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Acculturation and Colorectal Cancer Screening Among Older Latino Adults: Differential Associations by National Origin

Journal of General Internal Medicine volume 24, pages 963–970 (2009)Cite this article

ABSTRACT

BACKGROUND

Although modest improvements in colorectal cancer (CRC) screening utilization have occurred, rates remain low among Latinos. It is unclear whether acculturation plays a role in the utilization of CRC screening.

OBJECTIVE

This study aimed to examine the relationships between acculturation and CRC screening among older Mexican, Puerto-Rican and Cuban adults.

DESIGN

Cross-sectional observational study.

SUBJECTS

Latinos 50 years and older, never diagnosed with CRC, and who were surveyed in the 2000, 2003 and 2005 National Health Interview Survey (NHIS).

MEASURES

We measured acculturation with US nativity and language of interview, and examined three different CRC screening outcomes: fecal occult blood test (FOBT) in the past year, up-to-date endoscopy and any up-to-date CRC screening. Logistic regression models were adjusted for predisposing, enabling and health-care need factors consistent with the behavioral model of health-care utilization.

MAIN RESULTS

In adjusted analyses, US nativity was positively associated with up-to-date endoscopy among Mexicans (OR: 1.5; 95% CI: 1.1, 2.2), but negatively associated with FOBT in the past year among Puerto Ricans (OR: 0.3; 95% CI: 0.2, 0.7). In contrast to this latter finding among Puerto Ricans, English language interview was positively associated with FOBT in the past year (OR: 2.5; 95% CI: 1.1, 5.4).

CONCLUSION

Results underscore the importance of stratification by national origin in studies of acculturation and cancer screening and of targeting less acculturated adults to promote CRC screening. Clinicians, however, should consider the complexity of acculturation and treat US nativity and language preference as independent dimensions among their Latino patients.

INTRODUCTION

Colorectal cancer is the second leading cause of cancer-related death in the US1. Colorectal cancer (CRC) screening has been shown to effectively reduce mortality and morbidity from colorectal cancer due to early detection and treatment of cancer or precancerous lesions and is recommended for all average risk adults aged 50 and over2. Modest improvements in the utilization of CRC screening procedures have occurred in the past few years in the context of expanding Medicare coverage3. However, wide health disparities remain among Latino and non-Latino Whites, Asians and non-Latino Whites, and immigrants and their native counterparts4–8.

Immigrants’ poorer cancer screening practices relative to US natives may be related in part to immigrants having different values and beliefs about health service use9–11 or low levels of acculturation to US social norms concerning cancer screening. Several studies among Latino and Asian ethnic minority groups examine acculturation’s influence on colorectal cancer screening with mixed findings. Two studies on acculturation and CRC screening among Latinos found no association between acculturation and CRC screening after accounting for socio-economic factors and access to care12,13. In contrast, the majority of studies conducted in various Asian ethnic groups found that greater acculturation was associated with a higher likelihood of CRC screening14–19. Interpreting results of these studies is challenging due to varying study methodologies. Each study used a different measure of acculturation. Some used variants of English language preference or proficiency12,16,17, or time in the US measures18,19, while others used composite measures of acculturation13–15 reflecting concepts of language preference, time and co-ethnic relationships. Two studies measured ever using any CRC screening method13,15, while the remaining studies measured CRC screening based on recommended guidelines [i.e., fecal occult blood test (FOBT) in the past year or endoscopy in the past 5 years]12,14,16–19. The majority of the studies relied on convenience samples of adults, with notable exceptions12,17,19.

Most importantly, among the studies focusing on Latinos, none stratified analyses by country of origin. Past research has shown differential relationships between acculturation and health by ethnic group20,21; thus, aggregate analyses may underestimate the influence of acculturation, mask important ethnic group-specific patterns or produce contradictory findings. For breast cancer screening, national studies lumping Latino groups together and those that have had a more regional focus have produced inconsistent results with regard to the associations between acculturation and breast cancer screening, possibly because of varying ethnic group distributions22–27. Further, each ethnic group experiences a unique acculturation experience shaped by US immigration policy and the social and economic conditions of the receiving community at the time of immigration28,29.

Study Objectives

The primary goal of this study is to investigate the relationship between acculturation and colorectal cancer (CRC) screening in Latino adults 50 and older using nationally representative data. We address two important gaps in the literature. First, we stratify our analyses by national origin, examining whether the relationships between acculturation and CRC screening vary among groups of Mexican, Puerto-Rican and Cuban origin; no single existing study has done such a comparative analysis. Second, no past nationally representative study on acculturation and CRC screening has examined the different CRC screening modalities separately, an important consideration given the variability in access to, cost and nature of the different modalities. We examine the relationship between acculturation and three different CRC screening outcomes separately—FOBT, endoscopy and any CRC screening modality—all according to recommended guidelines. Acculturation has been conceptualized as a multidimensional process whereby immigrants adopt selected values and behaviors of their host culture and may discard or retain those of their country of origin28,30–32. We relate acculturation to CRC screening taking into consideration factors central to the behavioral model of health-care utilization, which suggests that health service utilization is a function of individuals’ predisposition due to age, gender or social status, factors that enable or impede use of services (such as health insurance), and actual need for health care33.

METHODS

This study used data from the 2000, 2003 and 2005 National Health Interview Survey (NHIS), the principal source of information on the health of the civilian non-institutionalized population of the US. The NHIS is an ongoing, nationally representative, household, in-person survey conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention (http://www.cdc.gov/nchs/nhis). To facilitate stratification by ethnic group, we combined the three survey years (NHIS 2000, 2003 and 2005) containing detailed data on colorectal cancer screening procedures. For the purpose of this study, we analyzed all adults 50 years of age and older without a prior history of colon or rectal cancer and who self-reported being Hispanic/Latino. A current feature of the NHIS sampling design is the oversampling of Latinos, permitting analyses of Mexicans, who constitute the single largest Latino ethnic group in the US, followed by Puerto Ricans and Cubans34. Thus, analyses were conducted separately for Mexican (N = 2,304), Puerto-Rican (N = 503) and Cuban (n = 484) adults to examine subgroup-specific relationships between acculturation and CRC screening.

Dependent Variables

Three CRC screening outcomes, available in the NHIS, were investigated: (1) whether individuals had undergone FOBT in the past year, (2) whether individuals had received a sigmoidoscopy in the last 5 years or colonoscopy in the last 10 years and (3) whether individuals had received any up-to-date CRC screening (or met the criterion for no. 1 or 2). These CRC screening criteria were based on clinical guidelines that were in place prior to the study period35.

Independent Variables

Acculturation was operationalized with two discrete variables: (1) nativity—whether the respondent was born outside the 50 US states or not (hereafter referred to as mainland US and (2) language preference—whether the respondent conducted the interview in English or not. Language has been shown to be a powerful indicator of ethnic identity, and nativity has been identified as a key objective measure of acculturation36–40. Nativity reflects exposure to US culture, and studies have shown that longer exposure to competing values of the larger society are expected to diminish the influence of values unique to an ethnic culture36.

We also analyze key covariates, including demographic variables (age, sex) and socio-economic factors known as predisposing variables (income status, education), enabling factors or those related to health-care access (type of insurance and usual source of care) and health-care need factors (number of chronic diseases), which is a count variable ranging from 0 to 6, of whether the respondent reported having diabetes, hypertension, ulcer, arthritis, any cardiovascular disease and any respiratory illness.

Statistical Analyses

We examined bivariate and adjusted relationships between acculturation measures and all three CRC screening outcomes. We used chi-square tests to examine unadjusted associations between nativity and language of interview and the three outcomes. Using logistic regression, models containing nativity, language of interview and all covariates were estimated to assess the independent contributions of each on the three outcomes. All analyses were adjusted for complex survey design using SAS (version 9.1.3) and SUDAAN41.

RESULTS

Sample Characteristics

Table 1 presents characteristics of adults who met the study inclusion criteria (non-Hispanic Black and White adults are presented for comparative purposes). Overall, the majority of Mexicans and Puerto Ricans conducted the interview in English (approximately 60%), while the majority of Cubans conducted the interview in Spanish or a combination of Spanish and English (75%). The majority of Mexicans were born in the US (56%). In contrast, the majority of Puerto Ricans and Cubans were born outside the mainland US, (79% and 95% respectively). Socioeconomic and health-care factors varied by national origin and racial and ethnic groups. For example, the percentages of college graduates ranged from 7% and 8%, respectively, among Mexican and Puerto-Rican adults to 20% among Cubans. Finally, the percentage of uninsured ranged from 9% among Puerto-Rican adults to 23% among Mexican adults.

Table 1 Respondent Characteristics (%) by Racial and Ethnic Group*, NHIS† 2000, 2003, 2005
Full size table

Rates of CRC Screening According to Nativity and Language of Interview

The rate of any up-to-date screening ranged from 29% among Mexicans to 37% among Cubans, and the rate of up-to-date endoscopy ranged from 24% among Mexicans and 31% among Cubans (Table 2). There was less variation in FOBT in the past year according to ethnic group (Table 2).

Table 2 CRC Screening Outcomes by Nativity and Language of Interview*: NHIS 2000, 2003, 2005†
Full size table
Table 3 Adjusted Odds Ratios (95% CI) for Any Up-To-Date Colorectal Cancer Screening*: NHIS 2000, 2003, 2005†
Full size table

There was wide variation by nativity and language of interview for all three CRC screening outcomes across ethnic groups. Among Mexicans, US-born adults and those who had English language interviews had significantly higher rates of all CRC screening outcomes measured compared to those born outside the US and who did not interview in English. In contrast, among Puerto-Rican and Cuban adults, rates for all CRC screening outcomes were higher in foreign-born adults relative to their US-born counterparts (with the exception of endoscopy among Puerto Ricans where the rates were similar). Further, compared to Cubans who had a Spanish/bilingual interview, those who had an English language interview had lower rates of all CRC screening outcomes; this was also true for FOBT use among Puerto Ricans.

Adjusted Analyses for Any Up-to-date Screening, FOBT in the Past Year, Up-to-date Endoscopy

After adjusting for all covariates in the model, including demographic variables (age, sex), predisposing (income, education), enabling (insurance and usual source of care) and need (number of chronic conditions) factors central to the health service utilization model, there are significant independent associations between nativity and any up-to-date CRC screening (Table 3). For example, Mexicans who were born in the US had higher odds of reporting any up-to-date screening compared to those born outside the US (OR = 1.4; 95% CI: 1.0-1.9). It is also notable that for Mexicans, family poverty level, education, usual source of care and number of chronic conditions all had independent associations with CRC screening.

In contrast, nativity and language of interview were not significant correlates of any up-to-date CRC screening among Puerto Ricans and Cubans (Table 3). Higher family income and a greater number of chronic conditions were significantly associated with a higher likelihood of any up-to-date CRC screening among Cubans. Insurance coverage, higher educational levels, male gender, and greater number of chronic conditions were also positively related to any up-to-date screening among Puerto Ricans only.

Interestingly, for FOBT, the study’s acculturation measures were only significant among Puerto Ricans (Table 4). Puerto Ricans who were born in the mainland US were less likely to report receiving an FOBT in the past year compared to those born outside the US. In contrast, Puerto Ricans who interviewed in English were more likely to report FOBT in the past year than those who interviewed in Spanish. It is notable that higher educational level and a greater number of chronic conditions were also significant and positively related to having received an FOBT in the past year among Puerto Ricans. Among Mexicans, having a usual source of care and a greater number of chronic conditions were significant and positive correlates of FOBT in the past year. Among Cubans, male gender was the only significant, positive correlate of the outcome.

Table 4 Adjusted Odds Ratios (95% CI) for Receipt of FOBT *in Past Year†: NHIS 2000, 2003, 2005‡
Full size table

Nativity mattered in the receipt of up-to-date endoscopy only for Mexicans (Table 5). For Mexicans, those who were born in the US were more likely to report an up-to-date endoscopy than those born outside (1.5; CI: 1.1-2.2). Additionally, higher family incomes, higher educational levels, having a usual source of care and a greater number of chronic conditions were significant, positive correlates of up-to-date endoscopy among Mexicans. Higher family incomes, higher educational levels, male gender and a greater number of chronic conditions were significant, positive correlates among Puerto Ricans; higher family incomes, age and a greater number of chronic conditions were significant positive correlates among Cubans.

Table 5 Adjusted Odds Ratios (95% CI) for Up-To-Date Endoscopy*†: NHIS 2000, 2003, 2005 ‡
Full size table

DISCUSSION

This study demonstrates that acculturation, inferred by nativity and language preference, is a significant determinant of CRC screening utilization in a nationally representative sample of older Latino adults even when taking into account a variety of health service utilization factors. For Mexican adults, US nativity was positively associated with any up-to-date screening or an up-to-date endoscopic procedure. The findings among Puerto Ricans were more complex with evidence of both positive and negative associations with the acculturation measures used in this study. Puerto Ricans who had an English language interview were more likely to receive FOBT in the past year relative to those who had a Spanish/bilingual interview; in contrast, Puerto Ricans who were born in the mainland US were less likely to receive FOBT in the past year relative to those born in Puerto Rico. There were no significant associations between acculturation and CRC screening among Cubans in adjusted analyses.

Enabling factors (insurance type and usual source of care) were also significant determinants of CRC screening for almost all ethnic groups and all CRC screening modalities. Further, for the more expensive screening modalities (e.g., colonoscopy or sigmoidoscopy), the conventional predisposing factors (income status and educational level, which can also be conceptualized as enabling factors) remained robust determinants. For FOBT, the less expensive test, however, predisposing factors were not significant determinants. The only exception to these findings was FOBT utilization among Puerto Ricans where, in addition to the acculturation measures and chronic conditions, educational level was a significant determinant.

These results are in contrast to those in an earlier study among Latinos that found an insignificant association between acculturation and CRC screening13. However, Shah et al. (2006) analyzed up-to-date screening among Latinos as an aggregate group, while our study disaggregated analyses by Latino national origin and CRC testing modality. Thus, aggregating ethnic groups and grouping CRC testing modalities together may lead to missed opportunities in identifying important predictors of CRC screening.

Our findings highlight the diversity of Latinos in the US by suggesting differential relationships between acculturation and CRC screening by national origin. Among Mexicans in our study, we observed a positive relationship: US nativity was associated with a higher likelihood of endoscopy and overall up-to-date CRC screening. Among Puerto Ricans, we observed the opposite relationship: US nativity was associated with a lower likelihood of FOBT use. These findings are consistent with evidence of differential associations by ethnic group between acculturation and preventive behaviors20. Allen et al. (2007) find overall improvement of preventive behaviors among Asian teens from one generation to the next and steady or worsening preventive behaviors among Latino teens20. These differential associations are also supported by contemporary theories of assimilation, which characterize heterogeneous paths of social mobility from one generation to the next28, leading to better or worse preventive behaviors.

The findings among Mexicans suggest US natives, relative to their Mexican origin counterparts, may be more likely to possess certain social norms or skills that encourage or facilitate cancer screening utilization. For example, because of their greater exposure to the US culture and medical system, US-born Mexicans may be more comfortable at discussing their health concerns with providers, be more skilled at navigating the health-care system or have more exposure to social circles that support positive screening behaviors when compared to their Mexican origin counterparts11,17,24,42–44. Older Mexican adults born in Mexico, relative to those born in the US, may also be more likely to mistrust the medical system, an interpretation consistent with a study of acculturation and breast cancer screening, which found that less acculturated Latina women were more likely to be suspicious of their medical care and screened less frequently45.

In contrast to the older Mexican adults in our study, mainland US nativity has a negative association with FOBT use among Puerto Ricans. This finding is consistent with recent work comparing willingness to participate in cancer screening among San Juan and New York City (NYC) Puerto Ricans, which found higher rates among San Juan Puerto Ricans46. Claudio et al.46 explain that San Juan Puerto Ricans, relative to NYC Puerto Ricans, possibly have greater exposure to health information and services because of the strong presence of the pharmaceutical and health-care industry in Puerto Rico, which is also a possibility in this study. Further, consistent with studies finding a positive association between provider patient language concordance and health care, Puerto-Rican health-care providers, compared to US health-care providers, may have been more effective at promoting FOBT use among their Puerto-Rican patients because of their shared culture and language47–49.

Finally, an important finding of this study is the divergent relationships between nativity and language of interview and FOBT use among Puerto Ricans. Because Puerto Rico is a US territory, mainland US nativity and English language preference may reflect different constructs than they do in other ethnic groups. While mainland US nativity may reflect exposure to imperfect social and health-care systems, English preference may reflect a process of acculturation that leads to a weakening of attitudes that foster feelings of fear, embarrassment or invulnerability discussed in previous studies of Latinos and Puerto Ricans in particular50,51, and adoption of more positive beliefs about cancer screening.

We should note some important limitations. First, estimated rates of CRC screening were based on self-report. However, a prior study found good agreement between self-report data and medical records for sigmoidoscopy and colonoscopy52. Second, we were not able to discern whether colonoscopies were performed for diagnostic or screening purposes, potentially overestimating CRC screening rates. Third, we were unable to examine physician recommendations for the test because NHIS does not collect these data. Physician recommendation data were collected in the 2000 and 2005 NHIS, but only for respondents who were never screened or who did not screen within the recommended timeframe.

US nativity and interview language were the only acculturation proxies available in all 3 years of NHIS. Although alone these measures may not capture the complexity of the acculturation process, US nativity offers an approximation of exposure to the dominant culture, while language measures have been shown to explain most of the variance in acculturation scales53. Further, both measures constitute a systematic approach to measuring acculturation12–19,31,39.

CONCLUSION

The results underscore the importance of targeting less acculturated individuals to promote CRC screening utilization in ethnically diverse settings. Clinicians, however, need to recognize the complexity of acculturation and treat common indicators, such as nativity and language as independent dimensions among their Latino patients.

References

  1. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008; 582: 71–96.

    PubMed  Article  Google Scholar 

  2. Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008; 1345: 1570–95.

    PubMed  Article  CAS  Google Scholar 

  3. Phillips KA, Liang SY, Ladabaum U, et al. Trends in colonoscopy for colorectal cancer screening. Med Care. 2007; 452: 160–7.

    PubMed  Article  Google Scholar 

  4. Ananthakrishnan AN, Schellhase KG, Sparapani RA, Laud PW, Neuner JM. Disparities in colon cancer screening in the Medicare population. Arch Intern Med. 2007; 1673: 258–64.

    PubMed  Article  Google Scholar 

  5. Shih YC, Zhao L, Elting LS. Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly? Health Aff (Millwood). 2006; 254: 1153–62.

    Article  Google Scholar 

  6. Liang SY, Phillips KA, Nagamine M, Ladabaum U, Haas JS. Rates and predictors of colorectal cancer screening. Prev Chronic Dis. 2006; 34: A117.

    PubMed  Google Scholar 

  7. Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer. 2003; 976: 1528–40.

    PubMed  Article  Google Scholar 

  8. Goel MS, Wee CC, McCarthy EP, Davis RB, Ngo-Metzger Q, Phillips RS. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med. 2003; 1812: 1028–35.

    PubMed  Article  Google Scholar 

  9. Gany FM, Herrera AP, Avallone M, Changrani J. Attitudes, knowledge, and health-seeking behaviors of five immigrant minority communities in the prevention and screening of cancer: a focus group approach. Ethn Health. 2006; 111: 19–39.

    PubMed  Article  Google Scholar 

  10. Johnson CE, Mues KE, Mayne SL, Kiblawi AN. Cervical cancer screening among immigrants and ethnic minorities: a systematic review using the Health Belief Model. J Low Genit Tract Dis. 2008; 123: 232–41.

    PubMed  Article  Google Scholar 

  11. Fernandez ME, Wippold R, Torres-Vigil I, Byrd T, Freeberg D, Bains Y, Guajardo J, Coughlin SS, Vernon SW. Colorectal cancer screening among Latinos from U.S. cities along the Texas-Mexico border. Cancer Causes Control. 2008; 192: 195–206. Epub 2007 Nov 24.

    PubMed  Article  Google Scholar 

  12. Shah M, Zhu K, Potter J. Hispanic acculturation and utilization of colorectal cancer screening in the United States. Cancer Detect Prev. 2006; 303: 306–12.

    PubMed  Article  Google Scholar 

  13. Yepes-Rios M, Reimann JO, Talavera AC, Ruiz de Esparza A, Talavera GA. Colorectal cancer screening among Mexican Americans at a community clinic. Am J Prev Med. 2006; 303: 204–10.

    PubMed  Article  Google Scholar 

  14. Tang TS, Solomon LJ, McCracken LM. Barriers to fecal occult blood testing and sigmoidoscopy among older Chinese-American women. Cancer Pract. 2001; 96: 277–82.

    PubMed  Article  CAS  Google Scholar 

  15. Teng EJ, Friedman LC, Green CE. Determinants of colorectal cancer screening behavior among Chinese Americans. Psychooncology. 2006; 155: 374–81.

    PubMed  Article  Google Scholar 

  16. Yip MP, Tu SP, Chun A, Yasui Y, Taylor VM. Participation in colorectal cancer screening among Chinese Americans. Asian Pac J Cancer Prev. 2006; 74: 645–50.

    PubMed  Google Scholar 

  17. Honda K. Factors associated with colorectal cancer screening among the US urban Japanese population. Am J Public Health. 2004; 945: 815–22.

    PubMed  Article  Google Scholar 

  18. Maxwell AE, Bastani R, Warda US. Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States. Am J Prev Med. 2000; 181: 62–8.

    PubMed  Article  CAS  Google Scholar 

  19. Ponce NA, Huh S, Bastani R. Do HMO market level factors lead to racial/ethnic disparities in colorectal cancer screening? A comparison between high-risk Asian and Pacific Islander Americans and high-risk whites. Med Care. 2005; 4311: 1101–8.

    PubMed  Article  Google Scholar 

  20. Allen ML, Elliott MN, Morales LS, Diamant AL, Hambarsoomian K, Schuster MA. Adolescent participation in preventive health behaviors, physical activity, and nutrition: differences across immigrant generations for Asians and Latinos compared with Whites. Am J Public Health. 2007; 972: 337–43.

    PubMed  Article  Google Scholar 

  21. Zsembik BA, Fennell D. Ethnic variation in health and the determinants of health amond Latinos. Soc Sci Med. 2005; 61: 53–63.

    PubMed  Article  Google Scholar 

  22. Zambrana RE, Breen N, Fox SA, Gutierrez-Mohamed ML. Use of cancer screening practices by Hispanic women: analyses by subgroup. Prev Med. 1999; 296 Pt 1: 466–77.

    PubMed  Article  CAS  Google Scholar 

  23. O’Malley AS, Kerner J, Johnson AE, Mandelblatt J. Acculturation and breast cancer screening among Hispanic women in New York City. Am J Public Health. 1999; 892: 219–27.

    PubMed  Article  Google Scholar 

  24. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventive services by Hispanics: findings from HHANES 1982-84. Am J Public Health. 1990; 80Suppl: 11–9.

    PubMed  Article  Google Scholar 

  25. Abraído-Lanza AF, Chao MT, Gates CY. Acculturation and cancer screening among Latinas: results from the National Health Interview Survey. Ann Behav Med. 2005; 291: 22–8.

    PubMed  Article  Google Scholar 

  26. Gorin SS, Heck JE. Cancer screening among Latino subgroups in the United States. Prev Med. 2005; 405: 515–26.

    PubMed  Article  Google Scholar 

  27. Suarez L. Pap smear and mammogram screening in Mexican-American women: the effects of acculturation. Am J Public Health. 1994; 845: 742–6.

    PubMed  Article  CAS  Google Scholar 

  28. Portes A, Zhou M. The New Second Generation: Segmented Assimilation and Its Variants. The Annals of the American Academy. 1993;530(November 1990).

  29. Massey DS. Latinos, poverty, and the underclass: a new agenda for research. Hisp J Behav Sci. 1993; 154: 449–75.

    Article  Google Scholar 

  30. Berry JW. Acculturation and adaptation in a new society. International Migration. 30:69–85.

  31. Lara M, Gamboa C, Kahramanian MI, Morales LS, Bautista DE. Acculturation and Latino Health in the Unites States: A Review of the Literature and its Sociopolitical Context. Annu Rev Public Health. 2005; 26: 367–97.

    PubMed  Article  Google Scholar 

  32. Marin G, Sabogal F, Marin BV, Otero-Sabogal R, Perez-Stable EJ. Development of a Short Acculturation Scale for Hispanics. Hisp J Behav Sci. 1987; 92: 183–205.

    Article  Google Scholar 

  33. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995; 361: 1–10.

    PubMed  Article  CAS  Google Scholar 

  34. Ramirez, R. We the People: Hispanics in the United States. U.S. Census Bureau, Census 2000 Special Report, CENSR-18, December 2004.

  35. Smith RA, von Eschenbach AC, Wender R, et al. American Cancer Society guidelines for the early detection of cancer: update of early detection guidelines for prostate, colorectal, and endometrial cancers. Also: update 2001-testing for early lung cancer detection. CA Cancer J Clin. 2001; 511: 38–75. quiz 77-80.

    PubMed  Article  CAS  Google Scholar 

  36. Bean FD, Swicegood G. Generation, female education and Mexican-American fertility. Soc Sci Q. 1982; 631: 131–44.

    PubMed  CAS  Google Scholar 

  37. Giles H, Johnson P. Ethnolinguistic identity theory: A social psychological approach to language maintenance. Int J Soc Language. 1987; 68: 69–100.

    Article  Google Scholar 

  38. Tong Y, Hong Y, Lee S, et al. Language use as a carrier of social identity. Int J Intercultural Relations. 1999; 23: 281–96.

    Article  Google Scholar 

  39. Afable-Munsuz A, Brindis CD. Acculturation and the sexual and reproductive health of Latino youth in the United States: a literature review. Perspect Sex Reprod Health. 2006; 384: 208–19.

    PubMed  Article  Google Scholar 

  40. Finch BK, Boardman JD, Bohdam K, Vega WA. Contextual effects of acculturation on perinatal substance exposure among immigrant and native-born latinas. Soc Sci Q. 2000; 811: 420–38.

    Google Scholar 

  41. SAS. Version 9.1.3. Cary, NC: SAS Institute; 2002-2003.

  42. Ponce NA, Hays RD, Cunningham WE. Linguistic disparities in health care access and health status among older adults. J Gen Intern Med. 2006; 217: 786–91.

    PubMed  Article  Google Scholar 

  43. Quesada GM. Language and communication barriers for health delivery to a minority group. Soc Sci Med. 1976; 106: 323–7.

    PubMed  Article  CAS  Google Scholar 

  44. Diaz JA, Roberts MB, Goldman RE, Weitzen S, Eaton CB. Effect of language on colorectal cancer screening among Latinos and non-Latinos. Cancer Epidemiol Biomarkers Prev. 2008; 178: 2169–73.

    PubMed  Article  Google Scholar 

  45. Thompson HS, Valdimarsdottir HB, Winkel G, Jandorf L, Redd W. The group-based medical mistrust scale: psychometric properties and association with breast cancer screening. Prev Med. 2004; 382: 209–18.

    PubMed  Article  Google Scholar 

  46. Claudio C, Katz RV, Green BL, Kressin NR, Wang MQ, Russell SL. Cancer screening participation: comparative willingness of San Juan Puerto Ricans versus New York City Puerto Ricans. J Natl Med Assoc. 2007; 995: 542–9.

    PubMed  Google Scholar 

  47. Eamranond PP, Davis RB, Phillips RS, Wee CC. Patient-Physician language concordance and lifestyle counseling among Spanish-speaking patients. J Immigr Minor Health. 2009;19.

  48. Ngo-Metzger Q, Sorkin DH, Phillips RS. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007; 22Suppl 2: 324–30.

    PubMed  Article  Google Scholar 

  49. Wilson E, Chen AH, Grumbach K, Wang F, Fernandez A. Effects of limited English proficiency and physician language on healthcare comprehension. J Gen Intern Med. 2005; 20: 800–6.

    PubMed  Article  Google Scholar 

  50. Goldman R. Barriers to intimate cancer screening testing among Dominican and Puerto Rican men. http://www.brown.edu/Research/ICAP/Modules/Modl ensHealthy/TeachingMats/Handout3HisponicMales.doc. Accessed Jan. 2009.

  51. Perez-Stable EJ, Otero-Sabogal R, Sabogal F, et al. Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Arch Intern Med. 1994; 154: 1073–81.

    PubMed  Article  CAS  Google Scholar 

  52. Hall HI, Van Den Eeden SK, Tolsma DD, et al. Testing for prostate and colorectal cancer: comparison of self-report and medical record audit. Prev Med. 2004; 391: 27–35.

    PubMed  Article  Google Scholar 

  53. Marin G. Issues in the measurement of acculturation among HispanicsIn: Geisenger KF, ed. Psychological Testing of Hispanics. Washington, DC: American Psychological Association; 1992: 23–51.

    Google Scholar 

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Acknowledgement

Authors wish to thank Kathryn A. Phillips, PhD, for her comments on an earlier draft of this paper. An earlier version of this paper was presented at the 60th Annual Scientific Meeting of The Gerontological Society of America on November 19, 2007. The research for this paper was supported by the National Cancer Institute (NCI) Diversity Supplement to R01 CA101849 awarded to Dr. Afable-Munsuz. Dr. Ponce’s time was supported by NCI/NIH K07 100097.

Conflict of Interest

None disclosed.

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Authors and Affiliations

  1. Division of General Internal Medicine, Department of Medicine, University of California, 3333 California Street, Box 0856, San Francisco, CA, 94143, USA

    Aimee Afable-Munsuz PhD

  2. Deparment of Clinical Pharmacy, University of California, San Francisco, CA, USA

    Su-Ying Liang PhD

  3. Department of Health Services, University of California, Los Angeles, CA, USA

    Ninez A. Ponce MPP, PhD

  4. Women’s Health Clinical Research Center, University of California, San Francisco, CA, USA

    Judith M. E. Walsh MD, MPH

Authors
  1. Aimee Afable-Munsuz PhD
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  2. Su-Ying Liang PhD
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  3. Ninez A. Ponce MPP, PhD
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  4. Judith M. E. Walsh MD, MPH
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Corresponding author

Correspondence to Aimee Afable-Munsuz PhD.

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Afable-Munsuz, A., Liang, SY., Ponce, N.A. et al. Acculturation and Colorectal Cancer Screening Among Older Latino Adults: Differential Associations by National Origin. J GEN INTERN MED 24, 963–970 (2009). https://doi.org/10.1007/s11606-009-1022-9

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  • DOI: https://doi.org/10.1007/s11606-009-1022-9

KEY WORDS

  • colorectal cancer screening
  • Latinos
  • aculturation