PI’s: Drs. Patricia Gonzalez, Jung-Wong Lim & Ming Wang Students: Suirong Li & Mee Yon Yum

11

The Role of Cultural Health Beliefs The Role of Cultural Health Beliefs on Health Behaviors among on Health Behaviors among Chinese, Korean, & Mexican Chinese, Korean, & Mexican

American American Breast Cancer SurvivorsBreast Cancer Survivors

PI’s: Drs. Patricia Gonzalez, Jung-Wong Lim & Ming PI’s: Drs. Patricia Gonzalez, Jung-Wong Lim & Ming WangWang

Students: Suirong Li & Mee Yon YumStudents: Suirong Li & Mee Yon Yum

Advisor: Dr. Kimlin Ashing-Giwa Advisor: Dr. Kimlin Ashing-Giwa December 11, 2008December 11, 2008

2

Background Background

► Breast cancer (BC) is the most frequently Breast cancer (BC) is the most frequently diagnosed cancer in Asian-and Latina-diagnosed cancer in Asian-and Latina-American women.American women.

► Favorable survivorship outcomes for Favorable survivorship outcomes for women with BC may be attributed to women with BC may be attributed to lifestyles and behavioral factors. lifestyles and behavioral factors.

► Given the growing ethnic minority Given the growing ethnic minority populations in the U.S., and emerging populations in the U.S., and emerging health disparity issues in cancer outcomes, health disparity issues in cancer outcomes, cultural factors of ethnic minorities need to cultural factors of ethnic minorities need to be consideredbe considered

3

Overall GoalOverall Goal

►Examine the relationships among Examine the relationships among cultural health beliefs, health cultural health beliefs, health behaviors, and factors influencing behaviors, and factors influencing them among Chinese, Korean and them among Chinese, Korean and Mexican breast cancer survivors Mexican breast cancer survivors (BCS).(BCS).

►Explore the differences and/or Explore the differences and/or similarities in cultural health beliefs & similarities in cultural health beliefs & health behaviors among Chinese-, health behaviors among Chinese-, Korean- & Mexican-American BCS. Korean- & Mexican-American BCS.

4

Phase I Specific AimsPhase I Specific Aims

1. Examine how acculturation is related to cultural health beliefs

2. Examine whether cultural health beliefs are related to treatment-related decisions, doctor-patient relationships, and health behaviors.

3. Examine whether treatment-related decisions and doctor-patient relationships mediate the relationship between cultural health beliefs and health behaviors.

4. Examine the differences and/or similarities in acculturation, cultural health beliefs, treatment-related decisions, doctor-patient relationships, and health behaviors among Chinese-, Korean-, and Mexican-American BCS.

5

Phase II Specific AimsPhase II Specific Aims

1. Explore the cultural health beliefs and 1. Explore the cultural health beliefs and health health

behaviors among Chinese-, Korean-, and behaviors among Chinese-, Korean-, and

Mexican-American BCS.Mexican-American BCS.

2. Explore the factors (e.g., acculturation, 2. Explore the factors (e.g., acculturation, doctor- doctor-

patient relationships) influencing health patient relationships) influencing health

behaviors among Chinese, Korean, and behaviors among Chinese, Korean, and

Mexican BCS. Mexican BCS.

6

Phase I: Overall FrameworkPhase I: Overall Framework

Acculturation Cultural health beliefs

Treatment Decision

Doctor-patient Relationship

Health behavior

H1

H2

H3

H4

H5

H6

77

• N = 237• Chinese (N=85), Korean (N=29), Mexican (N=123)• Age > 18• Stage 0-III• CCSP, Hospital registries Community agencies

MethodsMethods

MeasuresMeasuresSampleSample

•Cross-sectional

•Population-based

•Mixed Methods

•Culturally Responsive Model

Health behaviors:

Self-report health behavior instrument (5-items) Diet, exercise, alternative medicine, stress management

Research Research MethodMethod

Treatment-related decision (1-item)

Acculturation:

Short Acculturation scale (7-item)

Cultural health beliefs:

The Multidimensional Health Locus of Control (4-items) + 3 new items

Doctor-patient relationship:

The Adherence Determinant Questionnaire (6-items)

Secondary data analyses

8

Data AnalysesData Analyses

► Descriptive statistics Descriptive statistics

► Pearson product-moment correlationsPearson product-moment correlations

► T –TestsT –Tests

► ANOVAsANOVAs

► Chi-SquaresChi-Squares

9

Table 1. Table 1. Acculturation and cultural health beliefsAcculturation and cultural health beliefs (Aim1: H1)(Aim1: H1)

Acculturation (r)Acculturation (r)

Health belief itemsHealth belief items AllAll ChineseChinese KoreanKorean MexicanMexican

When people get sick it is the will of When people get sick it is the will of God or a higher power God or a higher power

-0.219***-0.219*** -0.267-0.267** -0.144-0.144 --0.354***0.354***

Harboring a lot of anger can make a Harboring a lot of anger can make a person vulnerable to illness person vulnerable to illness

-0.075-0.075 -0.249*-0.249* -0.110-0.110 0.0690.069

I am in control of my health I am in control of my health 0.053 0.053 0.115 0.115 -0.175-0.175 0.0060.006

My family situation has a lot to do My family situation has a lot to do with my becoming sick or staying with my becoming sick or staying healthy healthy

-0.144**-0.144** -0.282**-0.282** -0.082-0.082 -0.124-0.124

Luck plays a big part in determining Luck plays a big part in determining how soon I will recover from an how soon I will recover from an illness illness

-0.226***-0.226*** -0.188 -0.188 -0.106-0.106 -0.275**-0.275**

Health professionals control my Health professionals control my health health

--0.277***0.277*** -0.135-0.135 -0.026-0.026 --0.558***0.558***

My cultural background plays a big My cultural background plays a big part in how I feel about my illness part in how I feel about my illness and getting well and getting well

-0.036 -0.036 -0.168-0.168 -0.198-0.198 0.0200.020

*p<0.05, **p<0.01, ***p<0.001

10

Table 2.Table 2. Cultural health beliefs and doctor-patient relationship Cultural health beliefs and doctor-patient relationship (Aim2: H2)(Aim2: H2)

Health beliefs items

Doctor-patient relationship (r)

All Chinese Korean Mexican

When people get sick it is the will of God or a higher power

-0.101 -0.081 -0.062 -0.112

Harboring a lot of anger can make a person vulnerable to illness

0.045 -0.021 -0.049 0.039

I am in control of my health 0.170** 0.207 -0.090 0.190*

My family situation has a lot to do with my becoming sick or staying healthy 0.005 -0.120 0.031 0.040

Luck plays a big part in determining how soon I will recover from an illness -0.191** -0.172 -0.336 -0.247**

Health professionals control my health -0.079 0.162 0.030 -0.156

My cultural background plays a big part in how I feel about my illness and getting well

-0.006 -0.151 -0.186 0.027

*p<0.05, **p<0.01

11

Table 3. Cultural health beliefs and health behaviors (Aim2: H3)

Health behaviors

Health beliefs items

God Anger My control Family situation Luck

Health profession

al

Cultural backgroun

d

All BCS

Lifestyle changes Yes No

2.34 (1.0)2.32 (1.1)

3.11 (0.8)3.06 (0.9)

2.99 (0.8)2.99 (0.8)

2.63 (0.9)2.57 (1.0)

2.10 (0.8)2.07 (0.9)

2.34 (0.8)2.38 (0.7)

2.53 (0.9)2.38 (0.9)

t= 0.156 0.562 0.052 0.480 0.345 -0.413 1.427

Eating Yes No

2.39 (1.0)2.12 (1.0)

3.09 (0.8)3.24 (0.8)

2.99 (0.74)3.03 (0.84)

2.63 (0.9)2.64 (1.1)

2.13 (0.9)2.09 (0.9)

2.37 (0.8)2.24 (0.8)

2.50 (0.9)2.76 (0.9)

t= 1.463 -1.059 -0.257 -0.036 0.217 0.868 -1.568

Exercise Yes No

2.34 (1.0)2.38 (1.0)

3.17 (0.8)2.98 (0.8)

3.04 (0.8)2.92 (0.7)

2.64 (0.9)2.62 (0.8)

2.17 (0.9)2.02 (0.7)

2.31 (0.8)2.45 (0.8)

2.50 (0.9)2.61 (0.8)

t= -0.309 1.611 1.050 0.212 1.318 -1.185 -0.883

Complementary medicine Yes No

2.51 (1.0)2.24 (1.0)

3.13 (0.7)3.10 (0.8)

2.99 (0.8)3.01 (0.7)

2.56 (0.9)2.67 (0.9)

2.17 (0.8)2.07 (0.9)

2.40 (0.8)2.32 (0.8) 2.37 (0.8)

2.63 (0.9)

t= 2.032* 0.305 -0.184 -0.946 0.902 0.678 -2.173*

Reduce stress Yes No

2.29 (1.0)2.43 (1.0)

3.19 (0.8)2.98 (0.7)

3.07 (0.7)2.87 (0.8)

2.71 (0.8)2.47 (1.0)

2.15 (0.9)2.02 (0.8)

2.31 (0.9)2.41 (0.7)

2.57 (0.9)2.47 (0.8)

t= -1.070 1.985* 1.890 1.848 1.107 -0.899 0.848

*p<0.05

12

Mediating effects of treatment-related decision and doctor-patient Mediating effects of treatment-related decision and doctor-patient relationship (Aim 3: H5)relationship (Aim 3: H5)

Treatment decision

Doctor-patient relationship

Cultural Health belief

Health behavior

Treatment-related decisions and doctor-patient relationship did not mediate the relationship between cultural health beliefs and health behaviors. Thus, findings did not support the hypothesis.

13

Table 4. Acculturation & Doctor-patient relationship by Ethnicity & Language (Aim 4: H6)

Variables

Chinese Korean Mexican By ethnicity

By language

English(N=40)

Chinese(N=45)

Total(N=85)

English(N=7)

Korean(N=22)

Total(N=29)

English(N=64)

Spanish(N=59)

Total(N=123)

Acculturation

2.79(0.73)

1.95(0.59)

2.34(0.78)

2.49(0.72)

1.68(0.48)

1.88(0.64)

3.23(0.43)

1.90(0.62)

2.59(0.85)

F=9.853(p=0.000)

T=14(p=0.000)

T=5.806 (p=0.00) T=3.414 (p=0.002) T=13.653 (p=0.000)

Patient-doctor’s relationship

25.55 (4.01)

24.33 (3.46)

24.91 (3.76)

26.14 (4.10)

24.77 (4.52)

25.10(4.39)

24.27 (4.60)

21.32 (3.59)

22.85 (4.39)

7.53(p=.001)

3.38(p=.001)

*p<0.05, **p<0.01, ***p<0.001

14

Table 5. Treatment-related decisions by ethnicity (Aim4: H6)

Treatment-related

decisions

Chinese (N, %)

Korean (N, %)

Mexican (N, %)

X2 Square

Doctor 10 (11.8) 7 (24.1) 35 (28.5)

23.750**

Doctor and I 27 (31.8) 7 (24.1) 36 (29.3)

Doctor, I, and partner

33 (38.8) 6 (20.7) 23 (18.7)

I 10 (11.8) 5 (17.2) 26 (21.1)

Other 5 (5.9) 4 (13.8) 3 (2.4)

**p<0.01

15

Table 6. Table 6. Health behavior changes by ethnicityHealth behavior changes by ethnicity (Aim 4: H6)

Variables Chinese Korean Mexican X2

Life style change (Yes/No)

60 (70.6%) 24 (82.8%) 71 (58.7%) 7.313*

Eating 49 (81.7%) 19 (79.2%) 68 (89.5%) 3.356

Exercise 47 (78.3%) 17 (70.8%) 41 (56.2%) 7.507*

Complementary/alternative medicine

28 (46.7%) 7 (29.2%) 25(34.2%) 3.134

Reduce stress 40 (66.7%) 18 (75.0%) 36 (48.6%) 7.287*

* P < 0.05

16

ConclusionsConclusions

► This research is the first study to compare This research is the first study to compare health behaviors and cultural health health behaviors and cultural health beliefs across Chinese, Korean- and Latina beliefs across Chinese, Korean- and Latina BCS. BCS.

► The diverse sample provides a unique The diverse sample provides a unique opportunity to begin exploration health opportunity to begin exploration health behaviors and health belief issues. behaviors and health belief issues.

► Results suggest that cultural context must Results suggest that cultural context must be considered when understanding health be considered when understanding health behaviors among BCS.behaviors among BCS.

17

LimitationsLimitations

► Participants may have provided socially Participants may have provided socially acceptable responsesacceptable responses

► Self report data are subject to recall bias Self report data are subject to recall bias ► Certain health behavior information was Certain health behavior information was

not included not included ► Korean-American sample size was smallKorean-American sample size was small

18

Activities to DateActivities to Date►Phase I Phase I

Identified variables based on research Identified variables based on research hypotheses hypotheses

Secondary data analyses and interpretationSecondary data analyses and interpretation Findings reported / Manuscript Development Findings reported / Manuscript Development

►Phase II Phase II Focus Group Protocol and procedure preparationFocus Group Protocol and procedure preparation Questionnaire Questionnaire Contacted community agencies for recruitment Contacted community agencies for recruitment Two Chinese focus groups conductedTwo Chinese focus groups conducted One Korean focus group conductedOne Korean focus group conducted

19

Activities to DateActivities to Date (cont.)(cont.)

► Abstracts and ManuscriptsAbstracts and Manuscripts Two Poster presentationsTwo Poster presentations One Oral presentationOne Oral presentation One manuscript in press One manuscript in press (Supportive Care in

Cancer)

Two in preparationTwo in preparation

► Student research assistants recruitedStudent research assistants recruited

► Training and learningTraining and learning

20

Jan 08 to Dec 09 2008 2009J F M A M J J A S O N D J F M A M J J A S O N D

IRB Approval

Secondary data cleaning

Data analysis

Report findings

Interview protocol

Translation protocol

Site visits

Recruit subjects

Conduct focus group

Verbatim transcript

Translations

Data analysis

Final report

Manuscript

Abstract/Presentation

Future Grant

Training/Mentoring

Timeline & TasksTimeline & Tasks

Completed In process Target Schedule

21

AcknowledgementsAcknowledgements

Research Assistants: Research Assistants: Ann LeeAnn Lee

Suirong LiSuirong LiMee Yon Yum Mee Yon Yum

Ariel Bianca MorenoAriel Bianca Moreno

Dr. Ashing-Giwa: MentorDr. Ashing-Giwa: Mentor

Dr. Susan Kane & Dr. Jamil MomandDr. Susan Kane & Dr. Jamil Momand

Funding Source: NIH: 1P20CA118783-01A1 & Funding Source: NIH: 1P20CA118783-01A1 & 1P20CA118775-01A 1P20CA118775-01A