1. 1 The Role of Cultural Health Beliefs on Health Behaviors among Chinese, Korean, & Mexican American Breast Cancer Survivors PI’s: Drs. Patricia Gonzalez, Jung-Wong Lim & Ming Wang Students: Suirong Li & Mee Yon Yum Advisor: Dr. Kimlin Ashing-Giwa December 11, 2008

2. 2 Background ► Breast cancer (BC) is the most frequently diagnosed cancer in Asian-and Latina-American women. ► Favorable survivorship outcomes for women with BC may be attributed to lifestyles and behavioral factors. ► Given the growing ethnic minority populations in the U.S., and emerging health disparity issues in cancer outcomes, cultural factors of ethnic minorities need to be considered

3. 3 Overall Goal ► Examine the relationships among cultural health beliefs, health behaviors, and factors influencing them among Chinese, Korean and Mexican breast cancer survivors (BCS). ► Explore the differences and/or similarities in cultural health beliefs & health behaviors among Chinese-, Korean- & Mexican-American BCS.

4. 4 Phase 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. 5 Phase II Specific Aims 1. Explore the cultural health beliefs and health behaviors among Chinese-, Korean-, and behaviors among Chinese-, Korean-, and Mexican-American BCS. Mexican-American BCS. 2. Explore the factors (e.g., acculturation, doctor- patient relationships) influencing health patient relationships) influencing health behaviors among Chinese, Korean, and behaviors among Chinese, Korean, and Mexican BCS. Mexican BCS.

6. 6 Phase I: Overall Framework Acculturation Cultural health beliefs Treatment Decision Doctor-patient Relationship Health behavior H1 H2 H3 H4 H5 H6

7. 7 N = 237 Chinese (N=85), Korean (N=29), Mexican (N=123) Age > 18 Stage 0-III CCSP, Hospital registries Community agencies Methods Measures Sample 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 Method 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. 8 Data Analyses ► Descriptive statistics ► Pearson product-moment correlations ► T –Tests ► ANOVAs ► Chi-Squares

9. 9 Table 1. Acculturation and cultural health beliefs (Aim1: H1) Acculturation (r) Health belief items AllChineseKoreanMexican When people get sick it is the will of God or a higher power -0.219*** -0.267* -0.144 -0.354*** Harboring a lot of anger can make a person vulnerable to illness -0.075-0.249*-0.1100.069 I am in control of my health 0.0530.115-0.1750.006 My family situation has a lot to do with my becoming sick or staying healthy -0.144**-0.282**-0.082-0.124 Luck plays a big part in determining how soon I will recover from an illness -0.226***-0.188-0.106-0.275** Health professionals control my health -0.277*** -0.135-0.026 -0.558*** My cultural background plays a big part in how I feel about my illness and getting well -0.036-0.168-0.1980.020 *p<0.05, **p<0.01, ***p<0.001

10. 10 Table 2. Cultural health beliefs and doctor-patient relationship (Aim2: H2) Health beliefs items Doctor-patient relationship (r) AllChineseKoreanMexican 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 0.045-0.021-0.0490.039 I am in control of my health 0.170**0.207-0.0900.190* My family situation has a lot to do with my becoming sick or staying healthy 0.005-0.1200.0310.040 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 -0.0790.1620.030-0.156 My cultural background plays a big part in how I feel about my illness and getting well -0.006-0.151-0.1860.027 *p<0.05, **p<0.01

11. 11 Table 3. Cultural health beliefs and health behaviors (Aim2: H3) Health behaviors Health beliefs items GodAngerMy 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) 2.63 (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= 0.1560.5620.0520.4800.345-0.413 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= 1.463-1.059-0.257-0.0360.2170.868 -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= -0.3091.6111.0500.2121.318-1.185 -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*0.305-0.184-0.9460.9020.678 -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= -1.0701.985*1.8901.8481.107-0.899 0.848 *p<0.05

12. 12 Mediating effects of treatment-related decision and doctor-patient 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. 13 Table 4. Acculturation & Doctor-patient relationship by Ethnicity & Language (Aim 4: H6) Variables ChineseKoreanMexican 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. 14 Table 5. Treatment-related decisions by ethnicity (Aim4: H6) Treatment- related decisions Chinese (N, %) Korean (N, %) Mexican (N, %) X 2 Square Doctor10 (11.8)7 (24.1)35 (28.5) 23.750** Doctor and I27 (31.8)7 (24.1)36 (29.3) Doctor, I, and partner 33 (38.8)6 (20.7)23 (18.7) I10 (11.8)5 (17.2)26 (21.1) Other5 (5.9)4 (13.8)3 (2.4) **p<0.01

15. 15 Table 6. Health behavior changes by ethnicity Table 6. Health behavior changes by ethnicity (Aim 4: H6) VariablesChineseKoreanMexicanX2X2 Life style change (Yes/No) 60 (70.6%)24 (82.8%)71 (58.7%)7.313* Eating49 (81.7%)19 (79.2%)68 (89.5%)3.356 Exercise47 (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 stress40 (66.7%)18 (75.0%)36 (48.6%)7.287* * P < 0.05

16. 16 Conclusions ► This research is the first study to compare health behaviors and cultural health beliefs across Chinese, Korean- and Latina BCS. ► The diverse sample provides a unique opportunity to begin exploration health behaviors and health belief issues. ► Results suggest that cultural context must be considered when understanding health behaviors among BCS.

17. 17 Limitations ► Participants may have provided socially acceptable responses ► Self report data are subject to recall bias ► Certain health behavior information was not included ► Korean-American sample size was small

18. 18 Activities to Date ► Phase I  Identified variables based on research hypotheses  Secondary data analyses and interpretation  Findings reported / Manuscript Development ► Phase II  Focus Group Protocol and procedure preparation  Questionnaire  Contacted community agencies for recruitment  Two Chinese focus groups conducted  One Korean focus group conducted

19. 19 Activities to Date (cont.) ► Abstracts and Manuscripts  Two Poster presentations  One Oral presentation  One manuscript in press  One manuscript in press (Supportive Care in Cancer)  Two in preparation ► Student research assistants recruited ► Training and learning

20. 20 Jan 08 to Dec 0920082009 JFMAMJJASONDJFMAMJJASOND 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 & Tasks Completed In process Target Schedule

21. 21Acknowledgements Research Assistants: Ann Lee Suirong Li Mee Yon Yum Ariel Bianca Moreno Dr. Ashing-Giwa: Mentor Dr. Susan Kane & Dr. Jamil Momand Funding Source: NIH: 1P20CA118783-01A1 & 1P20CA118775-01A