www.elsevier.com/locate/ypmed

Preventive Medicine 39 (2004) 474–481

Predictors of adherence to screening mammography among Korean

American women

Hee-Soon Juon, Ph.D.,a,* Miyong Kim, Ph.D.,b Sharada Shankar, Ph.D.,c

and Wolmi Han, Ph.D.b

aDepartment of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USAbJohns Hopkins School of Nursing, Baltimore, MD 21205, USA

cDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA

Available online 3 July 2004

Abstract

Background. Breast cancer is the most commonly diagnosed cancer among Korean American women (KAW). Many KAW are not aware

of the importance of regular screening. This research estimates the rates of regular breast cancer screening and examines the predictors and

barriers to obtaining regular mammograms.

Methods. Face-to-face surveys were conducted with 459 KAW residing in Maryland. Study participants were recruited through Korean

churches and senior housing.

Results. About 33% had regular mammograms. In multiple logistic regression analyses, the strongest correlate of regular mammograms

was knowledge of screening guidelines. Age, spoken English proficiency, and physician recommendations were associated with regular

mammograms. Employment interacted with insurance: Employed women without insurance had lower rates of mammograms than those

employed with insurance. The most frequent reason for not having regular mammograms was a woman’s belief that she was at low risk for

breast cancer.

Conclusions. Results indicate that knowledge of screening guidelines and physician recommendations for screening are important in this

minority population. Culturally relevant educational programs about breast cancer screening should be developed for less acculturated

women and recent immigrants.

D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved.

Keywords: Mammography; Korean American; Access to health care; Physician recommendation; Knowledge; Barriers

Introduction 1997. During the same period, the breast cancer incidence

Lower rates of breast cancer incidence and mortality

among Asian American women in comparison to other

racial or ethnic groups led to the belief among health care

providers, policy makers, the general public, and Asian

American women themselves that they are not at risk for

breast cancer. However, recent study shows that breast

cancer incidence among Asian American women has been

rising rapidly: The annual age-adjusted incidence rate of

breast cancer among Asian American women increased

from 66.2 per 100,000 in 1988 to 77.6 per 100,000 in

0091-7435/$ - see front matter D 2004 The Institute For Cancer Prevention and

doi:10.1016/j.ypmed.2004.05.006

* Corresponding author. Department of Health Policy and Management,

Johns Hopkins Bloomberg School of Public Health, 624 North Broadway,

Baltimore, MD 21205. Fax: +1-410-955-7241.

E-mail addresses: hjuon@jhsph.edu (H.-S. Juon), mkim@son.jhmi.edu

(M. Kim), sshankar@jhsph.edu (S. Shankar), wpark@jhsph.edu (W. Han).

rate among Korean American women (KAW) increased

from 26.1 to 44.5 per 100,000 [1]. Breast cancer is the

most commonly diagnosed cancer among KAW [2].

Screening methods and programs are critical strategies for

early and timely treatment of breast cancer. Findings from

clinical trials evaluating the efficacy of screening mammog-

raphy indicate that deaths from breast cancer could be

reduced by 19–30% if guidelines for regular breast cancer

screening were followed [3]. In 2002, the U.S. Preventive

Services Task Force (USPSTF) recommended screening

mammography, with or without clinical breast examination,

every 1–2 years for women aged 40 and older [4].

The 1994 Behavioral Risk Factor Surveillance Survey

(BRFSS) of Korean Americans in California indicated that

KAW ever had mammograms far less often than the general

California population (55% vs. 90%) [5]. Similarly, about

half of the respondents in the 1993–1994 National Health

Elsevier Inc. All rights reserved.

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481 475

Interview Survey (NHIS) of KAWapproximately 40 years of

age reported ever having a mammogram [6]. In a telephone

survey of KAWapproximately 50 years of age in California,

only 34% reported having had a mammogram within the past

2 years [7]. These rates of mammography are far lower than

the Healthy People 2010 objectives for breast cancer screen-

ing, which calls for 70% of women approximately 40 years

of age to have had a mammogram within the past 2 years [8].

A growing number of researchers are concerned about

the low use of breast cancer screening among KAW. These

studies of breast cancer screening among KAW identified

several significant barriers to mammography. These barriers

included age, level of education, income, acculturation,

health insurance, knowledge about some aspect of breast

cancer screening, and lack of encouragement from family

members to have breast cancer screening [7,9–13]. Another

predictor of mammography includes lack of recommenda-

tions by health care providers as a common characteristic of

persons who underused screening examinations [10,11,14–

17]. The effect of provider status on cancer screening is also

important for non-English speaking minorities. Having a

doctor of the same ethnicity may be associated with lower

rates of breast and cervical cancer screening in some groups

of Asian American women [18–20]. Similarly, KAW who

had a non-Korean doctor were more likely to have a

mammogram than those who had a Korean doctor. Having

a Korean doctor indicates less access to preventive breast

cancer screening [21]. This phenomenon may have to do

with patient–provider communication issues related to

physician gender and cultural factors, as many immigrant

communities have a lot more male than female physicians.

Nearly all the previous studies of KAW have focused on

the rate and predictors of having a mammogram and having

had a mammogram in the past 2 years. Few studies have

examined adherence to screening mammography within

guidelines. The aims of our project, Korean American

Cancer Project in Maryland, are to collect qualitative and

quantitative information about the cancer prevention behav-

ior of KAW and to develop and test a culturally integrated

cancer education program. As part of this project, we

conducted face-to-face surveys in Maryland during 2000.

The goal of this paper was to provide information about

regular mammography barriers and facilitators that could be

used to develop intervention strategies for KAW. To the best

of our knowledge, this is the first study to examine the

estimated rates and predictors of adherence to regular

screening mammography among KAW.

Methods

The survey was designed to collect information

concerning knowledge, attitudes, and practices toward gen-

eral health, cancer in general, and access to health care.

Participants were recruited on a voluntary basis from Korean

churches (n = 14) and low-income senior housing (n = 2) in

the Baltimore-Washington metropolitan area. The study was

approved by the Committee on Human Research (CHR) at

the Johns Hopkins Bloomberg School of Public Health.

Study sample

Church recruitment methods

We based our church sampling frame on a list of 125

Korean churches. A county-stratified random sample of 35

churches was selected, and pastors were sent letters and

fliers explaining the purpose of the project. A week later,

introductory phone calls were made to each pastor to obtain

verbal permission to conduct the study. If the pastors were

willing to participate, we set a date for the survey. Of the 35

churches sampled, 24 were successfully contacted. Despite

repeated attempts, we were not able to make contact with 11

churches by phone or letter. Of the 24 churches contacted,

58% (n = 14) participated and 42% (n = 10) refused.

Reasons given by the pastors for refusal included too few

women in the congregation, no time for the survey, and

anticipation of low cooperation from congregants.

All female congregants 40 years of age and older were

asked to participate in the survey, administered at the church

after worship services. Given the central role of the church

in the Korean American community, the support from clergy

and female church lay leaders in the recruitment process was

a key issue. We asked participating pastors to announce the

upcoming survey in the church bulletins. We also sent

confirmation letters and called pastors to remind them 1

or 2 weeks before each survey. On the day of survey, the

pastors introduced the research team to their congregations,

encouraged women to participate, and gave a motivational

message of appeal during religious services.

Senior housing recruitment methods

From our previous survey work, we estimate that ap-

proximately 85% of Korean Americans in the Baltimore-

Washington area attend church [9]. To increase the repre-

sentativeness of our sample to include nonchurch attenders,

we also conducted data collection with KAW residents of

low-income senior housing. Two senior housing complexes

were selected by word-of-mouth: one from Howard County

and the other from Montgomery County, where most

Korean Americans live. Most residents participated in the

survey.

Data collection procedure

Data were collected in churches and at the housing

complexes from June through October 2000. Face-to-face

interviews were conducted by bilingual Korean American

graduate students trained and monitored by the investigators.

The average length of the interview was 30–40 min. Since

most women were born in Korea, all interviews were done in

Korean. Before interviewing, written consent was obtained.

Confidential aspects of the survey, voluntary participation,

and the rationale for the research were discussed. Of 475

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481476

women who came forward to be surveyed, 16 respondents

were excluded because they could not complete the interview.

The high completion rate (96%) was in part because of the

cultural rapport between interviewers and subjects who were

generally very positive about survey participation. Informa-

tion on a total of 459 women is included in the analysis: about

94% of women (n = 432) were from the churches and 6% (n =

27) were from senior housing. After the survey, women were

offered other health education opportunities, including blood

pressure screening and Korean language information pam-

phlets on hypertension, diabetes, and high cholesterol.

Table 1 incorporates the age distribution of the Korean

American women counted in 2000 U.S. census in Maryland.

Comparison of these two distributions is to demonstrate the

representativeness of our study sample. The age distribution

of our sample and that of the Census was about the same:

about two fifths were less than 50 years old (39.9% for

survey sample and 41.7% for Census). Less than one fifth

were more than 65 years old (18.5% vs. 17.3%). This

similarity in the age distribution suggests that our sample

represented the Korean population in Maryland.

Survey development and content

We used two sources of measures when developing our

survey instrument. First, we adopted measures validated and

used previously to measure health behaviors in national

surveys such as the BRFSS and the NHIS. The English

versions of these items were translated into Korean and back

translated into English to ensure equivalency. Second, the

survey development was guided by an earlier qualitative

study. The qualitative study included unstructured interviews

of key informants as well as focus groups with Korean

American women. Based on our qualitative findings, we

developed new measures to cover additional topics not in-

cluded in national survey instruments. The instrument was

pilot tested to ensure cultural appropriateness and acceptance.

This study is guided by the PRECEDE or PROCEED

model to provide a useful guide for designing and evaluat-

ing health promotion programs intended to change the

health behaviors of large groups [22]. This approach incor-

porates critical constructs from social support, adult learn-

ing, and behavior modification theories as predisposing,

enabling, and reinforcing factors related to early cancer

screening behaviors. Predisposing factors are antecedents

to behavior that provide the rationale or motivation for the

behavior, such as knowledge, beliefs, values, and attitudes.

Enabling factors are those that allow a predisposition to be

Table 1

A comparison of survey sample vs. 2000 Maryland census data

Age Survey group 2000 Census

n % n %

40–49 183 39.9 3688 41.7

50–64 191 41.6 3630 41.0

65+ 85 18.5 1534 17.3

Total 459 100 8852 100

translated into a behavior, such as accessing health care

resources and acquiring appropriate skills. Reinforcing

factors are those related to the feedback the learner receives

from others, the results of which may encourage or discour-

age behavioral change. Family members, peers, and health

care providers can offer such support. These three factors

are considered changeable characteristics. However, the

sociodemographic characteristics, acculturation, and health

condition are considered unchangeable.

Measures

The dependent variables measured respondents’ self-

reported recognition, receipt, recency, and adherence to

screening mammography based on the recent recommenda-

tions of USPSTF [4]. Respondents were asked (1) whether

they ever heard of mammograms; (2) whether they ever

received a mammogram; (3) when they received their most

recent mammogram; and (4) whether they obtained an

annual mammogram. Respondents who reported ever hav-

ing a mammogram, receiving their most recent mammo-

gram more than once in the past 2 years, and obtaining

mammogram annually were considered to be women who

get regular mammograms.

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, 50–

64, and 65+ years. Education (V12, >12), marital status

(married, not married), and employment (employed, not

employed) were included as a measure of SES. Proportion

of lifetime spent in the United States (<25% vs. approxi-

mately 25%) and spoken English proficiency (1 = none/

little, 2 = some, 3 = good/fluently) were included in the

analysis as a measure of acculturation.

Health status as well as existence and severity of chronic

conditions were measured by self-evaluated health status.

For measure of health status, respondents were asked to rate

their general health status on a five-point scale (1 = very

poor to 5 = excellent). A list of chronic conditions (arthritis,

hypertension, heart disease, stroke, diabetes, cancer, hip

fracture, and emotional problems) was dichotomized as ‘at

least two severe major conditions’ vs. ‘0–1.’ This method

of assessing comorbidity from chronic illnesses was adopted

from the NHIS Supplement on Aging [23].

Variables considered to be predisposing factors included

knowledge of mammography guidelines and a score for

knowledge or beliefs of cancer risk. The knowledge or

beliefs of cancer score were calculated as the sum of

answers to five questions about whether cancer is caused

by smoking, drinking alcohol, X-rays, too much sunlight,

and bruises on the body. The sum of scores ranged from 0 to

5, dichotomized as low (0–3) and high (4–5). The knowl-

edge of mammography guidelines was assessed with two

open-ended questions: ‘‘Do you know any breast cancer

screening tests for early detection?’’ If they mentioned

Table 2

Characteristics of Korean American women from Baltimore-Washington

metropolitan areas, 2000 (n = 459)

Characteristics n %

Education

<High school 79 18.0

High school graduate 137 31.4

>High school 222 50.6

Employment status

Employed 285 63.0

Unemployed 168 37.0

Marital status

Married 347 76.4

Not married 107 23.6

Length of stay in the United States

<5 years 35 7.8

6–10 years 51 11.3

>10 years 365 80.9

Speaking English

Well/fluently 79 17.5

Some 149 33.0

Little 161 35.6

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481 477

mammography as one of breast cancer screening tests, they

were then asked ‘‘How often do you need to have a

mammogram?’’ Based on these responses, their answer

was dichotomized as knowing mammography guideline

and no knowledge of guidelines.

Questions about insurance coverage and provider status

were considered enabling factors. 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?’’ Respondents who an-

swered 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.

Physician recommendations for a mammogram and

knowing family or friends who obtained mammograms

were considered reinforcing factors. The variable for num-

ber of friends or family who had a mammogram was

dichotomized (0 vs. more than 1).

Data analysis

We used logistic regression to examine the likelihood of

having regular mammograms across various levels of pre-

dictors. First, we performed bivariate analyses to determine

which independent variables would distinguish women who

had regular mammograms. Second, we tested interaction

terms between variables, based on literature and behavioral

or biologic plausibility. The interaction between health

insurance status and employment was to examine whether

employed women who do not have health insurance are

least likely to have regular mammograms. The significant

interactions were retained in the final mode. Finally, we

conducted multivariate logistic regression analyses to iden-

tify the most important predictors of having regular mam-

mograms for other variables. All variables with at least P <

0.20 in the bivariate analysis were included in our multi-

variate analyses [24]. The analysis was conducted using the

statistical package STATA [25], which provides maximum

likelihood logit coefficients while automatically checking

identification and collinearity.

Not at all 63 13.9

Health status

Excellent/very good 134 29.6

Fair 230 50.8

Poor/very poor 89 19.6

Health insurance

Uninsured 141 32.4

Medicaid/Medicare only 79 18.1

Private insurance 216 49.5

Provider status

No provider 87 19.0

Having a Korean doctor 289 63.0

Having a non-Korean doctor 83 18.0

Results

Sample characteristics

Demographic characteristics of respondents are shown in

Table 2. The sample consisted of 459 KAWage 40 and older

residing in the Baltimore-Washington metropolitan area.

The mean age was 54 years, ranging from 40 to 89 years.

About 51% had more than a high school education. About

76% were married or living with a partner. About two thirds

were employed on a full- or part-time basis.

About 81% had lived in the United States for more than

10 years. However, less than one fifth reported that they

could speak English well or fluently. About 20% reported

health status as poor to very poor. A third reported having

no health insurance. One half was covered by private health

insurance and 18% were covered under Medicare or Med-

icaid only. About two thirds reported having a regular

Korean doctor and 18% of the women did not have any

regular provider (Table 2).

Prevalence of mammography

Table 3 shows the prevalence of mammography by age

group. About 80% had heard of mammography and about

65% had ever had a mammogram. With regard to the recency

of mammography, less than half (45.3%) reported that they

had a mammogram within the past 2 years. Only one third of

the women (32.6%) were obtaining mammograms regularly.

The rates of mammography varied significantly by age group.

Older women were least likely to have had a mammogram in

their lifetime, currently, or regularly: less than 10% of women

approximately 65 years of age had mammograms within the

past 2 years (8.7%) or had regular examinations (7.3%).

Table 3

Rate of mammography by age (n = 459)

n (%) Age group % P value*

Ever heard 366 (79.7) 40–49 years old 40.2 0.001

50–64 years old 45.1

65+ years old 14.8

Ever had 300 (65.4) 40–49 years old 39.3 0.001

50–64 years old 48.7

65+ years old 12.0

Within 2 years 208 (45.3) 40–49 years old 36.5 0.001

50–64 years old 54.8

65+ years old 8.7

Regular use 150 (32.6) 40–49 years old 34.0 0.001

50–64 years old 58.7

65+ years old 7.3

*Standard chi-square test for comparing proportions.

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481478

Factors associated with having regular mammograms

Bivariate and multivariate analyses predicting regular

mammograms are shown in Table 4. In bivariate analysis,

age, education, health status, chronic conditions, proportion

of life spent in the United States, spoken English proficien-

cy, knowledge of mammograms guidelines, provider status,

insurance status, physician recommendations for mammo-

grams, and knowing others who had a mammograms were

significantly related to having regular mammograms (P <

0.05). Employment was marginally associated with having

regular mammograms (P < 0.10). Marital status and knowl-

edge of cancer risk were associated with having regular

mammograms at P < 0.20. In addition, interaction between

employment and insurance was suggested by stratified

analysis with regular mammograms so a multiplicative term

was included in the multivariate model.

In the final model, knowledge of mammography guide-

lines was the strongest independent correlate of having

regular mammograms. Women who had knowledge of

mammography guidelines had more than 10 times greater

odds of having regular mammograms (OR = 10.68; 95% CI,

4.97, 22.93). Spoken English proficiency was also associ-

ated: Women who speak English very well (OR = 5.76; 95%

CI 2.29, 14.49) and who speak some English (OR = 2.30;

95% CI 1.11, 4.77) were more likely to have regular

mammograms than those with poor spoken English profi-

ciency. Age was also related to having regular mammo-

grams: Women ages 50–64 were more likely to have regular

mammograms than those 40–49 of age (OR = 2.26; 95%

CI, 1.24, 4.13). Physician recommendations for mammo-

grams (OR = 2.37; 95% CI, 1.37, 4.11) were also important

correlates. The interaction between employment and insur-

ance status was significant: Employed women without

health insurance had lower rates of mammography than

those employed with insurance (OR = 0.41, 95% CI, 0.18,

0.95).

Barriers to regular screening

Those who have not had regular mammograms (n = 309)

were asked to describe the reasons for not having regular

mammograms. Beliefs of low risk of getting breast cancer

were the most cited reason (37.5%) followed by no time to

have a test (19.4%) and cost (15.2%). About 9% listed fear

to find out breast cancer. Language (8.7%) and not knowing

where to go (6.5%) were also important barriers to regular

screening (Table 5).

Discussion

Previous studies of breast cancer screening among KAW

focused on the rate of ever having a mammogram and

having had mammogram in the past 2 years. This study is

unique in its focus on obtaining a mammogram within

guidelines. Many Korean women misunderstood the con-

cept of preventive behaviors. They may not know that they

should receive a periodic mammogram and may assume

that if they once received a test, repeat screening is

unnecessary. Our estimate of mammogram in the past 2

years (45%) is similar to our previous study [9] and far

lower than the Healthy People 2010 objectives [8] for

mammography.

Knowledge of mammography guidelines was a major

predictor of regular screening. The findings here are con-

sistent with the previous study [26,27] and support the

positive effects of knowledge of mammography guidelines

on getting regular mammograms. However, evidence of

knowledge alone is not sufficient. Focus group discussions

among KAW in New York City revealed that there was

accurate knowledge about cervical cancer screening but

women rarely put this knowledge into action [28]. Similarly,

in this study, KAW with proper knowledge of breast cancer

screening guidelines may not put their knowledge into

action: Half of the women who knew the proper guidelines

were not advised by their physicians to have a mammogram.

These women could potentially be reached to have a

mammogram through physician recommendations. In con-

trast to a previous study of KAW [21], having a regular

Korean doctor was not associated with use of mammo-

grams. However, further study is needed to understand

whether physician recommendations for mammograms are

related to providers’ gender.

The proxy measure of acculturation, spoken English

proficiency, was an important correlate of regular mammo-

grams. Past studies found that lack of English language

proficiency is an important logistic barrier to screening [29–

31]. Women unable to speak or read English have many

difficulties in accessing health care services with scheduling

appointments, communication and interactions with health

professionals, and getting information on free or low-cost

cancer screening programs.

Having insurance was related to regular mammograms.

In addition, employment interacted with health insurance

status, with those employed with no health insurance being

less likely to have mammograms than women employed

with health insurance. Employed women without health

Table 4

Logistic regression for having regular mammogram (n = 459)

Crude odds ratio Adjusted odds ratio

I. Individual characteristics

Age

40–49 years old 1 1

50–64 years old 2.21

(1.44, 3.40)**

2.26

(1.24, 4.13)**

65+ years old 0.39

(0.19, 0.78)**

0.93

(0.31, 2.83)

Education

VHigh school graduate 1 1

>High school graduate 2.77

(1.83, 4.19)**

0.87

(0.45, 1.66)

Marital status

Married 1 1

Not married 1.36

(0.86, 2.15)

0.85

(0.44, 1.66)

Employment

No 1 N/A

Yes 1.48 (0.98, 2.22)*

II. General health status

Health status (1–5) 1.32

(1.06, 1.64)**

0.82

(0.60, 1.13)

Chronic conditions

0–1 1 1

2+ 0.50

(0.26, 0.95)**

0.49

(0.20, 1.19)

III. Acculturation

Proportion of life spent in the United States

<25% in life 1 1

z25% in life 4.08

(2.41, 6.90)**

1.31

(0.63, 2.76)

Speaking English

None/little 1 1

Some 3.72

(2.30, 6.03)**

2.30

(1.11, 4.77)**

Well/fluently 9.00

(5.04, 16.08)**

5.76

(2.29, 14.49)**

IV. Predisposing factors

Knowledge of cancer risk

Low (0–3) 1 1

High (4–5) 1.30

(0.87, 1.94)

0.97

(0.56, 1.68)

Knowledge of mammography guideline

No 1 1

Yes 9.92

(5.56, 17.68)**

10.68

(4.97, 22.93)**

V. Enabling factors

Provider status

Korean doctor 1 1

Non-Korean doctor 2.71

(1.64, 4.56)**

1.35

(0.68, 2.66)

No provider 0.38

(0.20, 0.73)**

0.51

(0.21, 1.28)

Having insurance

No 1 N/A

Yes 3.00

(1.89, 4.75)**

Table 4 (continued)

Crude odds ratio Adjusted odds ratio

VI. Reinforcing factors

Physician recommendations

No 1 1

Yes 3.83

(2.54, 5.77)**

2.37

(1.37, 4.11)**

Close friends or family with mammography

None 1 1

1+ 2.25

(1.49, 3.39)**

1.20

(0.68, 2.09)

Employment and insurance status

Employed with insurance 1 1

Employed/no insurance 0.21

(0.11, 0.40)**

0.41

(0.18, 0.95)**

Unemployed with insurance 0.49

(0.30, 0.78)**

1.36

(0.63, 2.92)

Unemployed/no insurance 0.34

(0.16, 0.72)**

2.54

(0.85, 7.63)

*P < 0.10.

**P < 0.05.

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481 479

insurance may require special attention. Many Korean

Americans own small businesses that do not provide em-

ployer-sponsored health insurance plans. Women work long

hours 6 days each week with their husbands in these shops

and may be hard to attract to screening programs offered

during the hours their businesses are open. Additionally,

screening programs with eligibility criteria based solely on

income may not target these women because they appear to

have some financial resources. Our data would argue for

special programs to target these women. Churches may be

an important point of contact because in light of work

schedules, many women consider Sunday involvement with

their church community as their primary opportunity for

social connections. This may explain that employment is

important in this population since they work very long

hours. About one fifth of the women reported no time to

have a mammogram as a barrier to regular screening.

A salient issue for having regular mammograms is

whether or not women understand and value a behavior

which is essentially early detection in nature. Their belief of

low risk of getting breast cancer is the most important

barrier to having regular mammograms. This may indicate

that many first generation KAW are not familiar with the

message of cancer control through early detection and

treatment.

Table 5

Barriers to having regular mammogram (n = 309)

n (%)

No risk for breast cancer 116 (37.5)

No time to have the test 60 (19.4)

Too expensive (cost) 47 (15.2)

Fear to find out breast cancer 29 (9.4)

Language barrier 27 (8.7)

Do not know where to go 20 (6.5)

H.-S. Juon et al. / Preventive Medicine 39 (2004) 474–481480

This study has several limitations. A sampling frame

from Korean churches was used because religion is an

important aspect of Korean culture. To minimize the

sampling bias due to excluding those who do not go to

church, we also included residents of low-income senior

housing. Therefore, the results of the study cannot be

generalized to KAW who do not attend church and who

do not live in senior housing. Second, there may have been

measurement error as a result of using self-reports of

cancer screening. Several studies have established that

self-reports overestimate the prevalence of cancer screening

[32–34]. In addition, a recent study of a multiethnic and

multilingual population showed the consistent findings of

overestimated rates of self-reported cancer screening [35].

However, these studies showed that self-reports of mam-

mogram are fairly reliable. Finally, the survey was admin-

istered by face-to-face interviews. The responses may be

subject to desirability response bias, in which the respond-

ents try to answer ways in which the interviewer would

prefer. For all these reasons, our findings should not be

considered in isolation, but together with information from

other studies of KAW, to build a composite understanding

of this diverse population.

Our findings have several implications for KAW. First, in

light of our finding that acculturation is significantly asso-

ciated with regular mammograms, targeting intervention

strategies to less acculturated women are of value. In

response to the rapid growth of this population, it is of

public health value to develop culturally relevant breast

cancer programs for less acculturated and recent immigrants.

Second, a strategy of education about screening guidelines,

along with physician referrals should be implemented. Fi-

nally, as many Korean Americans attend church, intervention

strategies through Korean churches will be effective to

coordinate with community outreach and professional efforts

and to provide health education and services.

Acknowledgments

This study was supported by the National Cancer

Institute (R03 CA84818) and the Susan G. Komen Breast

Cancer Foundation (POP0100420). For their support and

cooperation in this project, we thank the Korean pastors

who provided in-kind support for the survey.

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