Abstract / Summary
Breast cancer incidence has been rising among Asian American and Pacific Islander women, with Korean American women experiencing one of the highest increases and relatively lower mammogram screening rates compared to other subgroups. Health literacy specific to breast cancer may play a critical role in improving screening uptake in this population. Furthermore, psychosocial factors such as self-efficacy, decisional balance, cancer screening worry, lack of knowledge, and perceived susceptibility have been identified as potential correlates of mammogram use. These factors may mediate the relationship between health literacy and cancer screening behavior. For example, mammography uptake may be improved by increasing health literacy, as well as enhancing women’s confidence in cancer screening navigation (self-efficacy), teaching women to evaluate the benefits and risks of screening (decisional balance), increasing perceived personal risk of cancer (susceptibility), or influencing emotional responses such as fear or worry. Understanding how cancer-specific health literacy and these psychosocial factors are associated with mammogram screening is critical for designing culturally appropriate interventions to enhance mammogram screening. This study aimed to test and expand the Health Literacy Skills Framework in the context of Korean American women’s mammogram use. This was a secondary analysis of baseline data obtained from a sub-sample ( n = 423) of Korean American women aged 40 years and older, who were enrolled in a community-based cluster randomized control trial between 2010 and 2014. The parent study tested the effectiveness of a community health worker-led cancer literacy education intervention and phone counseling on mammogram and Pap testing uptake. All participants were overdue for screening based on American Cancer Society’s guidelines for mammogram screening at the time of enrollment. Structural Equation Modeling was used to test the paths linking breast cancer screening health literacy, psychosocial mediators, and mammogram screening uptake. Among the psychosocial factors examined, only decisional balance significantly mediated the relationship between health literacy and mammogram use (standardized indirect effect = 0.07; SE = 0.02; p < 0.01). In contrast, self-efficacy, perceived susceptibility, and breast cancer screening worry were not significant mediators. The direct association between health literacy and mammogram use was not statistically significant. Health literacy in breast cancer screening appears to influence Korean American women’s mammogram use indirectly through decisional balance. Our findings highlight the importance of integrating health literacy, as well as how to evaluate the benefits and risks of mammogram screening, into the design of culturally- and linguistically-tailored cancer prevention and screening programs. It is important to ensure interventions target not only health literacy, but also the multiple, complex factors (e.g., decisional conflicts) that affect mammography screening in diverse populations. These efforts may be particularly effective in promoting timely mammogram uptake among Korean American women.