Psycho-Oncology Psycho-Oncology (2010) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.

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The impact of cultural characteristics on colorectal cancer screening adherence among Filipinos in the United States: a pilot study
Rizaldy R. Ferrer1, Marizen Ramirez2, Linda J. Beckman1, Leda L. Danao3 and Kimlin T. Ashing-Giwa4
1 2

California School of Professional Psychology, Alliant International University, Alhambra, CA, USA Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA 3 Division of Cancer Prevention and Control Research, School of Public Health/Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA 4 Center of Community Alliance for Research and Education, Division of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA * Correspondence to: Alliant International University, 1000 South Fremont Avenue, Unit 5, Alhambra, CA 91803, USA. E-mail: rferrer@alliant.edu

Abstract
Objectives: Studies on colorectal cancer screening among specic Asian American groups are limited despite the fact that Asians are comprised of culturally distinct subgroups. The purpose of this study was to investigate the impact of cultural characteristics on colorectal cancer screening adherence among Filipinos in the United States. Methods: One hundred and seventeen Filipino men and women aged 50 years or older participated in the cross-section research design. Lifetime proportion of immigration, language preference and cultural beliefs of personal control regarding health outcomes measured cultural characteristics. Demographic and healthcare variables were also measured to describe the study sample. Participant recruitment employed culturally responsive sampling methods. Results: There was no signicant association between language preference and screening. Likewise, perceived personal internal control of health outcome was not related to screening. However, personal external control revealed a marginally signicant association. The percent of lifetime residence in the United States was signicantly greater among those who were adherent to screening than those who were not adherent. After adjusting for demographic and healthcare variables, the relationship between length of immigration and screening adherence was no longer signicant. Finally, age and doctors recommendation showed signicant impact on colorectal cancer screening adherence. Discussion: This pilot study adds to the knowledge regarding cultural factors associated with colorectal cancer screening behaviors among Filipino Americans. Future research is needed to conrm ndings that will be useful in developing culturally appropriate strategies to increase screening adherence. Copyright r 2010 John Wiley & Sons, Ltd.
Keywords: colorectal cancer; Filipino Americans; acculturation; Asian Americans; screening adherence

Received: 1 September 2009 Revised: 14 May 2010 Accepted: 27 May 2010

Introduction
Among ethnic minority populations in the United States (U.S.), Asians had the second highest incidence rate of colorectal cancer for men and third highest for women from 20022006. However, they showed lower colorectal cancer mortality rate compared with other ethnic minorities [1]. Regardless, characteristics associated with colorectal cancer outcomes are not well understood. Meanwhile, a deeper understanding of screening adherence might bring forth insight about eective interventions. High-quality screening procedures are eective in substantially reducing cancer incidence and

preventing many cancer-related deaths [2]. For colorectal cancer screening, fecal occult blood test (FOBT) every year, exible sigmoidoscopy (SIG) every 5 years, and colonoscopy (COL) every 10 years are recommended, according to the national guidelines for people at average risk [3]. These individuals are men and women aged 50 years or older with no known personal or family history of colorectal cancer. Despite strong evidence that incidence of colorectal cancer can be reduced through screening, adherence rates among Americans remain low [4]. Among Asian Americans aged 50 years or older, 55.9% reported receiving FOBT within the past year, and/or lower endoscopy (SIG or COL) in the past 10 years. This rate

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R. R. Ferrer et al.

was lower when compared with non-Hispanic White and non-Hispanic Black Americans.

Factors associated with colorectal cancer screening

Sociodemographic characteristics such as increasing age [59] and positive family history of colorectal cancer [8,1014] predicted screening adherence. However, other characteristics such as gender, socioeconomic status, and level of education resulted in inconsistent ndings [8,1319]. Healthcare factors having health insurance, regular physician, usual source of care, regular medical evaluation, and receiving a doctor recommendation for colorectal screening were associated with higher utilization of colorectal screening [5,811,14,2023].

Asian Americans and colorectal cancer screening

The impact of demographic and healthcare factors on screening adherence among Asian Americans is poorly understood. In addition, culture, an important determinant of cancer screening [24], remains an understudied factor in colorectal cancer screening [25]. In addition, generation level, language uency, and social activity preference had no impact on screening adherence among Chinese participants [26]. However, English prociency among Koreans was found signicantly associated with FOBT receipt [27]. In the same sample, Koreans who spent more than 25% of lifetime in the U.S. were two times likelier to have had SIG when compared with those who spent less than 25% of their lifetime. In general, knowledge about the relationships between length of immigration, language preference as well as other cultural factors, such as health beliefs and colorectal cancer screening, is limited. Exploration of the factors associated with colorectal cancer screening adherence among the Asian Americans is timely. They are comprised of more than 11 subgroups that dier in language and culture [28], and their cultural values and behaviors signicantly vary [29]. Therefore, it is important to disaggregate these groups in order to identify and understand unique factors associated with colorectal cancer screening. For example, the impact of language on adherence needs to be examined for each Asian subpopulation given that level of prociency may vary between groups.

colorectal cancer compared with their counterparts living in the Philippines [30]. Additionally, Filipinos were more likely to receive a late-stage diagnosis of colorectal cancer compared to their Caucasian and other Asian counterparts [31]. Filipinos reportedly ranked low in up-to-date colorectal cancer screening between 2001 and 2003 in comparison with their Japanese, Chinese, South Asian, and Vietnamese counterparts [32,33]. Likewise, conveniently sampled Korean women were more likely to be adherent to colorectal cancer screening than Filipino women [34]. In 2005, only 46% of Filipinos in California reported up-to-date receipt of FOBT or lower endoscopy [35]. One factor associated with colorectal cancer screening in the Filipino population is lifetime proportion of residency in the U.S. [34,35]. The role of other cultural characteristics such as language preference and cultural-related beliefs is still unknown. This study addressed a critical research gap. The goal was to describe the demographic, healthcare and cultural characteristics of Filipinos living in the U.S. who were surveyed regarding colorectal cancer screening adherence. The study also explored how the cultural factors impact screening adherence.

Methods Participants and procedures

The institutional review board of Alliant International University, Los Angeles, approved the study. The authors obtained written consent from a total of 117 eligible Filipino participants who met the following criteria of persons at average risk of colorectal cancer, dened by the American Cancer Society as: male or female, aged 50 years or older, and no previous personal or family history of colorectal cancer. Participant recruitment and data collection were executed based on a culturally responsive approach suggested in past studies [25,36,37]. This includes establishing liaisons between the investigator and prospective participants as well as utilizing purposive, convenience and snowball sampling methods. In the initial step, the principal investigator (PI) contacted a total of ve Filipino community group leaders as well as seven personal contacts to describe study purpose and determine their willingness to serve as liaisons to identify eligible participants. Those who agreed submitted a list of names and contact information using a standard referral form provided to them. After initial contact with the persons identied on the list, survey packets were sent to eligible individuals who agreed to participate. Completed surveys in sealed self-addressed stamped envelopes were mailed back to the PI.
Psycho-Oncology (2010) DOI: 10.1002/pon

Filipino americans and colorectal cancer screening

The second largest Asian subgroup in the U.S. is the Filipinos [28]. Knowledge about colorectal cancer outcome is sparse. Filipino men and women in the U.S. were reportedly at a greater risk of
Copyright r 2010 John Wiley & Sons, Ltd.

Colorectal cancer screening adherence among Filipinos

Participants were also recruited from three informal social events. The PI described the purpose of the study and invited volunteers to independently complete the self-administered survey packet. Participants who chose to respond at a later date were provided with a self-addressed stamped envelope for ease of returning the survey via mail. The second step utilized a snowball sampling method. Participants who were recruited and completed surveys through the convenience and purposive sampling method previously described were requested to voluntarily refer other eligible participants following similar procedure as during the initial phase. The locale of the study is in California; however, as a result of the dierent recruitment techniques, a few responses were also received from several other states in America.

Design and measures

A cross-section survey design was conducted in Spring 2006. Respondents reported their demographic characteristics: age, gender, academic completion, employment, and income level. To describe healthcare characteristics, participants were asked if they had medical insurance, one regular doctor, routine medical examination within the past year, and received physician recommendation to undergo colorectal cancer screening. Cultural characteristics were operationalized in several ways, beginning with language preference. The Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA) is a 21-item instrument that measures multiple dimensions of acculturation including language, behaviors, identity, friendship choice, generation level, and attitude [38]. For this study, only four items of the language dimension were used. Questions were asked about language spoken, preferred, used for reading, and used for writing. The term Filipino languages replaced Asian languages on the response options. The options were (1) Filipino languages only, (2) mostly Filipino languages, some English, (3) Filipino and English languages about equally well, (4) mostly English, some Filipino language, (5) only English. To obtain an average score, item scores were summed and divided by the number of items answered. Respondents were classied as Western identied if their mean score is X4, Filipino identied or preference towards native language if they score o3, and bicultural identied or equal preference to native and American English languages if their mean score is X3 but o4. Overall, SL-ASIA demonstrated acceptable internal consistency reliability with Cronbachs a ranging from 0.68 to 0.91 based on multiple studies of Asian adults [3841]. For this study using the four language items, the internal consistency reliability analysis yielded Cronbachs a 5 0.69.
Copyright r 2010 John Wiley & Sons, Ltd.

Second, length of immigration was measured using the lifetime proportion of U.S. residency. This was computed by dividing the participants reported number of years in the U.S. since immigration by their age expressed in years. Third, cultural health beliefs were measured by adapting two subscales from the Cultural Belief Scales for Mammography Screening (CBSMS) [42] because, to the authors knowledge, no instrument specic to colorectal cancer screening existed during the study period. Items on CBSMS were originally developed through rigorous literature review, focus groups, and content validation by identied experts in order to create three culturally sensitive constructs among African American women. One of the dimensions, personal control, with two distinct subscales was used in this study. Internal control is dened as the inuence of oneself to nding health problems early, whereas external control is the perception that health outcomes are inuenced by others and chance. An example item for the internal control subscale is Finding health problems early is my responsibility, whereas an example item for the external control subscale is There is nothing that I can do to nd health problems early. All 12 items focused on nding health problems early. For one item that asked specically about breast cancer, the term breast cancer was replaced by colorectal cancer. Responses ranged from 1, endorsing strongly disagree, to 5, strongly agree. To obtain a mean scaled score for each construct, the summed scores were divided by the number of answered items. A score of 5 for each construct suggests high internal control or external control. The instrument demonstrated acceptable internal consistency reliabilities for internal control subscale, Cronbachs a 5 0.76 and for external control, a 5 0.82 [42]. This study also has an acceptable reliability coecient for internal control and external control subscales (Cronbach a 5 0.91 and a 5 0.76, respectively). For the outcome measurecolorectal cancer screening adherence was dened as a self-report rather than clinical records. Participants were asked whether they have received any of the following colorectal cancer screening tests as described: FOBT, SIG and COL. The FOBT examines blood in the stool that could come from cancer or premalignant polyps in the colon or rectum. The SIG examines up to one-third of the colon through a exible lighted tube, whereas the COL, another colorectal cancer screening test similar to SIG, uses a longer tube that can examine the entire colon [43]. Respondents were classied adherent if they reported receiving any of the three screening tests at the recommended national guidelines [3]. Respondents were classied not-adherent if they had not received any tests at the recommended time interval or had never received any test.
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R. R. Ferrer et al.

Data analysis
The SPSS 16.0 and STATA 9.0 software packages were used for the statistical tests. Variables including education, current employment, and annual income were collapsed into two or three categories due to small cell sizes. Descriptive tests were used to describe the frequency distribution, central tendency, and dispersion of the independent and dependent variables. Bivariate tests using w2 test of independence for categorical variables and analysis of variance for continuous variables were conducted to determine dierences between colorectal cancer screening adherent and not-adherent groups. A multivariable logistic regression was performed to create models for predicting colorectal cancer screening adherence. The level of signicance was set at a level of ap0.05. First, cultural variables including proportion of lifetime in the U.S., cultural health beliefs (i.e. internal and external control), and language preference (i.e. Western identied, Filipino identied, or bicultural identied) were entered in a model to determine their mutually adjusted eects on colorectal cancer screening adherence. Then, two models were constructed to control for confounding by demographic and healthcare characteristics. In the rst model, the analysis included demographic and healthcare characteristics that had cell sizes greater than ve and were signicantly associated with screening determined by w2 tests. In the second model, the authors considered the possible mediating eect of doctors recommendation on cultural characteristics. It is possible, for example, that increased time of residency in the U.S. directly leads to increased healthcare utilization and thus, receipt of doctors recommendation for screening. Therefore, in model 2, we excluded this possible intermediate, doctors recommendation, from the multivariable model. For both models, age was rescaled to reect a 5-year increase in age, while lifetime proportion of residency was rescaled to reect a 10% increase.

Table 1. Colorectal cancer screening receipt among Filipinos in the United States (N 5 117)
Total Not adherent 83 75 68 45 (70.9) (64.1) (58.1) (38.5) Adherent

FOBT SIG COL Any of the above tests (FOBT/SIG/COL) Adherent to one test Adherent to two tests Adherent to three tests

117 117 117 117

34 42 49 72

(29.1) (35.9) (41.9) (61.5)

32 (27.4) 27 (23.1) 13 (11.1)

Value within parenthesis represents percentage.

Demographic characteristics
Forty-two men (35.9%) and 75 women (64.1%) were between 50 and 86 years old with a mean age of 61.02 years (SD 5 7.63) (Table 2). Those who are adherent were signicantly older (mean age 5 63.08) than those who were not adherent (mean age 5 57.76), po0.001. Majority of the sample completed higher education, in which 50 and 20% have college and graduate degrees, respectively. Among the Filipino sample, about 55% (n 5 64) were currently employed, and 45% (n 5 52) were not employed (i.e. retired, homemakers or currently unemployed). The annual income for 30% (n 5 32) of Filipinos waso$30 000, whereas 70% (n 5 76) have an annual income of $30 000. Gender, academic completion, employment, and annual income were not signicantly dierent between colorectal adherence groups.

Healthcare characteristics
In Table 2, 93.1% (n 5 108) reported that they were covered by medical insurance, but only 62% (n 5 70) were adherent to colorectal cancer screening. Additionally, of those who have received routine medical examination within the past 12 months (n 5 102), only about two-thirds (n 5 60) reported having had any colorectal cancer test within the ideal time interval. Approximately, 68% (n 5 79) of the participants were recommended by their doctor to undergo colorectal cancer screening, but only 60 individuals reported current adherence. There were statistically signicant dierences for having health insurance (p 5 0.005), receiving medical examination in the past year (p 5 0.004) and doctors recommendation (po0.001) between adherent and not-adherent groups.

Results Screening rates

Table 1 shows that 29.1% (n 5 34) of the sample (N 5 117) have received FOBT within the past 12 months. In addition, 35.9% (n 5 42) were adherent to SIG, whereas 41.9% (n 5 49) were adherent to COL. Overall, 61.5% (n 5 72) were adherent to any of the three tests (FOBT, SIG, or COL), while 38.5% (n 5 45) were not adherent. Of those who are adherent, approximately 34% of the participants actually received two or three tests within the recommended time interval.
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Cultural characteristics and bivariate results

Table 3 illustrates that on average, the participants have lived in the U.S 42.7% of their lifetime. Those who were adherent lived in the U.S. approximately 48.6% of their lifetime. In contrast, the proportion
Psycho-Oncology (2010) DOI: 10.1002/pon

Colorectal cancer screening adherence among Filipinos

Table 2. Demographic and healthcare characteristics

Total Demographic characteristics Agea Mean (years) SD Gender Male Female Academic completion High School/associate/some college College degree Graduate degree Employment status Not employed Employed Annual income o$30 K X$30 K Healthcare characteristics Health insuranceb Yes No One regular doctor Yes No Routine medical examinationb Yes No Doctor recommended screening Yes No Not-adherent Adherent p

o0.001 61.02 7.63 42 (35.90) 75 (64.10) 35 (29.9) 59 (50.4) 23 (19.7) 52 (44.8) 64 (55.2) 32 (27.3) 85 (72.6) 57.73 7.23 15 (12.8) 30 (25.6) 11 (9.4) 28 (23.9) 6 (5.1) 17 (14.7) 28 (24.1) 14 (12.0) 31 (26.5) 63.08 7.18 0.648 27 (23.1) 45 (38.5) 0.120 24 (20.5) 31 (26.5) 17 (14.5) 0.224 35 (30.2) 36 (31.0) 0.471 18 (15.4) 54 (46.2) 0.005 108 (93.1) 8 (6.9) 64 (54.7) 53 (45.3) 102 (88.7) 13 (11.3) 79 (67.50) 38 (32.50) 38 (32.8) 7 (6.0) 25 (21.4) 20 (17.1) 33 (28.7) 10 (8.7) 19 (16.2) 26 (22.2) 70 (61.90) 1 (0.90) 0.833 39 (33.3) 33 (28.2) 0.004 69 (60.0) 3 (2.6) o0.001 60 (51.3) 12 (10.3)

Some variables do not total to 100% (N 5 117) due to missing responses. Value within parenthesis represents percentage. a Analysis of variance test. b Fishers exact test, all other variables examined using w2test.

Table 3. Cultural characteristics and colorectal cancer screening adherence

Total Notadherent Adherent p

Cultural factorsa Lifetime proportion residency in the U.S. Language preference Internal control External control

0.43 (0.23) 3.13 (0.43) 4.01 (1.14) 2.26 (0.88)

0.33 (0.22) 3.06 (0.45) 3.89 (1.16) 2.43 (0.96)

0.49 (0.22) 3.17 (0.42) 4.08 (1.12) 2.14 (0.82)

o0.001 0.359 0.361 0.085

responsibility. Expectedly, perceived external control is low (mean 5 2.24), which means that the participants tended to disagree that nding health problems early is controlled by others or chance. For internal control, there was no signicant dierence between adherent (mean 5 4.08) and notadherent (mean 5 3.89) groups (p 5 0.361). The dierence in external control between adherent (mean 5 2.14) and not-adherent (mean 5 2.43) groups was marginally signicant (p 5 0.085).

Values are represented as mean (SD). a Analysis of variance test.

of lifetime spent in the U.S among the not-adherent sample (33.2%) was signicantly lower, Po0.001. The language preference average score in the sample population was 3.13. This suggests that the participants are able to speak, read and write, and prefer both English and Filipino languages equally well (bicultural identied). Language preference was not signicantly dierent between adherent and not-adherent groups. The participants have a high perceived internal control over health problems (mean 5 4.02), which suggests that nding health problems early is ones
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Predictors of screening adherence and multivariate results

Table 4 shows two multivariable models, one is adjusted for doctors recommendation and the other is not. In both the models, we found some consistent results. For every 5-year increase in age, the odds of being adherent to any colorectal cancer screening signicantly doubled (Model 1: OR 5 2.10, 95% CI 5 1.26-3.51, p 5 0.005; Model 2: OR 5 2.1, 95% CI 5 1.293.41, p 5 0.003). These eects were adjusted for demographic, healthcare and cultural variables. Perceived internal control was not signicantly associated with colorectal
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R. R. Ferrer et al.

Table 4. The impact of cultural factors on colorectal cancer screening among Filipinos, N 5 116
Model 1 OR Age (5-year increase) Doctors recommendation Lifetime proportion in the U.S. (10% increase) Cultural health beliefs Internal control External control Language proficiency Filipino identified (Reference) Bicultural identified Western identified 2.10 5.54 1.02 1.08 0.53 SEa 0.55 3.14 0.02 0.27 0.18 p 0.005 0.003 0.174 0.759 0.063 95% CI 1.253.51 1.8216.88 1.001.05 0.661.77 0.271.03 OR 2.10 1.04 1.19 0.58 SEa 0.52 0.01 0.28 0.18 Model 2 p 0.003 0.011 0.464 0.088 95% CI 1.293.41 1.011.06 0.751.87 0.311.08

0.54 0.67

0.41 0.59

0.421 0.652

0.122.43 0.123.71

0.74 0.76

0.53 0.62

0.676 0.733

0.183.00 0.153.78

Adjusted for gender, education, employment status, income, and having one regular doctor. One case was dropped out of the analysis due to missing responses. a SE, standard error.

cancer screening adherence after adjusting for covariates. However, as perceived external control increased, the odds of current adherence decreased (Model 1: OR 5 0.53, 95% CI 5 0.271.03, p 5 0.06; Model 2: OR 5 0.58, 95% CI 5 0.311.08, p 5 0.08). In model 1, the eect of doctors recommendation on screening was strong and positive. Compared with those who have not received recommendation, those who have were over ve times more likely to report current adherence (OR 5 5.54, 95% CI 5 1.8216.87). There were inconsistent results in the eect of lifetime proportion in the U.S. In model 1, increased lifetime proportion in the U.S. (OR 5 1.02, 95% CI 5 1.001.05) was not associated with screening. In terms of language preference, being bicultural identied (OR 5 0.54, 95% CI 5 0.122.43) or western identied (OR 5 0.67, 95% CI 5 0.123.71) was not associated with adherence to colorectal cancer screening. Similarly in model 2, bicultural and western identication had no eect on screening.

Discussion Demographic characteristics

This pilot study adds to the knowledge regarding factors associated with colorectal cancer screening among Filipino Americans. The ndings show that increasing age is an important factor for current adherence, consistent with a comprehensive review of literature [14]. However, the impact of age on colorectal cancer screening was only consistent with some Asian subgroups [5,33,44] but not with others [19,27]. Despite this inconsistency, it is still important to increase eorts to recruit Filipino Americans beginning at age 50 for colorectal cancer screening studies. There are useful methods to recruit and retain Filipino American participants, which is a hard-toreach population. This pilot study began to explore
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some of the culturally sensitive approach, which included inviting community liaisons and personal contacts to assist with subject recruitment. However, other strategies may also be employed in future studies such as performing key informant interviews as a process of identifying community leaders for recruitment leads; and targeting community based organizations, churches, and Filipino grocery stores as recruitment sites [36,45]. Having insurance, routine medical exam and/or received doctors recommendation predicted adherence to colorectal cancer screening for some Asian American groups [26,27,46]. In this study, Filipinos who received doctors recommendation were more than ve times likelier to report adherence. This further validates the important role of physicians or other appropriate health care providers to encourage people at the right age to screen for colorectal cancer. Having regular doctor and health insurance were insignicant predictors of colorectal cancer screening adherence [34,35]. However, this study is unable to present any ndings regarding these associations because some variations in responses were insucient to allow for an accurate estimation. Additional studies are, therefore, needed.

Cultural characteristics
The main purpose of the study is to explore cultural factors associated with colorectal cancer screening. The lack of signicant relationship between language preference and screening receipt among Filipinos is supported by previous literature [34]. Perhaps, prociency in English language does not pose a barrier to Filipino Americans, given that the Philippines considers English as an ocial language. It is important to emphasize that language is only one dimension of acculturation explored in this study. Therefore, additional research is still considered necessary to further describe the function of other dimensions, such as behaviors,
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Colorectal cancer screening adherence among Filipinos

identity, friendship choice, generation level and attitude [38,40]. Lifetime proportion in the U.S. among Korean and Filipino women predicted cervical, breast and colorectal cancer screening procedures [34]. Similarly, a 10% increase of lifetime spent in the U.S. increased the odds of current SIG or COL screening receipt by 1.3 times among Filipino American immigrants [35]. Interestingly, this study revealed that there is no relationship between length of immigration and screening adherence after adjusting for other variables, particularly doctors recommendation. However, when the eect of doctors recommendation was removed in the multivariate model, a signicant relationship was found. These interesting yet conicting ndings suggest two possible mechanisms through which doctors recommendation aect the relationship between immigration and screening behaviors. On one hand, previous studies [34,35] did not measure doctors recommendation to undergo colorectal screening as a determinant to adherence, and uncontrolled confounding may have led to spurious results. On the other hand, the strong positive association between doctors recommendation and screening may reect a mediating eect. It is interesting that, in the bivariate analyses, lifetime proportion of residency in the U.S. has a strong signicant association with screening; yet, this relationship completely disappears in the regression model. Therefore, it is possible that length of residency in the U.S. predicts healthcare utilization patterns and increased physician visits, which then increases the probability of receiving doctors recommendation for screening. This complex relationship then may predict actual screening behaviors. This relationship should be investigated further in future studies. Cultural perceptions of health outcomes were explored because these factors tend to inuence health behaviors among ethnic minority groups [42]. For example, fatalism is a belief that is shared by dierent cultures like Asians and African Americans. In the context of health-related behaviors, this is described as the belief that powerful others (e.g. God) and/or chance take control over ones health outcome [4749]. To the authors knowledge, this study is rst to explore and report on the role of culturally informed health beliefs on colorectal cancer screening among Filipino Americans. Although the adapted measure was initially validated for breast cancer screening, its use based on the items of internal control and external control subscales is justied. The reliability of these two subscales for the current sample was acceptable. The marginally signicant association found between external control and screening adherence suggests that higher perception of external control
Copyright r 2010 John Wiley & Sons, Ltd.

decreases the likelihood to be currently screened for colorectal cancer. Perhaps, Filipinos do not need to rely on the inuence of others in order to undergo colorectal cancer testing based on recommended guidelines. Moreover, it is reasonable that since the sample reported low external control, their internal control would be high. Yet, in the multivariate analysis internal control had no signicant impact on screening outcome. Perhaps, the two constructs are independent of each other. In fact, the results suggest that perceptions of external control may have a greater inuence on screening behaviors. The authors found no previous literature that oered a suitable explanation for this trend. Instead, two studies using an identical measure of health locus of control actually reported inconsistent results. In one study, participants highly endorsed internal locus and external locus of control [50]. Yet, in another study of Filipino migrant workers, only the external locus of control perception was high [51]. The perception of control regarding health among the Filipinos may depend on the type and severity of health problems. For certain, less severe health issues, it may be perceived that it is up to them to reduce the burden. While, for other types of diseases such as terminal illnesses of advanced stages, powerful others or chance dictate their health outcomes. In the interest of colorectal cancer screening research, a qualitative research method should be considered in future studies. For example, a focus group aimed at investigating the underlying perceptions surrounding cultural health beliefs, particularly perceived control may clarify what it means for Filipinos to endorse internal control or external control.

Limitations
This study has limitations that necessitate prudence in interpretation of results. For example, selfreport surveys are prone to response bias. In addition, changes in screening behaviors over time cannot be determined using cross-sectional designs. Therefore, factors associated with adherence need to be conrmed using longitudinal data. Convenience, purposive, and snowball sampling methods limit generalizability to the Filipino population. The present sample had a somewhat homogeneous grouping in demographic and healthcare characteristics. As a result, several variables had small cell sizes and, therefore, were excluded in the multivariate analysis. Nevertheless, the sampling methods appear to be appropriate when recruiting and maintaining hidden, hardto-reach participants. The authors acknowledge potential issues regarding cross-cultural validity of the measures
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R. R. Ferrer et al.

adapted in this study. However, the reliability coecients for the cultural characteristics subscales were reasonable. Sample size also limited the power in detecting eects. This was observed in the marginally statistically signicant association between external control and screening. With a larger sample, it could be expected that this relationship would reach statistical signicance. Finally, using several sampling strategies resulted in dierent sources of response. For example, on examining mailed-in surveys, there were unexpected responses from several U.S. states, outside the initial targeted region of Southern California. For this study, however, source of response (e.g. informal social gathering) and state of residence were not monitored and compared across groups. Future research with larger Filipino sample size should consider investigating possible dierences between source of data and colorectal cancer screening.

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Psycho-Oncology (2010) DOI: 10.1002/pon