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Impact of breast cancer screening intervention on
Korean-American women in Maryland
Hee-Soon Juon PhDa,*, Seunghee Choi MPHb,1,Ann Klassen PhDa,2, Debra Roter DrPHa,3
a Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N.
Broadway, Baltimore, MD 21205, United Statesb Howard County Health Department, 7178 Columbia Gateway Drive, Columbia, MD 21046, United States
Accepted 10 March 2006
Abstract
Background: Adherence to mammography guidelines among Korean-American women (KAW) is lower than that of Caucasian-
Americans, and disparities in breast cancer screening related to lack of English proficiency is under-researched. This study examined
the impact of a breast cancer intervention on intentions to use mammography among KAW. Methods: Face-to-face pre-intervention surveys
were conducted in control (n = 95) and intervention groups (n = 105), and were followed by implementation of a breast cancer education
program. At 6 months, both groups were re-interviewed by phone (92 control and 94 intervention participants). Generalized estimating
equation (GEE) analysis was used to assess the intervention effect before and after the breast cancer educational program. Results: The
intervention effect was statistically significant. Women in the intervention reported 2.96 times greater posttest intentions to have mammogram
than those in the control group (95% CI, 1.13–7.66). Prior intentions, age, and positive attitudes toward mammography were associated with
follow-up intentions to have a mammogram. Conclusion: This culturally and linguistically tailored educational intervention was effective in
increasing breast cancer awareness in a non-English speaking population.
# 2006 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved.
Keywords: Breast cancer; Korean-American; Mammogram; Intervention; Literacy; English proficiency; Health education; Cancer education program;
Cancer survivor; Cultural relevance; Aculturation; Early detection; Cronbach’s coefficient; Insurance provider status; Physician recommendation
www.elsevier.com/locate/cdp
Cancer Detection and Prevention 30 (2006) 297–305
1. Introduction
Breast cancer is one of the most common forms of
cancer; the incidence has increased in every race since the
early 1980s [1]. Breast cancer accounted for 32% of all
new cancer cases among women in 2004 and is the second
leading cause of cancer death overall, but the leading cause
of cancer death in women in the U.S. between the ages of
20 and 59 years [2]. The lifetime probability of a woman
developing breast cancer is 1 in 7 [3]. In 2003, the
* Corresponding author. Tel.: +1 410 614 5410; fax: +1 410 955 7241.
E-mail addresses: [email protected] (H.-S. Juon), [email protected]
(S. Choi), [email protected] (A. Klassen), [email protected] (D. Roter).1 Tel.: +1 410 614 3454.2 Tel.: +1 410 955 2218.3 Tel.: +1 410 955 6498.
0361-090X/$30.00 # 2006 International Society for Preventive Oncology. Publi
doi:10.1016/j.cdp.2006.03.008
American Cancer Society estimated that 4200 new cases of
breast cancer would be diagnosed among women and 800
women died of breast cancer in Maryland. The average
annual age-adjusted mortality rate for breast cancer in
Maryland was higher than the national average (29.6
versus 27.7 per 100,000). This rate among Asian Pacific
Islanders (API) in Maryland is 9.8 per 100,000, which is
lower than the national average for API (12.5 per 100,000)
[4].
The incidence of breast cancer per 100,000 from 1996 to
2000 was 140.8 among Caucasian-Americans, 121.7 among
African-Americans, 97.2 among API, 89.8 among Hispanic-
Americans, and 54.8 among American-Indians/Alaska
Natives (AI/AN) [3]. The incidence of breast cancer among
API increased at 2.1% per year from 1992 to 2000 [1].
Among women over the age of 50 years, the annual
shed by Elsevier Ltd. All rights reserved.
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305298
incidence increased 6.3% among Asian-Americans, com-
pared to 1.5% among non-Hispanic whites [5].
Data suggest that the incidence varies within the API
population [1]: Japanese-American women who have lived
in the U.S. long enough to have become fully acculturated
have a higher incidence than other subgroups of Asian-
Americans, close to that of Caucasian-Americans, and their
incidence rates appear to be continuously increasing. The
incidence of breast cancer among Korean-American women
(KAW) from 1988 to 1992 in Los Angeles was 21.5 per
100,000 [6] and increased to 45 per 100,000 from 1992 to
1997 [5]. Breast cancer was the most commonly diagnosed
cancer among KAW [6].
Data from the Surveillance, Epidemiology, and End
Results Program show the 5-year survival rates for breast
cancer, which are: 83% for stage I, 74% for stage II, 57% for
stage III, and 27% for stage IV [7]. These data indicate that
the survival rate is correlated with the stage at diagnosis;
thus, early detection of breast cancer increases the chance
for survival through earlier treatment. There are substantial
differences in the stage of diagnosis and survival rates
among races and ethnicities due to socioeconomic and
cultural effects [8]. Compared to Caucasian-Americans,
minority women are less likely to be detected at stage I. For
example, Caucasian-American women are more likely to
have breast cancer detected in stage I than KAW at the rates
of 50.4 and 43%, respectively, and mortality rates are lower
by 10% [8]. This lower survival rate for KAW is related in
part to lower breast cancer screening.
In spite of the controversy regarding the effectiveness of
mammography, the latest Swedish study estimated a 39%
decrease in mortality since 1980 for patients with invasive
breast cancer [9]. Mammograms and prevention programs
appear to play a key role in declining death rates. KAW have
the lowest rates of breast cancer screening among all ethnic
groups according to the 1994 National Health Interview
Survey [10]. Similarly, the mammogram screening rate in the
past 2 years among KAWage 50 years and older was 34% [11]
and in a 2000 study in Los Angeles, was 25% [12]. In our
previous study, the mammogram screening rate in the past 2
years among KAW age 40 years and older was 46.6% [13]. In
comparison to other subgroups of API, 41% of Filipino
women [12] and 63% of Chinese-American women aged 60
years and over had mammograms in the past 2 years [14].
These current breast cancer screening rates for each subgroup
of Asian-American women are unique, and KAW are far
behind the Healthy People 2010 Objectives which call for
70% of women age �40 years to have had a mammogram
within the past 2 years [15]. This suggests the importance of
analyzing the barriers to health care access for each Asian-
American subgroup separately, rather than in aggregate [12].
The Korean-American (KA) population was one of the
fastest growing in the U.S. between 1990 and 2000. The
Asian-American population increased from 2.8 to 4.2% of
total U.S. population during this time. In 2000, the KA
population was the fourth largest Asian-born population in the
U.S. [16]. Among languages other than English and Spanish,
the Korean language is the seventh most frequently spoken
language at home in U.S., and 60% of KA speak English less
than ‘‘very well’’ [17]. This reflects the fact that almost all KA
speak their native language at home. This makes it even more
difficult for KA to understand without interpretation
educational materials containing medical terminology.
In summary, with the increasing number of immigrants in
the U.S., the government must collect information on certain
races and ethnic groups to ‘‘implement special services and
evaluate programs, or enforce laws,’’ and ‘‘identify areas
needed services such as screening for diseases’’ [18]. For
this reason, detailed information about ethnic subgroups is
vital to approaching the hard-to-reach populations for
successful prevention and treatment programs.
One aim of our ongoing project, the Korean-American
Cancer Project in Maryland, is to develop and evaluate a
culturally integrated cancer education program among
KAW. As part of a breast cancer intervention program,
we developed a Korean-language photonovel, and in this
manuscript we report on the effect of this intervention in
promoting the intentions to have mammograms within 6
months. Specifically, the goal of this study is to test our main
research hypothesis that intervention participants would
have significantly greater intentions of receiving mammo-
grams than the control group after involvement in these
culturally appropriate intervention programs.
2. Methods
This study uses a non-equivalent control group, pretest–
posttest design [19] to test the effectiveness of a 90 min
educational intervention. Participants were recruited on a
voluntary basis from Korean churches and low-income
senior housing in the Baltimore Washington Metropolitan
Area. We chose the two geographical areas in Maryland
where 94% of the Korean population is concentrated. These
areas offered sufficient numbers of group venues for
recruitment and intervention activities, such as churches
and apartment complexes. Women who resided in the
Baltimore Metropolitan region were selected as the
intervention group, while women who resided in the
National Capital region were selected as the control group.
The study was approved by the Committee on Human
Research (CHR) at the Johns Hopkins Bloomberg School of
Public Health.
2.1. Church recruitment methods
We enumerated all Korean churches in our two geographic
areas of interest (n = 129) and randomly selected 12 churches.
The pastors of selected churches received a letter from the
principal investigator soliciting involvement, with follow-up
by phone. Each pastor identified one of the church members as
a contact person; usually this was the leader of the women’s
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305 299
group. Contact persons arranged the times and locations for
activities, and were instrumental in encouraging the
participation of other KAW from the congregation.
2.2. Senior housing recruitment methods
To increase the representativeness of our sample and to
include those who do not attend church, we also conducted
our research in low-income senior housing. Two senior
housing complexes were selected, one for the intervention
and the other for the control group.
2.3. Developing culturally integrated educational
materials
To develop a photonovel, we conducted focus groups with
breast cancer survivors or family members with cancer
experience. Eight focus groups consisted of 11 KAWages 42–
69 years (9 breast cancer survivors and 2 family members with
breast cancer experience). Most KAW found the breast cancer
themselves either accidentally or through BSE. Most KAW
were not getting regular breast cancer screening. Reasons for
not having annual screening included beliefs of low risk of
getting breast cancer, confidence in their health, lack of
knowledge of cancer screening guidelines, misconceptions of
family history, no physician recommendations, no time, and
no insurance. The role of the primary care provider is to be the
main source of information on breast cancer in terms of
treatment, decision-making, and breast reconstruction. After
the focus group study, we conducted a series of meetings of a
work group for the development of photonovels. The work
group served as a guide in specifying and refining the contents
and formats of photonovels. Group members were selected
from the Korean-American community such as church
groups, civic groups, and social groups. They were
Korean-American cancer survivors, family members with
cancer experience, health practitioners, researchers, and
Korean outreach workers. Every effort was made to follow the
critical principles of participatory research which emphasized
mutuality and partnership between researchers and the target
community. The work group determined the cultural
relevance, literacy, and acculturation congruence of the
photonovels. At the final stage of production, all the members
of work group participated in designing the cover, photo-
graphing, assembly and layout of photonovel, pretesting, and
evaluation. To our knowledge, this is the first Korean-
language photonovel to promote breast cancer screening.
2.4. Pretest
We recruited eligible Korean women, at least 40 years of
age, from the community sites (i.e., Korean churches, senior
housing). For the intervention group, eligible women were
recruited from Korean churches (n = 7) and low-income
senior housing in the Baltimore Metropolitan region. After
providing informed consent, a total of 105 women (87 from
churches, 18 from senior housing) voluntarily completed the
self-administered Korean pre-intervention survey, assisted
by our bilingual interviewers as necessary. In the control
group, a total of 95 women from Korean churches (n = 5)
and low-income housing in the National Capital region
completed the survey: 82 women were from churches and 13
from senior housing. Overall, 86% women were recruited
from churches. Two women who had already participated in
our project at church were excluded in senior housing.
Participants received US$ 20 compensation for their time
and expenses. The study period for the pretest and
intervention was September–December 2002.
2.4.1. Intervention
To develop intervention protocols, the work group met
bimonthly. We reviewed English educational materials for
breast cancer screening and discussed the contents for small
group presentations. The intervention consisted of three
components: (a) small group educational presentations, (b)
group showing of a Korean-dubbed videotape on how to
perform breast self-exam developed by the American Nurse
Practitioners Association, and (c) distribution of a Korean-
language photonovel. The content of the small group
presentation included cancer statistics, risk factors for breast
and cervical cancer, early warning signs of cancer,
symptoms of cancer, the importance of getting annual
screening for early detection, screening methods and
guidelines, and breast lump size using a bead necklace
developed by the North Carolina Breast Cancer Screening
Program. Participants received information on contacting
Korean outreach workers at local health departments
working with free and low cost mammogram screening
programs. Many intervention participants expressed interest
in these services. The intervention session lasted 90 min and
was conducted at churches, doctors’ offices, senior housing,
and individual homes. After the posttest, the delayed
intervention was provided to the control women, giving
photonovels and other information on free or low cost
mammogram programs in Korean.
2.5. Posttest
Six months after the intervention program, we evaluated
its effect. The 105 women in the intervention group and the
95 women in the control group received follow-up phone
interviews from March to June 2003. From the intervention
group of 105 participants, 94 were re-interviewed. Up to four
attempts to contact were made, with 65% successfully
interviewed on the first attempt. Eleven women were lost to
follow-up, due to unknown (n = 6) and disconnected phone
numbers (n = 2), moved to another state (n = 2), or extended
visits to Korea (n = 1). Ninety-two of the 95 controls were
re-interviewed. Two were lost to phone disconnection and
one due to moving.
We recontacted 93% of both groups, and all of those
contacted willingly participated in the phone follow-up, in
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305300
Table 1
Items used for the pros and cons of mammography
Pros (six items, Cronbach’s alpha = 0.90, 12–30)
1. Those people who are close to me will benefit if I have a
mammogram
2. I would be more likely to have mammogram if my doctor told
me how important it was
3. Having a mammogram every year or two will give me a feeling
of control over my health
4. Regular mammograms give you peace of mind about your health
5. Mammograms are necessary even when there is no history of
breast problems in a family
6. Mammograms are most helpful when you have one every year or
two
Cons (six items, Cronbach’s alpha = 0.83, 3–26)
1. If I eat a healthy diet, I will lower my risk of getting cancer enough
that I probably do not need to have a mammogram
2. If I have a breast exam from a doctor or nurse, I don’t need to
have a mammogram
3. Mammograms have a high chance of leading to breast surgery that
is not needed
4. Once you have a couple of mammograms that are normal, you do
not need to have any more for a few years
5. I would probably not have a mammogram unless I had some
breast symptoms or discomfort
6. If a mammogram finds something, then whatever is there will be
too far along to do anything about it anyway
Items answered on a 5-point, Likert-type scale of: (1) strongly disagree to
(5) strongly agree.
part due to the rapport established during the previous face-
to-face interviews and intervention program. The telephone
interview lasted 5–10 min and most women gave positive
feedback.
2.6. Conceptual framework
This study is guided by the Transtheoretical Model of
Behavior Change (TTM), as a general model of intentional
behavioral change based on cognitive and social learning
constructs [20]. Interventions based on the TTM provide
culturally integrated educational materials with the objective
of influencing an individual’s decision making to initiate or
not initiate a behavior. A key feature of this framework is the
integration of current behavioral status with future intention
to create a sequence of stages that range from not doing and
not intending, to the target behavior. This approach also
incorporates elements of decision making such as the pros
and cons—along with a decisional balance measures derived
from them.
2.7. Measures
The primary outcome variable was the respondent’s
intention to obtain a mammogram. Intention to obtain a
mammogram was one of the questions from the pre-
intervention survey and post-intervention survey asking
respondents whether they were planning on having a
mammogram in the future (in 6 months)?’’ It was
categorized into no intention to use mammograms (=0)
and intention to use mammograms (=1). We used intentions
to have a mammogram as our primary outcome, since we
could not obtain mammography screening behavior within 6
months.
2.8. Independent variables
Age, education, marital status, and employment status
were included in the analysis as demographic character-
istics. Age was categorized into three groups: 40–49 years,
50–64 years, and 65+ years. Education was dichotomized as
high school graduate or less than high school (�12 years),
versus any post-high school education (>12 years). Marital
status was dichotomized as married and not married.
Employment was dichotomized as employed and unem-
ployed.
As a proxy measure of acculturation, the proportion of
life spent in the U.S. was categorized as <25% versus
�25%. English proficiency, dichotomized as ‘‘cannot
speak’’ and ‘‘can speak,’’ was included. Since these two
measures were highly associated (x2 = 29.15 with d.f. = 1,
p < 0.001), English proficiency was use as a measure of
acculturation. For the measure of health status, respondents
were asked to rate their general health status on a 5-point
scale (1, very poor to 5, excellent), and used as a continuous
variable for the analysis.
Measures of access to health care were also included,
such as insurance coverage and provider status. Health
insurance status was dichotomized as having or not having
any health insurance coverage. The measure of provider
status was assessed by the following questions: ‘‘Is there any
place that you usually go to if you are sick or need advice
about your health, including oriental medicine doctor or
clinic?’’ and ‘‘Can your doctor speak Korean?’’ Respon-
dents who answered positively to both questions were
classified as having a regular Korean doctor. Those who
answered positively to the first question but not the second
question were considered to have a regular non-Korean
doctor. Respondents who answered negatively to both
questions were considered as having no regular doctor. To
assess the role of physicians associated with mammogram
screenings, physician recommendations for a mammogram
were included.
Familiarity with mammogram screening guidelines by
the U.S. Preventive Services Task Force recommendation
[21] was determined with two open-ended questions: ‘‘Do
you know any breast cancer screening tests for early
detection?’’ If respondents mentioned mammography as one
of the breast cancer screening tests, they were then asked:
‘‘How often do you need to have a mammogram?’’ Based on
these responses, their answers were dichotomized as
knowing mammography guidelines or no knowledge of
guidelines.
Opinions about the positive (pros) and negative (cons)
aspects of mammography screening were assessed with a
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305 301
translated version of the scale developed by Rakowski et al.
[20]. Responses were measured on a 5-point Likert scale
ranging from ‘‘Totally disagree’’ to ‘‘Totally agree.’’ Raw
scores of pros and cons were obtained by summing
responses to the items corresponding to each subscale.
The pros and cons of mammography were each measured by
six items (Table 1). The Cronbach’s coefficient a-
reliabilities of these indices were: pros, 0.90; cons, 0.83.
The variable of ‘‘decisional balance’’ was based on first
transforming the pros index and cons index into standardized
T scores (i.e., with mean, 50; S.D., 10). Next, a subtraction
was done (pros minus cons) to derive the summary
decisional balance score. Positive decisional balance values
indicate a favorable assessment of pros versus cons; negative
values indicate a relatively more unfavorable assessment.
Decisional balance of about zero represents a mixed
Table 2
Baseline characteristics of KAW in Maryland: control and intervention groups (
Characteristics Control (n = 95)
Number %
Age (mean � S.D.), range 56.95 � 13.67 (40–89)
Education
�12 grades 59 67.1
>12 grades 29 32.9
Marital Status
Not Married 32 33.7
Married 63 66.3
Health Status
Poor 26 27.4
Good 53 55.8
Excellent 16 16.8
Employment
No 46 48.9
Yes 48 51.1
English proficiency
Cannot 26 27.4
Can 69 72.6
Health insurance
No 32 34.0
Yes 62 66.0
Provider status
No provider 22 23.2
Korean doctor 61 64.2
Non-Korean doctor 12 12.6
Physician recommendation
No 69 72.6
Yes 26 27.4
Knowledge of mammogram guidelines
Wrong answer 50 52.6
Right answer 45 47.4
Decision balance (mean � S.D.) �0.16 (0.16)
Baseline intention
No 48 50.5
Yes 47 49.5
perspective of positive and negative opinion. Continuous
variables were used for the analysis.
2.9. Data analysis
Demographic and other characteristics were compared
between the control and the intervention groups using Chi-
square tests and t-tests. Bivariate analyses were conducted to
examine the association between outcome measure of
intention to have a mammogram in posttest and each
predictor variable. Interactions among independent vari-
ables were tested. Finally, multivariate analyses were
performed to examine the efficacy of intervention on the
intention to have a mammogram, controlling for prior
intention, sociodemographic characteristics (e.g., age,
marital status, education), health status, acculturation
n = 200)
Intervention (n = 105) x2/t-test p-Value
Number %
52.45 � 12.31 (40–91) 2.45 0.02
1.84 0.17
58 57.4
43 42.6
8.25 <0.01
17 16.2
88 83.8
1.28 0.52
22 21.0
66 62.9
17 16.1
0.34 0.55
47 44.8
58 55.2
0.07 0.79
27 25.7
78 74.3
4.30 0.03
51 48.6
54 51.4
6.90 0.03
38 36.2
48 45.7
19 18.1
2.17 0.14
66 62.9
39 37.1
3.20 0.07
42 40.00
63 60.00
0.149 (0.15) �1.40 0.16
1.84 0.17
43 40.9
62 59.1
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305302
(e.g., English proficiency), health insurance, provider status,
physician recommendation, and knowledge of mammogra-
phy guidelines.
It is possible that there is statistical interdependence
within the groups, based on the fact that groups were
assigned as a single unit to the intervention and the
educational program was delivered in group format.
Generalized estimating equations (GEE) [22] were used
as an extension of the logistic regression model for non-
independent observations, to assess the intervention effect.
The analysis was conducted using the STATA 8.0 statistical
package [23], which provides maximum likelihood logit
coefficients to check colinearity.
3. Results
3.1. Sample characteristics
The comparison of the baseline and follow-up character-
istics of women in the control and intervention groups is
presented in Table 2. Although the two groups were similar
at baseline, there were statistically significant differences in
age and marital status: women in the intervention group
were more likely to be married than those in the control
(85% versus 70%), and women in the control group were
slightly older on average than those in the intervention group
(56 years versus 52 years). Women in the control group were
more likely to have health insurance than those in the
intervention group (66% versus 51%), and to have a source
of medical care (77% versus 64%). The two groups did not
differ significantly at baseline on knowledge of mammo-
graphy guidelines, decision balance, or intention to receive
mammograms, although the intervention group did show a
trend towards a more pro-mammography profile on all four
measures.
Based on results from the GEE logistic regression
analysis, Table 3 presents the posttest survey results of
bivariate relations between predictors and having intention
to have mammograms. In bivariate analyses, group status
(control/intervention), baseline intention, age, martial status,
education, English proficiency, self-reported health status,
physician recommendations, knowledge of mammography
guidelines, and decision balance were related to outcome
( p < 0.05). Having health insurance and provider status
were not statistically significant predictors of the outcome.
Following the bivariate analyses, a multivariate logistic
regression model was created. The effect of the intervention
on posttest intention to have mammograms was statistically
significant. Women in the intervention group were 2.95
times more likely to have posttest intentions to have
mammograms than those in the control group (95% CI,
1.13–7.66). Pretest intention was also an important predictor
of later intention. Women with prior intention were 5.71
times more likely to have posttest intention than those
without prior intention (95% CI, 2.08, 16.3). Age and
decision balance were also important for posttest intentions:
women 65 years of age and older reported lower posttest
intentions to have mammograms than those 40–49 years of
age (RR = 0.05, 95% CI, 0.01, 0.26). Women with favorable
attitudes toward mammograms at baseline were more likely
to express posttest intention than women with unfavorable
baseline attitudes (RR = 1.47, 95% CI, 1.01, 2.14).
4. Discussion and conclusion
In this research, we explored the effects of intervention on
women’s intentions of having a mammogram. Previous
research with KAW has primarily investigated current or
recent breast cancer screening practices [11–13], but our
results would suggest this may not predict future regular
cancer screening behaviors [24]. We found that some women
who were currently receiving mammograms said that they
did not plan to receive further mammograms, and
conversely, some women who never had a mammogram,
desired to receive one, if they could reduce personal barriers,
such as work, lack of time, and so forth. It is important to
know the current health behavior of these KAW, but it is also
important to understand their intentions, in order to meet
their needs in the future.
We found the strongest predictor of posttest intention to
have a mammogram was baseline intention. This result
indicates that most intentions are enduring, and developed
over time. However, KAW in the intervention group who
participated in the education session were more likely than
controls to have a positive posttest intention toward
adherence to mammogram screening. This suggests that
the intervention group may have increased their knowledge
of breast cancer screening guideline, or changed their
perceptions of pros and cons in mammography and helped
them decide in favor of screening.
Another predictor of posttest intention was age. The 50–
64 year old age group and the 40–49 year old group were not
significantly different in their posttest intentions; however,
the 65+ year old group was less likely to have intentions
compared to the 40–49 year old group. Although some
elderly women may discontinue screening due to physician
recommendations, previous research has identified age-
related influences of transportation and logistics, modesty,
and age-related fatalism, such as the belief that one is ‘‘too
old for mammogram.’’ It may not be appropriate in the
geriatric population to continue with mammograms or other
screening tests. However, especially in minority population
if preventive screening was not done, it may be indicated that
further intervention is needed to develop age-sensitive
strategies for growing and diverse elderly population in the
U.S.
Decision balance between the pros and cons of
mammogram is related to reporting positive intentions.
Many of the items used in this index measure misconcep-
tions, such as breast cancer fatality, or the need for surgery
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305 303
Table 3
Relative risks of posttest intention to have mammogram for KAW in the intervention and control group (n = 186)
Unadjusted relative risk (95% CI) Adjusted relative risk (95% CI)
Group
Control 1 1
Intervention 2.31 (1.28–4.17)* 2.95 (1.13–7.66)*
Having intention at pretest
No 1 1
Yes 13.09 (6.30–27.1)* 5.71 (2.01, 16.2)*
Age
40–49 years 1 1
50–64 years 0.74 (0.33–1.65) 0.55 (0.17–1.77)
65+ years 0.03 (0.01–0.10)* 0.05 (0.01–0.26)*
Marital
Not married 1 1
Married 5.99 (2.79–12.9)* 1.61 (0.42–6.25)
Education
�High school 1 1
>High school 4.03 (2.06–7.85)* 1.29 (0.46–3.64)
Having health insurance
No 1 1
Yes 0.57 (0.31–1.04) 0.90 (0.52–2.55)
English proficiency
Cannot 1 1
Can 5.02 (2.57–9.82)* 1.35 (0.48–3.81)
Provider status
No provider 1 1
Korean doctor 0.72 (0.37–1.39) 1.20 (0.41–3.51)
Non-Korean doctor 2.05 (0.75–5.66) 3.44 (0.61–9.41)
Physician recommendation
No 1 1
Yes 2.22 (1.15–4.28)* 1.21 (0.39–3.75)
Knowledge of mammogram guideline
Wrong answer 1 1
Right answer 4.11 (2.22–7.61)* 2.11 (0.81–5.55)
Decision balance 1.90 (1.51–2.38)* 1.47 (1.01–2.14)*
Health status 1.56 (1.07–2.28)* 1.39 (0.72–2.68)
* Note: p < 0.05.
after any abnormal mammogram. Health education about
the benefits of early detection is needed on an ongoing basis
in the Korean community, in combination with distribution
of educational materials and physician recommendations.
As is commonly done in community-based health
education and communication trials, we assigned groups
as a single unit to the intervention and control conditions and
delivered the educational intervention program in group
format. Therefore, one issue we must consider is whether
baseline differences in our control and intervention
populations could cause differences in our outcome
measures, thus weakening the causal validity of our
intervention. Our intervention and control women were
very similar at baseline in many characteristics known from
the literature to influence health behavior among immigrant
groups, as they did not differ significantly in terms of years
of formal education, health status, employment, or
proficiency in English. There were several sociodemo-
graphic differences in groups at baseline. In each instance,
the differences favored the control group: control women
were actually slightly advantaged towards mammography
by their higher rates of health insurance and access to
medical providers. In terms of the proximal influences on
screening propensity, we observed few differences in
screening attitudes or knowledge between intervention
and control women at baseline. Although slightly more
intervention women could correctly define a mammogram
(60% versus 47%, p = 0.07), there were no significant
differences between intervention participants and controls in
decision balance between pros and cons of mammography,
or intention to screen. Therefore, in this non-equivalent
control group study design, the intervention effect only can
be trusted to the extent that all confounding influences were
controlled for in the final model.
There are limitations in this study. First, because the
follow-up survey was conducted only 6 months after the
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305304
intervention, there was insufficient time to observe receipt of
mammograms. Second, findings in these concentrated
populations of Maryland may not be generalized to Koreans
who are more acculturated, or living in other types of
communities. Third, those who voluntarily participated in the
study might be more motivated to learn about breast cancer or
other health issues, and could overestimate the effect of a
similar intervention if conducted with less motivated
populations. However, the use of a similarly motivated
control group, recruited in the same manner, strengthens the
causal validity of our posttest intervention effect. The fourth
limitation may be in the nature of self-reported data. Women
may be over-reporting their mammograms if they sense that
affirmative responses to this question are socially desirable.
Self-reported mammography use tends to be over reported,
often by reporting a more recent date than the actual date for
most recent mammogram [25].
The strength of this study is that the culturally and
linguistically appropriate methods, such as face-to-face
interviews, phone contact, and referral to local low-cost
mammography services built trust and rapport with
participants. The educational materials such as photonovels,
brochures, and videos in the Korean language with the
picture of a Korean layperson, helped participants identify
messages in the materials. With Korean health workers and
research work groups, these resources can be effective tools
to influence and motivate the participants. They suggest
community involvement in the development process of
health messages, and the use of testimonials and photo-
graphs from community laypersons as role models for the
reader to use as they build their own motivation to adopt the
target behavior.
Our experiences confirm what other researchers have
reported: health education is viewed positively within the
Korean-American community, and educational programs
can produce beneficial results. The high response rates to
each phase of data collection, as well as participation rates
during the intervention session, reflected the participants’
high motivation to learn about their health. Additionally,
some women requested health counseling after the session,
while others had questions regarding women’s health in
general. We were asked to offer additional presentations,
suggesting that this ‘‘research’’ activity was seen as a benefit
rather than a burden within this community. The study of
Korean-Americans in California found that KAW are highly
motivated to learn about cancer education and suggested that
culture and language were critical elements to improve
health in the Korean community [26,27]. In addition, they
pointed out that bilingual health educators with linguisti-
cally relevant education materials are vital to health
education in the Korean community [26,28,29].
Wismer et al. [29] described the reasons for being
‘‘ineffective’’ in their Korean community intervention, and
pointed out the importance of relationship building within the
Korean community. They also stressed that strong relation-
ships with the community may lower the risk that a lack of
cultural understanding could influence results of a project.
They suggested that language and culture are the key factors
for successful intervention if the participants have a different
culture. These results may suggest appropriate strategies to
consider for other Asian-American community interventions.
Because preventive behavior is influenced by factors not only
at the individual level but also at the community level, health
promotion projects among minority populations should be
developed with an understanding of the impact of socio-
cultural variation within the community [30].
The KA population is one of the fastest growing
populations in Maryland, but its health behavior is under-
studied. Compared to mainstream populations in the U.S.,
this population affiliates mostly within the same ethnic
group, is largely dependent on the community they are
involved in, and less likely to get medical resources except
from primary care doctors. However, the role of Korean
doctors as medical resource persons has not been shown to
significantly influence early detection for women. In this
study, 78% of the primary doctors of KAW are male. It is
interesting that this study’s results described that neither
health access nor the doctor had significant relationship to
the positive intention outcome. Collaboration with doctors
and the Korean community, churches, and outreach workers
is critical in raising the role of social networks and
community awareness of the health issues to promote early
detection programs.
In conclusion, this study supports many previous studies
of Asian-American women’s health, which show Asian-
American women no longer being considered a ‘‘low-risk
group’’ for breast cancer. English proficiency was the
significant factor for KAW having a lack of knowledge about
mammograms, especially in the elderly group. They are less
likely to be aware of their risk for breast cancer. To improve
screening rates, KAW need to be educated about breast
cancer screening guidelines to change their misconceptions
regarding mammograms. We suggest the distribution of the
Korean language materials in the community such as
doctor’s offices, grocery stores, and churches as one way to
change social norms to increase preventive medicine.
Another possible way is to use a mobile mammogram
clinic on weekends at churches or senior housing centers.
We recommend providing Korean breast cancer education
through bilingual health workers. This is vital to increasing
community awareness. We hope this study will lay the
groundwork for community-based interventions for suc-
cessful promotion of cancer prevention and screening
activities among KAW, and contribute to reduce racial and
ethnic health disparities in the nation by the year 2010.
Acknowledgements
This study was supported by the Susan G. Komen
Breast Cancer Foundation (POP0100420) and the Maryland
Cigarette Restitution Fund. For their support and cooperation
H.-S. Juon et al. / Cancer Detection and Prevention 30 (2006) 297–305 305
in this project, we thank the breast cancer survivors who
helped develop the Korean-language breast and cervical
cancer photonovels. We thank all workgroup members for
their dedication in helping to complete this project. We are
also grateful to Martin Blair for his edits of the manuscript.
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