. Only two questions assessed the perceived benefi ts of detecting and treating BC early, and only 7% of participants dis-agreed with these two statements. Further questions should be developed to better assess this belief variable.

Limitations There were several limitations in this study. First, the

study utilized self-reported measures of MMG screenings

that could have been over- or underreported. This report-ing method is particularly vulnerable to socially desirable behavior biases ( Yi, 1994 ), suggesting that the actual oc-currence of MMG screening among CAW may be lower than obtained in this study. However, Zapka et al. (1996) found that 83% accurately reported the use of MMG within the past year. McGovern, Lurie, Margolis, and Slater (1998) also found that 88% of women were able to recall the year of their MMGs accurately. Chart review could help verify self-reported information if studies re-quiring more precise dates. For this study, due to the fact that participants were recruited from a large Chinese com-munity sample where health care services may be geo-graphically and organizationally diverse, it is believed that chart review is not cost effective. Further studies with a design of adequate verifi cation of self-reported informa-tion are warranted.

Second, the participants were a convenience sample recruited exclusively from the Chinese community in a single northwestern city. Thus, the results cannot be generalized to the general population of immigrant CAW. However, the fi ndings of this descriptive study can provide a foundation for future intervention studies of CAW and a comparison with other Asian subgroups.

Implications for Practice

The fi ndings indicate that the CAW in this study re-ported a higher rate of ever having had an MMG (86%) compared to CAW from other studies ( Lee, Lee, & Stewart, 1996; Tang et al., 2000; Tu et al., 2003; Yu et al., 1998, 2001 ). However, the rate for MMG within the past year (48.5%) continues to remain low, suggesting that when surveying MMG rates, it is important to assess tim-ing of the last MMG. It is critical to educate CAW regard-ing the importance of annual MMGs and adhering to MMG guidelines of the ACS.

Not surprisingly, higher perceived MMG barriers sig-nifi cantly predicted lower odds of having had an MMG in the past year. The most commonly identifi ed BC screening barriers in CAW samples included forgetting, lack of time, poor knowledge, lack of English ability, cost, lack of symptoms, lack of physician recommendation or lack of recent physical examination, and not living in the United States more than 25% of their lives ( Lee-Lin & Menon, 2005 ). The fi ndings of this study were similar with the ad-dition of three barriers identifi ed: “ having had a painful procedure, ” “ worry of being exposed to x-rays, ” and “ feeling that having an MMG is not important when com-pared with other health problems. ” A study from a popu-lation-based sample of New Hampshire women ( Carney, Harwood, Weiss, Eliassen, and Goodrich, 2002 ) found that previous negative MMG experiences, particularly related to MMG technologists, appeared to infl uence

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220 JOGNN Volume 36, Number 3

women ’ s behavior in MMG adherence. Creating a com-fortable MMG environment and a less painful process may improve MMG adherence. Specifi cally addressing barriers identifi ed in programs targeting Asian women will increase the likelihood of success in MMG screening participation. Furthermore, fi ndings of this study under-score both the value of a recommendation from a regular HCP to obtain screening and having adequate insurance coverage to pay for cancer screening. Primary HCPs should be reminded of their powerful role in increasing cancer screening adherence.

The top three barriers for obtaining a mammogram were having trouble

remembering, believing a mammogram is painful and worrying about being

exposed to x-rays.

Conclusions

A low MMG adherence rate is a major health concern for CAW. Regular MMG screening can prevent the deaths of many CAW. In many ways, the fi ndings of this descriptive study are consistent with fi ndings in other Chinese American studies. We have identifi ed other vari-ables (having an immediate family member diagnosed with cancer, and perceived benefi ts to detecting and treating BC early) and barriers (having had a painful procedure, worry of being exposed to the x-ray, and feeling that having an MMG is not important) that may infl uence CAW ’ s behaviors in MMG screening. Strate-gies are needed to improve BC screening among CAW and other Asian American women. The fi ndings that those with insurance coverage for mammography were approximately six times more likely to have ever had an MMG and three times more likely to have had an MMG within the past year than those women who had no coverage can guide advocacy and policy making efforts to increase health care access and reduce health disparities.

Acknowledgments

Supported by ACS, Oncology Nursing Society (ONS), Sigma Theta Tau, and National Cancer Institute training grant. We also thank Drs J. Itano and R. Erickson for their editorial assistance.

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Frances Lee-Lin, RN, PHD, OCN, CNS, is an assistant professor in the School of Nursing, Oregon Health & Science University, and the College of Nursing, University of Utah.

Usha Menon, PHD, RN, is an associate professor in the College of Nursing, University of Illinois — Chicago.

Marjorie Pett, Mstat, DSW, is a research professor in the College of Nursing, University of Utah.

Lillian Nail, PHD, RN, CNS, is a professor in the School of Nursing, Oregon Health & Science University.

Sharon Lee, PHD, is a professor in the Department of Sociology, Portland State University, OR.

Kathi Mooney, PHD, RN, is a professor in the College of Nursing, University of Utah.

Address for correspondence: Frances Lee-Lin, RN, PHD, OCN, CNS, Oregon Health & Science University, School of Nursing, 3455 SW Veterans Hospital Rd., Portland, OR 97239. E-mail: [email protected] .