Acculturation and Breast Cancer Screening of Asian American Women in California Open Access

Abstract

Breast cancer incidence rates continue to rise in Asian American women, contrasting with the decreasing rates observed in non-Hispanic white (NHW) and black women and the stable rates observed in Hispanic women. Despite this increase in breast cancer incidence rates, Asian American women continue to have the lowest screening rates of all racial and ethnic groups. Acculturation has been linked to both the increase in incidence rates and the low rates of breast cancer screening. This thesis aims to study how acculturation indicators, interview language and nativity, impact screening rates in Asian American women. It hypothesizes that acculturation mediates the negative association between Asian American ethnicity and breast cancer screening adherence. Additionally, the study hypothesizes that more acculturated Asian American women will have higher odds of breast cancer screening adherence than less acculturated women. The study was developed using the Andersen Healthcare and Utilization model to identify focal relationships, mediating mechanisms, moderating relationships, and important covariates. Logistic regression analyses were conducted on pooled California Health Interview Survey from 2001 to 2009. Results from these analyses showed that most Asian American women, with the exception of Vietnamese women, had lower odds of adherence than the reference group NHW women. Acculturation was found to mediate the focal association in a suppressing, rather than enhancing manner. Korean and Chinese women who interviewed in English had higher odds of adherence than those who interviewed in non-English languages. Filipino and Japanese women who were born in the US had higher odds of adherence than those born elsewhere. Future studies on this topic should conduct qualitative interviews for Korean and Vietnamese American subpopulations. Additionally, the role of acculturation as a mediator should be analyzed more thoroughly with longitudinal data and a repeat analysis should be conducted on post Affordable Care Act data.

Table of Contents

Table of Contents

Chapter 1 - Introduction.......................................................................................................................................... 1

Overview............................................................................................................................................................... 1

Rationale............................................................................................................................................................... 2

Research Questions................................................................................................................................................. 3

Research Design...................................................................................................................................................... 4

Study Implications................................................................................................................................................... 5

Chapter 2: Literature Review..................................................................................................................................... 6

Overview................................................................................................................................................................ 6

Breast Cancer.......................................................................................................................................................... 7

Breast Cancer Screening........................................................................................................................................... 8

Asian American Population........................................................................................................................................ 10

Table 1. Demographics of the Asian American population............................................................................................... 10

Breast Cancer Incidence among Asian American Women................................................................................................ 12

Figure 1. Breast Cancer Incidence Rates...................................................................................................................... 13

Breast Cancer Screening among Asian American Women................................................................................................ 14

Figure 2. Breast Cancer Screening Rates...................................................................................................................... 16

Acculturation and Breast Cancer.................................................................................................................................. 16

California................................................................................................................................................................. 19

Summary................................................................................................................................................................. 20

Chapter 3: Methods................................................................................................................................................... 21

Overview.................................................................................................................................................................. 21

Conceptual Framework............................................................................................................................................... 21

Figure 3: Conceptual Framework Model......................................................................................................................... 22

Focal Relationship....................................................................................................................................................... 22

Moderator.................................................................................................................................................................. 23

Mediators.................................................................................................................................................................. 23

Confounders.............................................................................................................................................................. 24

Testable Hypotheses................................................................................................................................................... 26

Dataset.................................................................................................................................................................... 26

Construct Measurement.............................................................................................................................................. 28

Table 2. Construct Measurement.................................................................................................................................. 31

Analytic Strategy....................................................................................................................................................... 32

Chapter 4 Results...................................................................................................................................................... 34

Overview.................................................................................................................................................................. 34

Descriptive Statistics.................................................................................................................................................. 35

Table 3. Descriptive statistics of study population (Pooled sample of CHIS 2001-2009)........................................................ 37

Main Analyses............................................................................................................................................................ 38

Table 4. Asian American ethnicity and breast cancer screening adherence.......................................................................... 38

Table 5. Main Analysis using Pooled CHIS 2001-2009 data for Chinese, Korean, and Vietnamese women................................ 40

Table 6. Interaction odds ratios for Chinese, Korean, and Vietnamese women..................................................................... 41

Sub-analysis.............................................................................................................................................................. 42

Table 7. Sub-analysis using Pooled CHIS 2001-2009 data for Filipino, South Asian, and Japanese women............................... 43

Table 8. Interacted odds ratios for Filipino, South Asian, and Japanese women.................................................................... 44

Exploratory Analysis.................................................................................................................................................... 44

Sensitivity Analysis..................................................................................................................................................... 45

Chapter 5 Discussion................................................................................................................................................... 47

Key Findings............................................................................................................................................................... 47

Study Implications....................................................................................................................................................... 49

Strengths and Limitations............................................................................................................................................. 50

Recommendations for Future Research........................................................................................................................... 52

Conclusion.................................................................................................................................................................. 53

Appendix.................................................................................................................................................................... 55

Table 9. KHB Mediation Analysis results........................................................................................................................... 55

Table 10. Sensitivity Analysis Interaction Odds Ratios using Pooled CHIS 2001, 2003, 2005, and 2009 data with USOC for Chinese, Korean, and Vietnamese women...................................................................................................................................................... 55

Table 11. Sensitivity analysis Interaction Odds Ratios using Pooled CHIS 2001, 2003, 2005, and 2009 data with USOC for Filipino, South Asian, and Japanese women.......................................................................................................................................................... 55

Table 12. Sensitivity Analysis using Pooled CHIS 2001, 2003, 2005, and 2009 data with USOC for Chinese, Korean, and Vietnamese women.. 56

Table 13. Sensitivity analysis using Pooled CHIS 2001, 2003, 2005, and 2009 data with USOC for Filipino, South Asian, and Japanese women. 57

Table 14. Sensitivity analysis with Chinese as the reference group........................................................................................ 58

Table 15. Sensitivity analysis with Filipino as the reference group......................................................................................... 58

Table 16. Sensitivity analysis with reference group NHW women........................................................................................... 59

References.................................................................................................................................................................... 60

About this Master's Thesis

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School	Rollins School of Public Health
Department	Health Policy and Management
Degree	MSPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, General
Keyword	Asian American Acculturation Breast Cancer Screening
Committee Chair / Thesis Advisor	Blake, Sarah, Emory University
Committee Members	Lash, Timothy L, Emory University Von Esenwein, Silke, Emory University Joski, Peter J, Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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