Preventive Care Service Usage Among Chinese

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Preventive Care Service Usage Among Chinese
Journals of Gerontology: MEDICAL SCIENCES
Cite journal as: J Gerontol A Biol Sci Med Sci. 2014 November;69A(S2):S7–S14
doi:10.1093/gerona/glu143
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: [email protected]
Preventive Care Service Usage Among Chinese Older
Adults in the Greater Chicago Area
Melissa A. Simon,1 Yu Li,1 and XinQi Dong2
Northwestern University Medical Center, Chicago, Illinois.
2
Rush University Medical Center, Chicago, Illinois.
1
Address correspondence to Melissa A. Simon, MD, MPH, Department of Obstetrics and Gynecology, Northwestern University, Feinberg
School of Medicine, 633 North St Clair, Suite 1800, Chicago, IL 60611. Email: [email protected]
Background. Preventive care is important for reducing morbidity and mortality among the elderly, but racial/ethnic
disparities exist in use of preventive care services. We aimed to develop a better understanding of preventive care service
utilization among Chinese older adults in the Greater Chicago area.
Methods. We used data collected from the Population Study of Chinese Elderly in Chicago study, a population-based
survey of 3,159 community-dwelling Chinese older adults in the Greater Chicago area. Preventive care services assessed
include use of flu, pneumonia, and hepatitis B vaccines as well as colon, breast, cervical and prostate cancer screening.
We also examined sociodemographic, health and quality of life correlates for preventive care service use.
Results. We found that although Chinese older adults had lower utilization rates for the pneumonia vaccine and cancer screening, their utilization of the flu shot was consistent with national utilization rates. No sociodemographic, selfreported health, or quality of life characteristics were associated with all nine of the preventive care services.
Conclusion. Use of preventive care services except flu vaccination was low among Chinese older adults in the Greater
Chicago area. However, future longitudinal studies may be necessary to further elucidate preventive care service utilization patterns among Chinese older adults.
Key Words: Screening—Cancer—Flu—Pneumonia—Hepatitis B.
Received June 11, 2014; Accepted July 17, 2014
Decision Editor: Stephen Kritchevsky, PhD
P
reventive care such as immunization and cancer
screenings has been increasingly recognized for its
importance in reducing morbidity and mortality among
older adults in the United States. Elderly populations are
vulnerable to influenza-related complications and invasive
pneumococcal infection. In 2010, influenza and pneumonia
caused approximately 43,000 deaths among people aged
65 and older (1). Because influenza and pneumococcal
vaccination remain the most effective ways to prevent and
control influenza and pneumonia, annual flu shots and onetime pneumonia shots have been recommended nationwide.
With cancer ranked as the second leading cause of death for
people aged 65 and older (1), early detection is important.
Cancer screening tests have proven efficacy in detecting
colon cancer, breast cancer, and cervical cancer at an early
stage when chances of treatment and survival are highest.
To improve public health and promote utilization of preventive care services, Healthy People 2020 (2) established
long-term objectives for immunization and cancer screening, with a target increase from 66.6% to 90% for flu vaccination and increase from 60.1% to 90% for pneumonia
vaccination among people aged 65 and older. Healthy
People 2020 (2) cancer screening goals include participation
rates of 70.5% for colon cancer screening, 81.1% for breast
cancer screening, 93% for cervical cancer screening, and
15.9% for discussion with health providers about the prostate-specific antigen (PSA) test for prostate cancer.
Although preventive care utilization has greatly increased
over the years, strong evidence indicates that preventive care utilization remains relatively low among ethnic
minority groups, including Asian Americans. For example,
among older adults aged 65 and older, Asian Americans had
significant lower utilization of screening mammography
than whites (3). Common barriers for use preventive care
services among ethnic minority groups include lower socioeconomic status, lack of insurance, poor access to health
service providers, and lack of physician recommendation
(4,5). In addition, barriers more unique to Asian Americans
relate to traditional beliefs and cultural heritage—such as
Eastern approaches to medicine and using health care services only when symptomatic (6,7).
Although the Chinese community is the largest Asian
American subgroup population, systematic studies focusing on Chinese Americans are still scarce. To date, despite
the heterogeneity of Asian American subgroup with respect
to culture, immigration history, and socioeconomic status,
S7
S8
SIMON ET AL.
research studies generally pool Asian Americans together
when comparing different racial groups. Some prior studies of preventive service utilization have focused on different Asian American subgroups, such as Chinese, Japanese,
Korean, and Vietnam Americans—but these studies tend to
focus on only one specific preventive care service.
To bridge these knowledge gaps, the objectives of this
study are to: (i) study the utilization of immunization and
cancer screening services among community dwelling
Chinese older adults in the Greater Chicago area; and (ii)
assess the extent to which sociodemographic characteristics
and self-reported health and quality of life factors are associated with preventive care service use.
Methods
Population and Settings
The Population Study of Chinese Elderly in Chicago
(PINE) is a community-engaged, population-based epidemiological study of U.S. Chinese older adults aged 60 and older
(60–105) in the Greater Chicago area. In brief, the purpose
of the PINE study is to collect community-level data of U.S.
Chinese older adults to examine the key cultural determinants
of health and well-being. The project was initiated by a synergistic community-academic collaboration among the Rush
Institute for Healthy Aging, Northwestern University Medical
Center, and many community-based social services agencies
and organizations throughout the Greater Chicago area (8).
To ensure study relevance and enhance community participation, the PINE study implemented extensive culturally
and linguistically appropriate community recruitment strategies guided by community-based participatory research
(CBPR) approach (9). With over 20 social services agencies, community centers, health advocacy agencies, faithbased organizations, senior apartments, and social clubs
serving as the basis of study recruitment sites, eligible participants were approached through routine social services
and outreach efforts serving Chinese American families in
the Chicago city and suburban areas (9). Out of 3,542 eligible older adults approached, 3,159 agreed to participate in
the study, yielding a response rate of 91.9%.
Based on available data drawn from U.S. Census 2010
and a random block census project conducted in Chicago’s
Chinese community, the PINE study is representative of the
Chinese aging population in the Greater Chicago area with
respective to key demographic attributes, including age,
sex, income, education, number of children, and country
of origin (10). The study was approved by the Institutional
Review Board of the Rush University Medical Center.
Measurements
Sociodemographics.—Sociodemographic profile characteristics included age (in years), education (in years),
personal income on a 10-point scale (1 = $0–$4,999; 2
= $5,000–$9,999; 3 = $10,000–$14,999; 4 = $15,000–
$19,999; 5 = $20,000–$24,999; 6 = $25,000–$29,999; 7
= $30,000–$34,999; 8 = $35,000–$39,999; 9 = $40,000–
$44,999; 10 = ≥$45,000), marital status (married/not
married), number of alive children, living arrangement
(in a scale from 0 to 10), language preference (English/
Cantonese/Mandarin/Taishanese), country of origin (China/
Other), years in the United States (in years) and years in the
community (in years).
Overall health status, quality of life and health changes
over the last year.—Overall health status was measured by
“in general, how would you rate your health” on a four point
scale (1 = poor, 2 = fair, 3 = good, 4 = very good). Quality
of life was assessed by asking “in general, how would you
rate your quality of life” on a four-point scale ranging from
1 = poor to 4 = very good. Health changes over the last year
was measured by “compared to one year ago, how would
you rate your now” on a three-point scale (1 = worsened;
2 = same; 3 = improved).
Utilization of preventive care services.—Preventive
care services assessed include use of flu, pneumonia, and
hepatitis B vaccines as well as colon, breast, cervical, and
prostate cancer screening. Specifically, participants were
asked whether they had received flu shot within the past
12 months, pneumonia shot within the past 5 years, and
the series of three hepatitis B shots in the past. Participants
were asked whether they had ever received blood stool test
or colonoscopy to assess colon cancer screening, mammogram or clinical breast exam to assess breast cancer screening, pap test to assess cervical cancer screening, and PSA
test to assess prostate cancer screening (Table 1).
Data Analysis
Descriptive statistics were used to summarize sociodemographic, health-related and quality of life information of
Chinese older adults. We used Wilcoxon two-sample test,
folded-F statistics and chi-square statistics to compare the
sociodemographic characteristics of those who have used
preventive care services and those who have not. Pearson
correlation coefficients were used to determine whether
there is any significant association between sociodemographic, health-related and quality of life independent
variables with utilization of preventive care services. All
statistical analyses were conducted using SAS, Version 9.2
(SAS Institute Inc., Cary, NC).
Results
Sample Characteristics
The PINE study surveyed 3,159 Chinese older adults,
their age ranged from 60 to 105 years. Approximately 60%
of the participants were female. Around 80% of the participants received less than 12 years of education and less
PREVENTIVE CARE SERVICE USE AMONG U.S. CHINESE OLDER ADULTS
S9
Table 1. Usage of Preventive Care Among Study Population
Immunization
Flu shot in the past 12 mo
Pneumonia shot in the past 5 y
Hepatitis B shot
Colorectal cancer screening
Blood stool test
Within the past year
Within the past 2 y (1 y but <2 y ago)
Within the past 3 y (2 y but <3 y ago)
Within the past 5 y (3 y but <5 y ago)
≥5 y ago
Colonoscopy exam
Within the past year
Within the past 2 y (1 y but <2 y ago)
Within the past 3 y (2 y but <3 y ago)
Within the past 5 y (3 y but <5 y ago)
Within the past 10 y (5 y but <10 y ago)
≥10 y ago
Breast cancer screening (women only)
Mammogram
Within the past 2 y
More than the past 2 y
Clinical breast exam
Within the past 2 y
More than the past 2 y
Cervical cancer screening (women only)
Pap test
Within the past 2 y
More than the past 2 y
Prostate cancer screening (men only)
PSA test
Within the past year
Within the past 2 y (1 y but <2 y ago)
Within the past 3 y (2 y but <3 y ago)
Within the past 5 y (3 y but <5 y ago)
≥5 y ago
Yes: Numbers (%)
No: Numbers (%)
2,076 (65.7)
782 (25.3)
581 (18.8)
1,082 (34.3)
2,309 (74.7)
2,516 (81.2)
765 (24.3)
401 (52.6)
95 (12.5)
84 (11.0)
68 (8.9)
114 (15.0)
896 (28.5)
238 (27.0)
129 (14.6)
130 (14.7)
169 (19.1)
106 (12.0)
111 (12.6)
2,386 (75.7)
1,077 (59.6)
635 (59.2)
437 (40.8)
847 (46.8)
532 (63.2)
310 (36.8)
729 (40.4)
736 (40.7)
337 (45.9)
397 (54.1)
1,071 (59.3)
336 (26.5)
164 (49.1)
55 (16.5)
35 (10.5)
30 (9.0)
50 (15.0)
930 (73.5)
2,253 (71.6)
964 (53.2)
Note: PSA = prostate-specific antigen.
than 5% had an annual income more than $15,000. Nearly
one third of Chinese older adults were separated, divorced,
or widowed. More than 20% of the elderly lived alone and
only 4% of the participants did not have children. About
93% of the participants reported China as their country
of origin and more than three quarters preferred speaking
Cantonese or Taishanese.
Immunization and Cancer Screening Utilization
Overall, 2,076 (65.7%) participants reported they had
received the flu shot within the past 12 months. In contrast,
only a quarter of participants reported they had received the
pneumonia shot in the past 5 years and less than 20% of
participants had completed the series of Hepatitis B shots.
As for cancer screening coverage, only 12.9% of participants had a blood stool test within the past year and only
28.5% of participants reported ever having had a colonoscopy in their life. The breast and cervical cancer screening
were also low; 635 (35.2%) of female participants reported
mammogram use, 532 (29.5%) had a clinical breast exam,
and 337 (18.7%) had a pap test within the past 2 years. Only
336 (26.5%) of men ever had a PSA test (Table 1).
Chinese Older adults who have received a flu shot or
pneumonia shot were significantly older than those who
have never used such services (flu shot: 74.5 vs 69.7, p <
.01; pneumonia shot: 73.9 vs 72.4, p < .01) and they lived
with fewer people (flu shot: 1.6 vs 2.4, p < .01; pneumonia
shot: 1.6 vs 2.0, p < .01). Compared with those who have
not received the Hepatitis B vaccine series, older adults who
had completed Hepatitis B immunization were younger
(71.4 vs 73.1, p < .01), had fewer children (2.5 vs 3.0, p <
.05), resided in the United States for fewer years (18.4 vs
20.4, p < .01) and reported a higher quality of life (2.6 vs
2.5, p < .01) (Table 2).
Older adults who have never had colon cancer screening
were significantly older (blood stool test: 73.3 vs 72.6.7, p
< .01; Colonoscopy: 73.3 vs 72.6, p < .01) and have resided
in the United States for more years (blood stool test: 22.5 vs
S10
<.01
.76
.34
<.01
.08
<.05
<.001
<.001
.25
<.01
.43
Note: QOL = quality of life.
No (N = 2,516)
73.1 (8.4)
8.3 (4.9)
1.9 (1.1)
0.7 (0.5)
1.9 (1.9)
3.0 (1.5)
20.4 (13.0)
12.5 (11.1)
2.2 (0.8)
2.5 (0.7)
2.6 (0.8)
71.4 (7.6)
10.7 (5.0)
2.1 (1.5)
0.8 (0.4)
1.9 (1.8)
2.5 (1.4)
18.4 (13.9)
10.5 (10.6)
2.3 (0.8)
2.6 (0.7)
2.6 (0.8)
<.001
.31
<.001
.86
<.001
.19
<.01
.34
.70
.17
<.05
72.4 (8.5)
8.2 (4.9)
1.9 (1.1)
0.7 (0.5)
2.0 (1.9)
2.9 (1.5)
19.7 (13.1)
12.0 (10.9)
2.3 (0.8)
2.5 (0.7)
2.6 (0.7)
Yes (N = 581)
p Value
No (N = 2,309)
73.9 (7.4)
10.4 (5.1)
2.1 (1.4)
0.7 (0.5)
1.6 (1.7)
2.7 (1.5)
21.2 (13.5)
12.7 (11.6)
2.2 (0.8)
2.6 (0.7)
2.6 (0.8)
Yes (N = 782)
p Value
<.01
<.001
<.001
<.001
<.001
<.001
<.001
<.001
.12
.26
<.05
69.7 (7.6)
8.6 (4.8)
1.8 (1.1)
0.8 (0.4)
2.4 (2.1)
2.7 (1.4)
16.6 (12.5)
10.2 (10.0)
2.4 (0.8)
2.5 (0.7)
2.6 (0.7)
No (N = 1,082)
Yes (N = 2,076)
19.2, p < .01; Colonoscopy: 22.8 vs 18.9, p < .01) than those
who have been screened before for colon cancer (Table 3).
Compared with women who have never been screened
for breast or cervical cancer, women who have used such
services were significantly younger (mammogram: 71.5 vs
74.6, p < .01; clinical breast exam: 71.1 vs 74.3, p < .01; pap
test: 70.4 vs 74.4, p < .01) and had a higher annual income
(mammogram: 2.1 vs 1.8, p < .01; clinical breast exam: 2.1
vs 1.8, p < .01; pap test: 2.1 vs 1.9, p < .05) (Table 3).
Correlations between sociodemographic and healthrelated factors with cancer screening use is also presented
in Table 4. Age, income, number of children and years spent
in the United States were associated with immunization utilization, but the association directions for different immunization services were sometimes inconsistent. Years spent in
the United States and in community were positively associated with colon cancer screening. Positive associations
were also found among different preventive care services.
74.5 (8.2)
8.8 (5.2)
2.0 (1.1)
0.7 (0.5)
1.6 (1.7)
3.0 (1.6)
21.8 (13.2)
13.1 (11.4)
2.2 (0.8)
2.6 (0.7)
2.6 (0.8)
Age, mean ± SD
Education (y), mean ± SD
Income (USD), mean ± SD
Marital status, mean ± SD
Living arrangement, mean ± SD
Number of children, mean ± SD
Years in the United States, mean ± SD
Years in the community, mean ± SD
Health status, mean ± SD
QOL, mean ± SD
Health changes in the last year, mean ± SD
Pneumonia Shot, N = 3,091 (%)
Flu Shot, N = 3,158 (%)
Table 2. Characteristics of Study Population by Immunization
Hepatitis B Shot, N = 3,097 (%)
p Value
SIMON ET AL.
Discussion
The PINE study indicates that although utilization of
the flu vaccine was rather common, usage of other recommended preventive care services was generally low among
our sample of Chinese older adults in the Greater Chicago
area. Approximately two-thirds of our study participants
had received the flu shot within the last 12 months, which
is consistent with vaccination rates nationally and in the
state of Illinois for adults aged 65 and older (11). Although
25.3% of Chinese older adults surveyed reported receiving a pneumonia shot or pneumococcal vaccine within the
past 5 years, the pneumococcal vaccine coverage rate over
the lifetime for adults aged 65 and older was about 60%
nationally, according to the 2012 National Health Interview
Survey (12). Although this 60% national level reflected
ever having used the pneumococcal vaccine in their lifetime instead of during the past 5 years as was assessed in
our study, it is possible that Chinese older adults underused
immunization services against pneumococcal diseases and
this potential disparity warrants further investigation.
For colon cancer screening tests, including the blood stool
test and colonoscopy, our study participants reported an overall lower usage rates than the national level. Approximately
13% had a blood stool test within the last 12 months and
a quarter had a colonoscopy within the past 10 years. In
comparison, among adults aged from 50 to 64 years nationally, over 55% reported having had a blood stool test within
the past year, sigmoidoscopy in the past 5 years, or a colonoscopy in the past 10 years and this rate was even higher,
63.7%, among people aged 65 and older (13).
The reported hepatitis B immunization rate among
Chinese older adults in our sample was less than 20%,
which is alarming in light that Asian Americans, especially those born in foreign countries, are at high risk of
Hepatitis B virus (HBV) infection (14). With the strategy
of having children vaccinated for hepatitis B, HBV acute
72.6 (8.5)
8.7 (5.1)
1.9 (1.1)
0.7 (0.5)
1.9 (1.9)
2.8 (1.5)
19.2 (12.8)
11.8 (10.7)
2.3 (0.8)
2.5 (0.7)
2.6 (0.8)
2.0 (1.3)
0.7 (0.5)
1.8 (1.9)
3.0 (1.5)
22.5 (14.0)
13.3 (11.8)
2.2 (0.8)
2.5 (0.6)
2.6 (0.8)
No
(N = 2,386)
73.3 (7.8)
8.7 (4.9)
Note: QOL = quality of life.
Age, mean ± SD
Education (y),
mean ± SD
Income (USD),
mean ± SD
Marital status,
mean ± SD
Living arrangement,
mean ± SD
Number of children,
mean ± SD
Years in the United
States, mean ± SD
Years in the community,
mean ± SD
Health status,
mean ± SD
QOL, mean ± SD
Health changes in the
last year, mean ± SD
Yes
(N = 765)
Blood Stool Test,
N = 3,151 (%)
.10
.24
.07
<.01
<.001
.53
.43
.90
.61
<.01
.20
p Value
2.6 (0.7)
2.6 (0.8)
2.2 (0.8)
13.3 (12.2)
22.8 (13.9)
2.8 (1.5)
1.6 (1.7)
0.7 (0.5)
2.2 (1.5)
73.3 (7.7)
10.0 (5.2)
Yes
(N = 896)
2.5 (0.7)
2.6 (0.7)
2.3 (0.8)
11.7 (10.5)
18.9 (12.7)
2.9 (1.5)
2.0 (1.9)
0.7 (0.5)
1.9 (1.0)
72.6 (8.5)
8.2 (4.9)
No
(N = 2,253)
Colonoscopy Exam,
N = 3,149 (%)
Colon Cancer Screening
.14
<.05
.70
<.01
<.001
.47
<.001
.34
<.001
<.001
<.05
p Value
2.6 (0.7)
2.6 (0.8)
2.2 (0.8)
12.3 (11.2)
20.9 (13.2)
2.8 (1.5)
1.7 (1.8)
0.6 (0.5)
2.1 (1.3)
71.5 (7.7)
8.9 (5.1)
Yes
(N = 1,077)
2.5 (0.7)
2.6 (0.8)
2.2 (0.8)
12.5 (10.9)
19.6 (12.6)
3.2 (1.6)
1.9 (2.1)
0.5 (0.5)
1.8 (0.7)
74.6 (9.3)
6.4 (4.6)
No
(N = 729)
Mammogram,
N = 1,806 (%)
.95
.50
.09
.41
.08
<.05
1.0
<.01
<.01
<.001
<.01
p Value
2.6 (0.7)
2.6 (0.8)
2.2 (0.8)
12.0 (11.0)
20.4 (13.4)
2.8 (1.5)
1.8 (1.9)
0.6 (0.5)
2.1 (1.3)
71.1 (7.6)
9.1 (5.1)
Yes
(N = 847)
2.5 (0.6)
2.6 (0.8)
2.2 (0.8)
12.7 (11.1)
20.3 (12.5)
3.2 (1.6)
1.7 (2.0)
0.6 (0.5)
1.8 (0.8)
74.3 (9.1)
6.8 (4.7)
No
(N = 964)
.31
.91
.50
.14
.81
.06
<.05
<.05
<.001
<.001
<.05
p Value
Clinical Breast
Exam, N = 1,811 (%)
Breast Cancer Screening
Table 3. Characteristics of Study Population by Cancer Screening
2.7 (0.7)
2.6 (0.8)
2.2 (0.8)
11.8 (11.0)
20.2 (13.4)
2.6 (1.4)
1.8 (1.9)
0.6 (0.5)
2.1 (1.3)
70.4 (7.4)
9.5 (5.0)
Yes
(N = 736)
2.5 (0.7)
2.6 (0.8)
2.2 (0.8)
12.8 (11.1)
20.5 (12.6)
3.2 (1.5)
1.7 (1.9)
0.5 (0.5)
1.9 (0.8)
74.4 (8.9)
6.8 (4.8)
No
(N = 1,071)
Pap Test,
N = 1,807 (%)
.63
.90
.46
<.05
.37
.09
<.05
<.001
<.05
<.001
.18
p Value
Cervical Cancer Screening
PREVENTIVE CARE SERVICE USE AMONG U.S. CHINESE OLDER ADULTS
S11
Notes: BST = blood stool test; CBE = clinical breast exam; Children = number of children; CLN = colonoscopy; Edu = education; Living = living arrangement; FLU = flu shot; HC = health changes over last year;
HEP = hepatitis B shot; LP-CT = language preference of Cantonese and Taishanese; MAM = mammogram; MS = marital status; OHS = overall health status; Origin = country of origin; PAP = pap test; PSA= prostatespecific antigen test; PNU = pneumonia shot; QOL = quality of life; Yrs in com = years in the community; Yrs in U.S. = years in the United States.
*p < .05, **p < .01, ***p < .001.
0.27***
0.08***
−0.08***
0.03
0.04*
−0.18***
−0.19***
−0.23***
0.14***
0.06***
−0.01
−0.00
−0.00
−0.00
N/A
N/A
N/A
N/A
0.02
0.08*** −0.12*** −0.20*** 0.09***
0.19*** 0.08*** 0.00
−0.09*** −0.05**
0.19*** 0.06**
0.05**
0.01
−0.12***
−0.00
0.03
0.00
−0.01
0.05**
0.16*** 0.11*** −0.02
0.08*** −0.03
0.24*** 0.12*** 0.07** −0.03
−0.13***
0.23*** 0.13*** 0.06*
0.03
−0.13***
0.27*** 0.11*** 0.10*** 0.03
−0.18***
0.18*** 0.10*** −0.01
−0.15*** −0.05
0.19***
0.05**
−0.06**
0.10***
0.14***
0.04
0.00
−0.01
0.13***
0.12***
0.02
−0.07***
0.06**
0.07***
−0.01
−0.03
−0.04
0.08**
−0.03
−0.06***
−0.07***
−0.03
−0.12***
−0.08**
−0.05*
−0.08***
−0.08**
0.00
−0.16***
−0.17***
0.03
−0.14***
−0.16***
−0.15***
−0.20***
−0.20***
−0.09*** 0.03
−0.04*
−0.01
0.09*** −0.03
0.04*
0.07**** −0.00
−0.02
−0.00
0.00
−0.07*** 0.04*
−0.04*
−0.01
0.09*** 0.02
0.00
0.08*** 0.02
0.00
0.12*** −0.03
−0.06*
0.08** −0.00
1
0.30***
0.13***
0.10***
0.13***
0.10***
0.06***
0.04***
0.15***
1
0.45***
0.13***
0.15***
0.20***
0.15***
0.15***
0.20***
1
0.07***
0.12***
0.21***
0.16***
0.19***
0.18***
1
0.21***
0.15***
0.12***
0.11***
0.16***
1
0.22***
0.16***
0.22***
0.23***
SIMON ET AL.
FLU
PNU
HEP
BST
CLN
MAM
CBE
PAP
PSA
HC
QOL
OHS
LP-CT
Origin
Yrs in U.S. Yrs in Com
Children
Living
MS
Income
Edu
Sex
Age
Table 4. Correlations Between Immunization, Cancer Screening, and Sociodemographic Characteristics
FLU
PNU
HEP
BST
CLN
S12
infection rates have dropped by 96% among children and
adults in the United States (15). However, there are still
approximately 1.4–2 million chronic HBV carriers in the
United States (16). A large body of literature has reported
that Asian Americans have disproportionally high chronic
HBV infection rates; the majority of the HBV infections
were acquired before they immigrated to the Unites States
(17,18).
With over 90% of our study participants reported China
as their country of origin, a country where HBV infection is
highly endemic, Chinese older adults in the Greater Chicago
area may be at high risk of HBV infection. Although the
reported Hepatitis B vaccination rate of around 18% among
study participants was slightly higher than the vaccine coverage rate of 15.1% nationally for adults over 60 years with
diabetes (another group with increased risk of HBV infection) (12), it is important to increase Hepatitis B vaccination
coverage among U.S. Chinese older adults.
In addition, our study findings call for more primary care
physicians to carry out HBV screening tests—a suggestion based on several factors. First, our 18% self-reported
Hepatitis B vaccination rate may be an overestimate of
Chinese older adults’ capacity against HBV infection.
A population-based study in California from 2001 to 2006
found that among the 12% of Asian Americans who reported
prior Hepatitis B vaccination, approximately 5% carried
HBV and 20% failed to develop protective antibodies (19).
Therefore, we need to be cautious when using self-reported
vaccination data to estimate Chinese older adults’ capacity against HBV infection. Additionally, because 50%–60%
of chronically infected HBV carriers do not experience any
symptoms (20), it is all the more important for Chinese
older adults to get HBV infection screening tests so that
they can be better informed of their health status.
Although no single sociodemographic characteristic or
self-reported health and life quality factor was found to be
significantly associated with all nine preventive care services assessed in our study, each variable was associated
with at least one preventive care service use. Some characteristics were associated with more preventive care use than
others. For example, number of years spent in the United
States was positively significantly associated with having
received the flu shot, pneumonia shot, blood stool test, and
colonoscopy while gender was only positively associated
with flu vaccine utilization (ie, higher flu vaccine utilization
among the female). However, it is worth noting that a characteristic can be associated with preventive care services in
different directions. For example, Chinese older adults who
reported better overall health status had a lower flu shot and
colonoscopy screening rate, but higher hepatitis B shot coverage than adults who reported poorer overall health status.
These mixed results need to be further studied.
Of all the associations revealed in this study, the association between living arrangement and use of flu shot and
pneumonia shot warrants further research. These significant
PREVENTIVE CARE SERVICE USE AMONG U.S. CHINESE OLDER ADULTS
negative associations indicate that Chinese older adults who
lived alone or with one other person were more likely to
receive the flu shot and pneumonia shot, whereas Chinese
older adults who lived with more people were less likely
to have received these vaccinations. Such an observation is
partially consistent with prior study findings. In a study of
13,038 community-dwelling older adults 65 years and older
in the United States, there were no significant differences in
flu vaccination rates between older adults living alone and
older adults living with more people (eg, such as living with
both the spouse and adult offspring). However, when older
adults lived with the spouse only, they were more likely
to receive preventive care services than those living with
more people or living alone (21). Possible explanations for
this trend among Chinese older adults may pertain to the
spouse’s central role in use of preventive care services (22),
whereas offspring (especially those who are employed) may
have more difficulty in assisting older adults with preventive care (21). On the other hand, when Chinese older adults
living with more people especially with their children, they
could become occupied by additional household chores
such as taking care of grandchildren, which may restrict
their ability to pursue preventive health services. It is also
possible that compared with older adults living with more
people, Chinese older adults living alone or with fewer
people may have a higher level of self-reliance and may be
more proactive in managing their own care and more willing to get vaccinations to stay healthy. Further studies are
necessary to better understand how living arrangement is
related to preventive care service utilization patterns among
Chinese older adults.
Our study also showed significant positive associations among preventive care services. In other words, U.S.
Chinese older adults who had used one preventive care service were more likely to use other preventive care services.
This pattern may be related with Chinese older adults’
knowledge of and attitudes toward preventive care services.
More than 90% of our study participants are immigrants
from China. Therefore, in consideration that some important preventive care services were not provided in China’s
national programs (23,24), it is possible that a majority of
our study participants were lacking in knowledge of preventive care use and benefits. In addition, their acceptance of
preventive care might be dampened by various concerns,
ranging from vaccination side-effects to acculturation issues
as identified in prior studies (4–7). Therefore, it is possible
that Chinese older adults with more knowledge of preventive care in the United States and a higher acceptance level
of these services were more likely to use multiple preventive care services, whereas those with less knowledge and
a lower acceptance level tended not to have used preventive care services. Further research is necessary to explore
whether culturally appropriated education and outreach can
improve Chinese older adults’ knowledge and use of preventive care services.
S13
Our study is subject to a few limitations. First, because
provision of preventive care services, costs, and payment
resources may vary by region, generalizing the findings
from this study to Chinese populations in other U.S. regions
and in other countries should be done with caution. Second,
we used self-report data in our assessment of preventive
care service use, which is subject to selective memory
issues, especially for data related to the hepatitis B vaccination, an immunization procedure requiring three shots.
Third, our study did not explore the barriers and facilitators
for utilization of preventive care services. More research
is necessary to examine potential barriers and facilitators
identified among other ethnic groups, such as physician recommendation (5).
This study has practical implications for researchers,
health care providers, and policy makers. We found a significant disparity in U.S. Chinese older adults’ use of different
preventive care services. Although utilization of pneumonia
vaccine and cancer screening services among Chinese older
adults was much lower than that of the general populations,
the 66% flu shot vaccination rate was consistent with the
national level. Further studies of this apparent contrast may
help researchers, health care providers, and policy makers
to better understand the barriers to the use of preventive care
services among Chinese older adults and develop appropriate strategies to promote other preventive care services. For
example, by identifying the traditional and nontraditional
locations where Chinese older adults received the flu shot,
future research can explore the feasibility of providing
other vaccination services together with the flu shot at these
locations, which may increase vaccination levels across the
board for U.S. Chinese older adults.
Conclusion
Our study indicates that the use of preventive care services, with the exception of the flu vaccine, was low for
Chinese older adults in the Greater Chicago area. Because
Chinese Americans are at high risk for the HBV and their
current HBV immunization rate is low, we call for more
attention to this issue. In addition, future longitudinal studies are necessary to improve our understanding of preventive care service utilization patterns among Chinese older
adults.
Funding
X.D. and M.A.S. were supported by National Institute on Aging grants
(R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443,
R34MH100393, P20CA165588, R24MD001650, RC4 AG039085), Paul
B. Beeson Award in Aging, The Starr Foundation, American Federation
for Aging Research, John A. Hartford Foundation, and The Atlantic
Philanthropies.
Acknowledgments
We are grateful to Community Advisory Board members for their continued effort in this project. Particular thanks are extended to Bernie Wong,
Vivian Xu, and Yicklun Mo with the Chinese American Service League
S14
SIMON ET AL.
(CASL); Dr. David Lee with the Illinois College of Optometry; David Wu
with the Pui Tak Center; Dr. Hong Liu with the Midwest Asian Health
Association; Dr. Margaret Dolan with John H. Stroger Jr. Hospital; Mary
Jane Welch with the Rush University Medical Center; Florence Lei with
the CASL Pine Tree Council; Julia Wong with CASL Senior Housing; Dr.
Jing Zhang with Asian Human Services; Marta Pereya with the Coalition
of Limited English Speaking Elderly; and Mona El-Shamaa with the Asian
Health Coalition.
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