Asian Nursing Research 9 (2015) 81e90

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Review Article

Cultural Factors Associated with Breast and Cervical Cancer Screening in Korean American Women in the US: An Integrative Literature Review Shin-Young Lee, PhD * Department of Nursing, Chosun University, Gwangju, South Korea

a r t i c l e i n f o

s u m m a r y

Article history: Received 28 April 2014 Received in revised form 3 February 2015 Accepted 5 February 2015

Purpose: This study examined current research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in Korean American (KA) women. Methods: Based on Ganong's guidelines, the literature on cultural factors associated with breast and cervical cancer screening in KA women was searched using MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Sixty-eight articles on breast cancer screening and 66 articles on cervical cancer screening were retrieved from both databases, and a total of 22 articles were included in the literature review based on the selection criteria. Results: Of the 22 studies reviewed, 14 (63.6%) were descriptive and 8 (36.4%) were interventional. Many studies have used individual focused cognitive theories such as health belief model and different types of operationalization for measures of cultural beliefs. Cultural factors associated with breast and cervical cancer screening in KA women that were identified in descriptive quantitative and qualitative studies included family, embarrassment, preventive health orientation, fatalism, and acculturation. Most culturally relevant interventional studies used education programs, and all education was conducted by bilingual and bicultural health educators at sociocultural sites for KA women. Conclusions: Theories focusing on interpersonal relationships and standardized, reliable, and valid instruments to measure cultural concepts are needed to breast and cervical cancer screening research in KA women. Traditional cultural factors associated with cancer screening should be considered for practical implications and future research with KA women. Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

Keywords: breast cancer cervical cancer culture Korean Americans screening

Introduction Although Korean Americans (KAs) represented 9.2% of the total Asian American/Pacific Islander group in 2010 [1], KAs constitute one of the fastest growing Asian groups in the US between 2000 and 2010. Their population increased by 60.0% from 1 million to 1.6 million, whereas the total U.S. population grew only 9.7% from 281 million to 308 million [1,2]. Existing data show that breast and cervical cancer were the first and sixth most commonly diagnosed cancers in KA women from 1998 to 2002 [3]. Breast and cervical cancer incidence rates for KA

* Shin-Young Lee, PhD, Department of Nursing, Chosun University, 309 Philmundaero, Dong-gu, Gwangju, 501-759, South Korea. E-mail address: [email protected]

women from 1998 to 2002 were 53.5 per 100,000 and 10.8 per 100,000 individuals, respectively [3]. The mortality rates of these two types of cancer during the same period were 7.8 per 100,000 and 3.1 per 100,000 individuals, respectively [3]. Regular breast and cervical cancer screening is an effective way for reducing the burden of these cancers because early detection leads to timely treatment and high survival rates [4,5]. However, KA women have low levels of participation in breast and cervical cancer screening programs. For example, the 3-year merged data from the 2001, 2003, and 2005 California Health Interview Surveys found that KA women (N ¼ 1,152) consistently showed the lowest rates of breast (57.1%) and cervical cancer screening (79.2%) utilization among American women including non-Latina white, Chinese, Filipino, South Asian, Japanese, and Vietnamese [6]. The low rates of breast and cervical cancer screening in KA women can be explained by their cultural beliefs and attitudes

http://dx.doi.org/10.1016/j.anr.2015.05.003 p1976-1317 e2093-7482/Copyright © 2015, Korean Society of Nursing Science. Published by Elsevier. All rights reserved.

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S.-Y. Lee / Asian Nursing Research 9 (2015) 81e90

toward cancer screening [6e8]. Studies found that low cancer screening rates persist after controlling for socioeconomic status and access to health care (e.g., having health insurance and usual source of health care) for Asian Americans including KAs [8e13], which means that low rates of cancer screening in Asian ethnic groups are only in part explained by differences in demographic characteristics and access to care. For this reason, cultural barriers and attitudes as factors influencing cancer screening behaviors have been identified as major themes in research with Asian Americans including KAs [14]. Culture is a powerful, comprehensive, and multifaceted construct that influences beliefs, attitudes, behavior, and health [15e18]. The significance of culture influencing behavior such as cancer screening participation and playing an important role in explaining cancer screening disparities in racial and ethnic groups have been emphasized in research [6,8,15,19e27]. Thus, there has been a consensus among health behavior researchers and practitioners that health behavior change intervention programs must be culturally appropriate for targeting specific populations because there are differences in the prevalence of behavioral risk factors and in the predictors of health behaviors across racial and ethnic groups [17,28]. Identification of the prevailing cultural factors associated with breast and cervical cancer screening behavior among KA women would be very useful for developing population-specific health promotion programs and strategies to increase cancer screening utilization and reduce the rates of late-stage diagnosis and mortality. However, cultural factors associated with breast and cervical cancer screening or culturally relevant intervention programs for cancer screening in KA women have not been clearly addressed in the literature. To my knowledge, this is the first literature review to focus on cultural factors or culturally relevant interventions related to breast and cervical cancer screening in KA women. Both breast and cervical cancer screening were chosen because (a) breast and cervical cancer screenings are recommended for women by the American Cancer Society [4,5] and (b) the breasts and cervix are sexual organs in women, and women encounter similar issues, such as embarrassment, for both breast and cervical cancer screening. The main goal of this literature review was to examine cultural factors associated with breast and cervical cancer screening in KA women. The research theories and methods were carefully examined to identify cultural factors associated with breast and cervical cancer screening behavior in KA women, as these theoretical and methodological factors can be associated with research outcomes. For an accurate analysis of factors associated with breast and cervical cancer screening behavior, it was necessary to examine research theories and methods in KA studies. The research questions for this literature review were the following: (a) What are the current research theories and methods used for studying cultural factors related to breast and cervical cancer screening behaviors in KA women? (b) What cultural factors are associated with breast and cervical cancer screening utilization in KA women? (c) What culturally relevant interventions are conducted to promote breast and cervical cancer screening utilization in KA women?

Methods The methodology of this integrative literature review was based on Ganong's [29] guidelines for conducting such a review. Ganong [29] suggested that the methodology of integrative reviews include six tasks: (a) selecting the hypotheses or research questions, (b)

sampling the research to be reviewed, (c) representing the characteristics of the studies and their findings, (d) analyzing the findings, (e) interpreting the results, and (f) reporting the results. By using the keywords “breast cancer”, “breast cancer screening”, “breast self-examination”, “clinical breast examination”, “mammogram”, “cervical cancer”, “cervical cancer screening”, “Pap smear test”, “Korean American”, and “Korean immigrants”, the electronic databases MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched in December 2013 for published articles in the US related to cultural factors associated with breast and cervical cancer screening utilization in KA women. Related articles and references in key papers were also searched. There was no limit on publication dates. All research articles written in English on breast and cervical cancer screening in KA women were searched. However, articles that reported only cancer screening rates were excluded. The MEDLINE search yielded 29 articles on breast cancer screening in KA women and 40 articles on cervical cancer screening in KA women, whereas CINAHL yielded 39 articles on breast cancer screening in KA women and 26 articles on cervical cancer screening in KA women. Six articles on breast cancer screening and 8 articles on cervical cancer screening were duplicated between the two databases. The selection criteria for studies to be included in the review were as follows: (a) duplicated articles between the two databases were removed; (b) articles that involved nonspecific Asian populations or Koreans in South Korea were excluded from this review; and (c) studies in which the researchers indicated that factors may be associated with traditional Korean culture or that they constructed intervention programs considering Korean culture were included. Only articles pertaining to cultural factors or culturally relevant interventions associated with breast or cervical cancer screening in KA women were included in this review. Therefore, a total of 22 articles were reviewed for this article; of these, 13 articles addressed breast cancer screening behavior in KA women, 8 addressed cervical cancer screening behavior in KA women, and 1 addressed both breast and cervical cancer screening behavior in KA women (Table 1). Results The analysis of the reviewed studies focused on the research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in quantitative and qualitative studies. Research theories and methods In terms of the study designs of breast and/or cervical cancer screening research in KA women, 8 quasi-experimental studies, 11 cross-sectional studies, and 3 qualitative studies were conducted (Table 1). Many studies on breast cancer screening in KA women used a quasi-experimental study design [32,34e37,40] or a crosssectional study design [30,31,33,38,39,41]. Most studies on cervical cancer screening used a cross-sectional study design [44,47e50]. All eight interventions were quasi-experimental studies. There were seven breast cancer screening intervention studies [32,34e37,40,41] and one cervical cancer screening intervention study [43] that focused on promoting breast or cervical cancer screening in KA women. Four studies [34,37,40,43] included interventions with two arms (treatment and control), one study [35] included three groups (two treatment groups and one control group), and the other intervention studies had a one-group design. These studies assessed pretest-posttest differences between the treatment and control groups. Qualitative studies conducted focus group interviews or individual interviews to investigate cultural

Table 1 Breast and Cervical Cancer Screening studies in Korean American (KA) Women. References

Types of cancer screening

Research design

Sample

Framework

Variables/questions

a

BSE

Descriptive quantitative study/crosssectional survey

133 KA women  35 yrs

HBM

Beliefs, breast cancer knowledge, demographics

[31]

a

Mammography, CBE

Descriptive quantitative study/crosssectional survey

107 KA  40 yrs

HBM

Beliefs, breast cancer knowledge, demographics

[32]

a

Mammography, CBE, BSE

Quasi-experimental, pre-/post-test one group design

100 KA women  40 yrs

HBM, TTM

Breast cancer knowledge, beliefs, cultural beliefs

[33]

a

Mammography

Descriptive quantitative study/crosssectional survey

459 KA women  40 yrs

PRECEDE/PROCEED model

[34]

a

Mammography

Quasi-experimental, pre-/post-test two group design

200 KA women  40 yrs

TTM

[35]

a

Mammography

Quasi-experimental, pre-/post-test, three-group design

141 KA women aged 40e75 yrs

PRECEDE-PROCEED model

Predisposing, enabling, reinforcing factors, knowledge, acculturation, sociodemographics Pros & cons of mammography, access to health care, demographics Predisposing factors for mammography, enabling factors, reinforcing characteristics

[36]

a

Mammography

Quasi-experimental, pre-/post-test one group design

300 KA women  40 yrs

TTM

Acculturation, knowledge, beliefs, stages of readiness, sociodemographics

[37]

a

Mammography

Quasi-experimental, pre-/post-test two group design

180 KA women  40 yrs

HBM, TTM

[38]

a

Mammography

Descriptive quantitative study/crosssectional survey

100 KA women  40 yrs

HBM

[39]

a

Mammography

Descriptive quantitative study/crosssectional survey

229 KA women,  50 yrs

None

[40]

a

Mammography

Quasi-experimental, pre-/post-test two group design

656 KA women  40 yrs

[41]

a

Annual mammography, annual CBE, monthly BSE

Quasi-experimental, pre-/post-test one group design

216 KA women  20 yrs

The health behavior framework combined with HBM, Theory of reasoned action/ Planned behavior HBM

Breast cancer-related knowledge & beliefs, traditional Korean cultural beliefs, acculturation, demographics Health beliefs, cultural beliefs, sociodemographics, years in USA, breast cancer knowledge Knowledge & misconceptions, modesty, acculturation, demographics Barriers, knowledge, provider recommendation, susceptibility, efficacy of early detection, social norms & support, cultural factors Barriers to education, breast cancer knowledge, sociodemographics, breast cancer screening practices & attitudes

Champion's HBM scale [51], McCance et al.’s breast cancer knowledge scale [52] Revised Champion's HBM scale, McCance et al.’s breast cancer knowledge scale [52] Champion's HBM scale [53], Tang, Solomon, & McCracken's scale [82] Scales developed by researchers or adopted from national surveys Scales developed by researchers Champion's attitudes scales [53], Powe fatalism inventory [54], Miller & Champion's knowledge scale [55], Acculturation scale Champion, Menon, Scott scales [51,56,57,58], SuinnLew Asian self-identity acculturation scale [59], Powe fatalism inventory [54] Champion's HBM scale [51], the Powe fatalism inventory [54]

S.-Y. Lee / Asian Nursing Research 9 (2015) 81e90

[30]

Instruments/interview guidelines

Champion's HBM scale [53], Tang et al.’s scales [60] for modesty & use of Eastern medicine Scales developed by researchers

Not explained

Scales developed by researchers

(continued on next page) 83

References

84

Table 1 (continued ) Types of cancer screening

Research design

Sample

Framework

Variables/questions

Instruments/interview guidelines

What comes to your mind first when you think about breast cancer? Have you ever practiced BSE, CBE, or mammogram? Health care access, health beliefs, demographics, outcome variable: Pap smear testing behavior Predisposing factors, enabling factors, reinforcing factors, demographics

The grounded theory method, semi-structured & open-ended interview questions

a

Mammography, CBE, BSE

A set of 2 consecutive qualitative individual interviews

20 Korean immigrant women aged 20e81 yrs

Symbolic interactionism, the meta-concept of cultural competence

[43]

b

Pap smear test

Quasi-experimental, pre-/post-test two group design

102 KA women  18 yrs

HBM, social cognitive theory

[44]

b

Pap smear test

Descriptive quantitative study/crosssectional survey

459 KA women  40 yrs

PRECEDE/PROCEED model

[45]

b

Pap smear test

Qualitative focus group interviews

16 KA women  18 yrs

None

[46]

b

Pap smear test

Qualitative focus group interviews

102 KA women  18 yrs

HBM

[47]

b

Pap smear test

Descriptive quantitative study/crosssectional survey

189 KA women  40 yrs

HBM

[48]

b

Pap smear test

Descriptive quantitative study/crosssectional survey

202 KA women aged 20e90 yrs

None

[49]

b

Pap smear test

Descriptive quantitative study/crosssectional survey

189 KA women  40 yrs

HBM

[50]

b

Pap smear test

Descriptive quantitative study/crosssectional survey

209 KA women  18 yrs

HBM

[61]

c

Mammography, Pap smear test

Descriptive quantitative study/crosssectional survey

130 KA elderly  60 yrs

None

Note. CBE ¼ clinical breast examination; BSE ¼ breast self-examination; HBM ¼ health belief model; TTM ¼ transtheoretical model. a Breast cancer screening in KA women (n ¼ 13, including 5 descriptive quantitative studies, 7 quasi-experimental studies, 1 qualitative study). b Cervical cancer screening in KA women (n ¼ 8, including 5 descriptive quantitative studies, 1 quasi-experimental studies, 2 qualitative study). c Breast and cervical cancer screening in KA women (n ¼ 1, descriptive quantitative study).

Have you ever heard of cervical cancer & screening? Why do you think KA women do not get cervical screening? What is the degree & type of knowledge about cervical cancer? What are the barriers & motivators for cervical cancer using the Pap smear test? Health beliefs, knowledge, sociodemographics Cultural barriers, sociodemographics, immigration, health information, health accessibility, receipt of cervical cancer screening Health beliefs, knowledge, sociodemographics Barriers to cervical screening, acculturation, sociodemographics Background, acculturation level, health status, access to health care, mammography & Pap smears

Scale developed by authors

Scale adopted from national surveys such as behavioral risk factor surveillance system & national health interview survey Semi-structured, openended questions

Semi-structured, openended questions

Modified Champion's HBM scale for cervical cancer screening Tang et al.’s scale on cultural barriers to breast & cervical cancer screening [60]

Modified Champion's HBM scale for cervical cancer screening Scale developed by authors

Researchers developed instruments

S.-Y. Lee / Asian Nursing Research 9 (2015) 81e90

[42]

S.-Y. Lee / Asian Nursing Research 9 (2015) 81e90

85

meanings of the breast and cervix, breast and cervical cancer, and screening to describe factors related to breast and cervical cancer screening [42,45,46]. The most frequently used theory was the health belief model (HBM) (Table 2). The HBM was used as a theoretical framework in the quasi-experimental [32,41] and cross-sectional studies [30,31,47,49,50]. The transtheoretical model (TTM) [34] and the PRECEDE-PROCEED model [35,44] were used as theoretical frameworks to guide the quasi-experimental and cross-sectional studies followed by the HBM. The other studies did not mention a theoretical framework [39,48,51] (Table 2). Some research studies on breast cancer screening [34,39,41], cervical cancer screening [43,50], and breast and cervical cancer screening [61] used instruments developed by the researchers to conduct the studies, whereas other studies used preexisting instruments including Champion's HBM instruments, the Powe fatalism inventory, national surveys such as the National Health Interview Survey or the California Health Interview Survey, and surveys from other studies to measure cancer screening behavior. Many instruments in the studies were modified so that the items were culturally appropriate for KAs by using focus group interviews or expert reviews of cancer screening [30,31,33,44,47,49,50]. Regarding psychometric properties, some articles did not report reliability or validity of the instruments [33,39,40]. Only three studies on breast cancer screening [30e32] and two studies on cervical cancer screening [43,50] reported both the reliability and validity of the adopted instruments. Three screening methods were available to screen for breast cancer: breast self-examination (BSE), clinical breast examination (CBE), and mammography. Some researchers focused on only one method, whereas others combined CBE and mammography or investigated all three screening methods. The most frequently measured method of breast cancer screening was mammography [33e40], and all studies on cervical cancer screening measured Pap smear tests [43e50].

Table 3 Cultural Factors Associated with Breast and Cervical Cancer Screening in Korean American Women: Descriptive Quantitative Studies.

Cultural factors associated with breast and cervical cancer screening

Cultural factors related to breast and cervical cancer screening in the quantitative and qualitative studies included (a) family, (b) embarrassment, (c) preventive health orientation, (d) acculturation, and (e) fatalism. Common cultural factors in both breast and cervical cancer screening studies with descriptive quantitative and qualitative study designs included family, embarrassment, and preventive health orientation (Tables 3 and 4).

Cultural factors associated with breast and cervical cancer screening were identified by reviewing the articles. These factors in quantitative studies were reported as significantly associated (p < .050) or nonsignificant, as shown in Table 3. The study results of the qualitative studies are described in Table 4.

Table 2 Breast and Cervical Cancer Screening in Korean Americans: Theoretical Frameworks.

Cultural factors

Breast cancer screening studies

Significant Nonsignificant Significant Nonsignificant associations associations associations associations Family Husband's [30,31] nationality [30,31] Encouragement from family members Embarrassment [39] Embarrassed about getting mammograms or Pap smear tests [39] Comfortable talking to doctor & asking questions about cancer screening Preventive health orientation e Awareness of importance of early detection of health problems through screening Not having e symptoms Regular checkup [31,48,61] Acculturation English [33,61] proficiency Length of [31,33,61] residence [39] 3 types (traditional, bicultural, assimilated)

e

e

e

e

e

e

e

[47]

[48]

[38]

e

e

e

[48]

e

e

[47]

e

e

e

e

e

[44,50,61]

e

e

[50]

e

e

e

e

Table 4 Cultural Factors Associated with Breast and Cervical Cancer Screening in Korean American Women: Qualitative Studies. Cultural factors

Design

HBM TTM HBM, TTM HBM, social cognitive theory PRECEDE-PROCEED Symbolic interactionism, the meta-concept of cultural competence Health behavior framework combined with the HBM, the adherence model, the theory of reasoned action/planned behavior No framework

Breast cancer screening (n ¼ 13)

Cervical cancer screening (n ¼ 8)

Breast and cervical cancer screening (n ¼ 1)

4 2 2 e 2 1

4 e e 1 1 e

e e e e e e

1

1

e

2

Note. HBM ¼ health belief model; TTM ¼ transtheoretical model.

e

1

Cervical cancer screening studies

Family No room for the breast exam in daily life because of family matters It is troublesome for my family to get screening Embarrassment Covering breasts, breast not to be touched Sexual organs are a private matter & are not a topic of discussion Lack of preventive health orientation No symptoms indicates no illness Going to see a doctor only when I get sick Fatalism The cause of breast cancer is God's plan or a fatalistic notion of Pal-Ja (fate)

Breast cancer screening studies

Cervical cancer screening studies

[42] [42]

[42]

[46]

e

[45]

e [42]

[46] [45]

[42]

[46]

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Regarding family, the husband's nationality was a cultural factor related to breast cancer screening [30,31]. Women who had Caucasian American husbands were more likely to have had two methods of breast cancer screeningdBSE and CBEdthan women who had KA husbands, although husband nationality was not significantly associated with mammogram utilization [30,31]. Additionally, family members were shown to act as facilitators of (family encouragement for breast cancer screening) or barriers to breast cancer screening (lack of time because of family issues and problems within family). Specifically, women who received encouragement from family members were more likely to have had BSE, CBE, and mammography [30,31]. Family-related barriers to breast cancer screening differed by age according to a qualitative study [42]. For example, most middleaged participants lacked the time for breast examination because they cared for their family [42], whereas older KA women required help from their family members to communicate in English or be transferred to a hospital. As a result, family members had to take time off for the participants to receive breast cancer screening, and this issue was considered troublesome for many older KA participants. Embarrassment was significantly associated with breast and cervical cancer screening utilization in some studies (Table 3). In particular, KA women felt embarrassed to discuss this topic with others or show their breasts and pubic area to others, especially a male physician [39,42,45e47]. Regarding Pap smears, the degree of embarrassment in exposing one's body to a health care provider, especially to a male, was much greater than for mammography and CBE [46]. However, some studies reported that there was no significant association between embarrassment and breast and cervical cancer screening [38,48]. Awareness regarding the early detection of cancer, lack of symptoms, and need for regular checkups have been found to be associated with breast and cervical cancer screening behavior in KA women [31,46e48,61]. These factors indicate preventive health orientation. Most KA elderly were unfamiliar with preventive health practices, such as those for the early detection of cancer [62]. In addition, a lack of symptoms was a main reason why KA women had not received breast and cervical cancer screening in cross-sectional quantitative and qualitative studies, which may reflect the lack of preventive orientation in KA women [42,45e47]. Many KA women also thought that cancer screening tests were needed only after symptoms of cancer occur and that they should only seek care when they become sick [42,45e47]. Studies have shown that routine checkups were also related to cancer screening behavior [31,48,61], and receiving a regular checkup was shown to measure access to health care but also reflected individual preventive health orientations [61]. There were statistically significant effects of acculturation on having mammography and a Pap smear test in KA women [31,33,39,44,50,61]. In many studies, acculturation was measured by English proficiency and length of residency in the US [31,33,61], English proficiency only [44], length of residence only [31], or 3 types of acculturation (traditional, bicultural, and assimilated) [39]. A fatalistic attitude was one of the most frequently mentioned cultural barriers in KA women [46]. Two qualitative studies found that fatalism was a barrier to participation in breast and cervical cancer screening because having cancer was Pal-Ja (fate) or God's plan [42,46], which makes people believe that screening and/or treatment are not necessary. However, KA women in one study [46] also believed that health outcomes could be influenced through preventive efforts, such as having a healthy lifestyle, regardless of their fatalistic perspective. Culturally relevant intervention studies Most quasi-experimental studies [32,34e37,41,43] conducted education programs only or education combined with navigation

assistance or low-cost mammography, whereas only one study [40] tested the effectiveness of print materials to increase repeated mammography utilization (Table 5). Culturally relevant intervention studies using education were analyzed using three components: educator, place, and intervention (Table 5). All education intervention studies were conducted in a culturally sensitive way using bilingual and bicultural health educators at sociocultural sites, such as Korean churches, Korean community centers, and senior housing. Intervention methods were somewhat different between the studies, as studies used educational content containing culturally specific beliefs (e.g., preventive health orientation, modesty, and fatalism), education and follow-up counseling with lay health workers focusing on reducing cultural barriers, or culturally sensitive educational materials (e.g., Korean language photo-novel) to improve breast or cervical cancer screening utilization. Additionally, considering cultural aspects of breast cancer screening behaviors in KA women, stage-based education [36] and follow-up counseling [32] were provided differently to participants who were grouped according to their baseline stage of mammography use (e.g., pre-contemplators, contemplators, and relapse) based on TTM. Both studies [32,36] conducted education or followup counseling with lay health workers emphasizing breast cancer screening benefits at the intervention group of precontemplators while focusing on decreasing perceived specific cultural barriers (e.g., acculturation, perceived modesty, and perceived fatalism) to getting screened at the intervention group of contemplators. The primary outcome measured in studies was the completion or evaluation of willingness to consider mammography (e.g., intentions to have mammogram and schedule CBE and mammogram). Outcome measurements were assessed 2 weeks to 6 months post-intervention. Although there were some differences in the intervention methods, four of the eight studies reported significantly increased rates of breast and/or cervical cancer screening utilization or intention in the intervention groups after application of the intervention. Discussion This study examined current research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in KA women by reviewing 22 studies. This literature review showed that there are important issues in breast and cervical cancer screening studies in KA women. From the theoretical and methodological perspectives, the predominant theoretical frameworks (e.g., HBM and TTM) used in breast and cervical cancer screening in KA women are individualfocused cognitive models of rational decision making, while social-cultural contextual factors were not included in these theories [63,64]. Although Korean immigrants show strong attachment to traditional Confucian values, particularly collectivism [65e69], relationships between cultural factors such as familism (family interest over individual interest) and breast and cervical cancer screening behaviors in KA women have not been fully investigated in many studies with KA women, which might be partially due to the use of individual cognitive theories in these studies. Methodologically, many studies have modified preexisting scales by using focus group interviews or expert reviews to develop culturally appropriate instruments [30,31,33,44,47,49,50]. However, these instruments should be modified to be culturally sensitive if concepts are measured for KAs using preexisting scales that were used for other ethnic groups, such as whites, because they may show construct bias, which is caused by the incomplete overlap of definitions of a construct across cultures, differential appropriateness of the content, or incomplete coverage of the construct [70,71].

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Table 5 Culturally Relevant Intervention Studies on Breast and Cervical Cancer Screening in Korean American (KA) Women. Interventions Breast cancer screening studies Education

Education at Asian grocery store

Education, counseling & navigational assistance

Education & educational materials

Education & low-cost mammography

Print materials

Cervical cancer screening studies Education & navigational assistance

Characteristics

Study results in intervention group

References

Educator: bilingual, bicultural KA immigrant woman Place: Korean American Senior Center (a sociocultural site) Intervention: educational content focusing on cultural cons (acculturation, modesty, fatalism) Educator: bilingual, bicultural KA immigrant woman Place: church (a sociocultural site) Intervention: educational content focusing on cultural beliefs (preventive health orientation, fatalism, modesty) Educator: bilingual, bicultural Asian American university students Place: Asian grocery store (a culturally acceptable community education site) Intervention: general information on BSE & State's free & low-cost screening services Educator: bilingual, bicultural female lay health workers Place: community sites including a community center, ethnic churches, ethnic grocery stores, & participants' homes. Intervention: lay health workers follow-up counseling focusing on reducing barriers such as embarrassment (neighborhood-based, culturally sensitive intervention) Educator: bilingual, bicultural educators Place: Korean churches & senior housing Intervention: small-group education presentations, BSE videotape, Korean language photo-novel developed to be culturally appropriate by focus groups Educator: bilingual, bicultural female KA nurse practitioner Place: Korean churches Intervention: the women's advisory groups encouragement for mammography (culturally sensitive approach)

No statistically significant intervention effect on upward shift in stage of readiness for mammography use at 6 weeks post intervention.

[36]

No statistically significant intervention effect on mammography use between the intervention (34%) & control groups (23%) at 24 weeks post baseline.

[37]

Of the 94 women who completed the 2week follow up, 7 women reported that they had set up a CBE & 8 reported having set up a CBE at 2 weeks post intervention.

[41]

Rates of breast cancer screening behaviors significantly increased at 6 months (p < .001); changes between pre- & post-intervention were 31.9% for mammography, 23% for CBE & 36.2% for BSE.

[32]

Women in the intervention group significantly increased (by 2.96-fold) their posttest intentions to receive mammogram compared to those in the control group at 6 months post intervention. At 2 months after the baseline test, both interventions (group 1: education groups & mammography-access [87%], group 2: mammography-access-only group [72%]) proved to be significantly more effective than no intervention (47%). No significant difference in mammography use between the intervention & control groups. In the 3month intervention period, 136/360 (38%) received a repeat screening mammogram. In the 3-month comparison period, 94/296 women (32%) received a repeat screening mammogram.

[34]

At 6 months post-intervention, 82.7% of women in the intervention group had significantly obtained screening compared with 22.0% in the control group.

[43]

Importance of women for the well-being of a twogeneration KA family with women in the center

Educator: bilingual, bicultural Korean health educators Place: Korean community centers (sociocultural centers) Interventions: education content focusing on the life roles of Asian women (e.g., social norms, family responsibilities)

[35]

[40]

Note. BSE ¼ breast self-examination; CBE ¼ clinical breast examination.

Cultural factors associated with breast and cervical cancer screening in KA women that were identified in this literature review included family, embarrassment, preventive health orientation, fatalism, and acculturation. These cultural beliefs are grounded on traditional philosophies, including Confucianism, Buddhism, and Taoism in KAs [72]. Confucian values, particularly family-centered values, are the cornerstone of Korean culture [65,73e75]. Indeed, researchers have emphasized that because family is considered a basic unit of Korean cultural and health practices, providing information on cancer and cancer screening to

the family as an intervention could work synergistically with education programs [41,76]. Embarrassment is based on Confucianism, and KA women try to avoid feeling embarrassed around others [77,78]. Korean women's lives are very restricted because of social and cultural values influenced by Confucianism, which is considered the root of gender oppression [74,79,80]. Because of this issue, KA women are reluctant to reveal their sexual organs to male doctors and prefer to use female physicians, especially for Pap smears. Because of the modesty of KA women, male KA doctors may be less likely to

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perform or recommend breast and cervical cancer screening tests for their female patients [77,81]. Statistically significant associations between embarrassment and breast and cervical cancer screening were inconsistent across the studies examined, which may have been due, in part, to different measures of cultural factors used in these studies [38]. For example, Maxwell et al. [39] examined the relationships between embarrassment and undergoing a mammography by asking two items (i.e., embarrassed about mammograms and comfortable talking to a doctor about breast cancer), whereas embarrassment was included in a perceived barrier scale about cervical cancer screening in the study by Lee et al. [47]. In addition, modesty was measured using Tang et al.'s scale [82] which consisted of six 5point Likert-type items (e.g., I feel uncomfortable talking about my body with a doctor) in studies [38,48]. KAs typically show a crisis-oriented health care perspective (e.g., no symptoms indicates no illness or going to see a doctor only when I get sick) [7,44,83e85]. Crisis health orientation or lack of preventive health orientation is associated with KAs focusing on primary preventive behavior. Although secondary prevention through screening is the most promising intervention for controlling cancer [4,5], KAs are more likely to be more familiar with primary prevention (e.g., healthy food, regular exercise, and positive thinking to maintain health and prevent cancer) rather than secondary prevention (e.g., cancer screening) because of traditional values and beliefs including (a) the concepts of Taoism and its methods for cultivating mind and body and harmonizing with nature and (b) traditional Korean medicine including the principles of yin-yang [72,86,87]. These concepts may be also related to the husband's nationality, which is a family-related factor. For example, Korean women who have non-Korean husbands were more likely to receive cancer screening [30,31], which means that Korean husbands may have less familiarity with secondary prevention than non-Korean husbands. Traditional philosophies, including Confucianism, Buddhism, and Taoism, emphasize both external (fate by God or supernatural power) and internal controls (human efforts in life), which may influence cancer screening behavior in KAs [72,88]. In the reviewed studies, KA women had both fatalistic attitudes and beliefs about preventive efforts for health. These external and internal forces seem to conflict, although both contributed in the same way to breast and cervical cancer screening behavior. A previous study [72] found that KAs showed a unique, active attitude toward fatalism (i.e., human efforts can change fate) that may be based on traditional philosophies (Confucianism, Buddhism, and Taoism) of Korea. From the methodological perspective, measuring acculturation using items such as English proficiency and length of residence in the US may not be sufficient, as acculturation is a multidimensional process of adopting attitudes, values, and behaviors from another culture [68]. However, in many studies, acculturation was measured using these two items, English proficiency and/or length of residence. Particularly, measuring the length of residence in the US may not reflect acculturation because KAs' strong ethnic attachment is often unaffected by length of residence in the US. Many KAs keep their traditional cultural values intact while adopting particular dimensions of American values and social attitudes [65e69]. The findings of this review revealed characteristics of culturally relevant interventions to increase breast and cervical cancer screening rates in KA women. All education studies used bilingual health educators at cultural settings to deliver the intervention, which was an effective strategy to promote breast and cervical cancer screening in KA women. Cultural beliefs, such as embarrassment, lack of preventive health orientation, and fatalism, were

incorporated into intervention studies with KA women to construct educational content to modify cultural beliefs and eventually improve breast and cervical cancer screening utilization [36,37]. Additionally, this literature review found that education and other additional intervention methods (e.g., providing counseling, navigational assistance, or low-cost mammography) produced synergistic effects on increasing breast and cervical cancer screening utilization as compared to education intervention alone. Limitations Although this review highlighted the research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in KA women, the results of this review may be limited to the studies retrieved and reviewed. Additionally, as indicated above, inconsistent operational definitions of constructs, such as embarrassment, may contribute to different study results, which makes the comparison of cultural factors and results across studies difficult. Finally, all of the studies in this review used self-reports to assess breast and cervical cancer screening utilization, including CBE, mammography, or Pap smear test, which were not validated by a medical record review. Thus, medical record reviews to confirm participants' selfreports would provide more accurate information to researchers. Conclusion Cultural beliefs, values, and experiences influence healthrelated behavior [16]. Because understanding culture is essential for improving cancer screening behavior, we identified current research methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening test utilization in KA women by reviewing 22 research studies. This review highlights several important implications for practice and future research. First, although Korean culture places great importance on family, many studies have used individual-focused cognitive theories. Theories that focus on interpersonal relationships and preventive health behaviors may add new knowledge to cancer screening research in KAs. Second, because different types of operationalization for measures of cultural beliefs associated with breast and cervical cancer screening in KA women may result in ambiguous study results, standardized, reliable, and valid instruments to measure cultural concepts are needed to obtain accurate study results. Third, researchers and health professionals should understand that many KA women have cultural beliefs such as lack of preventive health orientation (e.g., no symptoms indicates no illness, so they go to see a doctor only when they are sick) or the embarrassment associated with discussing and showing the breasts or cervix to others. Finally, acculturation is a significantly important factor related to breast and cervical cancer screening in many studies despite various measurements used to address this measure. Because levels of acculturation may be different in KA women, interventions may be more effective if KA women receive specific interventions based on their level of acculturation, as stagebased interventions using TTM were shown to be effective in promoting breast and cervical cancer screening behavior in KA women. Conflict of interests The author declared no potential conflicts of interest. Acknowledgments This study was supported by research fund from Chosun University 2013.

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