Health literacy, language, and understanding of colon cancer prevention information among English-as-a-second-language older Chinese immigrant women to Canada
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Introduction: Colon cancer incidence and mortality rates in Canada are among the highest worldwide. If detected early colon cancer is highly curable and regular screening can significantly decrease risk of colon cancer mortality. Despite this, screening rates in Canada are consistently low and immigrant and senior populations are particularly vulnerable due to low health literacy and language barriers. This research consists of three studies that were designed to explore the cancer prevention experiences of older English-as-a-Second Language (ESL) Chinese immigrant women in Canada. This includes an investigation of colon and breast cancer screening utilization, health literacy skills and comprehension of colon cancer prevention information, and experiences and preferences when seeking cancer information by these immigrant women. Methods: A convenience sample of 110 Mandarin and Cantonese-speaking ESL immigrant women were recruited from two Southern Ontario communities. For study inclusion participants were required to: (1) be 50 years of age or older, (2) have immigrated to Canada, (3) have Cantonese or Mandarin as their first language and English as their second language, and (4) be able to read in English. Participants were excluded if they or their spouse had been previously diagnosed with any type of cancer. Participants completed a battery of questionnaires assessing demographic characteristics, use of breast and colon cancer screening, acculturation, self-efficacy, health beliefs and health literacy. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and comprehension of a colon cancer prevention information sheet from Cancer Care Ontario was assessed using the cloze procedure. Participants participated in a semi-structured interview to explore cancer information seeking preferences and experiences, and their understanding of cancer prevention information. Multivariate logistic regression was used to identify predictors of colon and breast cancer screening. To identify variables significantly associated with performance on the S-TOFHLA and cloze test regression analyses were performed. Directed content analysis was used to identify themes associated with barriers to cancer information seeking and understanding that emerged from the interviews. Results: Study #1: There was high self-reported screening for breast and colon cancer. Eighty-five percent of the women were current mammography screeners and 75% were current colon cancer screeners. Recommendation from a physician (OR=.140; 95% CI= .044, -.448), having a female physician (OR=.141; 95% CI= .033, .591), and high or moderate proficiency in English (OR=.283; 95% CI= .089, .902) significantly predicted mammography screening. Physician recommendation (OR=.103; 95% CI= .031, .349), first language (OR= 1.85; 95% CI= .055, .628) and higher self-efficacy (OR= 3.613; 95% CI= 1.179, 11.070) predicted use of colon cancer screening. Other important predictors included greater health literacy and longer residency in Canada. Study #2: Only 38.7% of the women had adequate health literacy on S-TOFHLA and 54.3% had adequate comprehension of the colon cancer information. Comprehension of the colon cancer information was significantly lower among women who received the information in English, compared to those who received the information in Chinese (p<0.01). Age, acculturation, self-reported proficiency reading English, and education were significant predictors of health literacy but varied depending on the measure (S-TOFHLA, cloze) and language of information (English, Chinese). Study #3: There were unique health information seeking preferences among the older Chinese immigrant women including a strong preference for interpersonal and interactive cancer information from their physician and trusted others, such as friends and family. Barriers to cancer information seeking included language difficulties and limited time with physicians. Differences in health literacy did not distinguish the women on any of the major themes. Conclusion: Language, culture, health literacy and the role of the physician emerged across all three studies examining the cancer prevention experiences of older Chinese immigrant women. While language concordant educational materials may improve understanding of cancer information, the results from this study suggest that it is important to consider factors other than language alone and to address important cultural issues that play a role in the access, use, and understanding of cancer information.