The study used a mixed methods (Brewer and Hunter, 1989) approach to gather and analyze data using key informant interviews, focus groups and surveys. This study was conducted in Washington, D.C. metropolitan area in 2014. Seventeen key informant interviews and 12 focus group discussion sessions were held to elicit patient and provider concerns and priorities for CRC prevention and control. All participants completed both surveys and interviews. Key informant interviews were conducted with four oncologists and colorectal surgeons, six primary care physicians, two local health department employees, two patient navigators, and three community leaders who are familiar with the Chinese and/or Korean communities regarding health and health behaviors. The interviews were held in doctor’s office, community center and patient navigator’s office. Focus group (n=120) consisted of Chinese and Korean adults who were 50 to 81 years of age and had not been diagnosed with CRC. Some focus group participants were recruited from local community organizations and senior centers. Others were recruited through newspaper advertisements placed in local ethnic newspapers. The focus group were conducted in community centers, churches, and University of Maryland. The Institutional Review Board (IRB) of the University of Maryland, College Park approved the protocol for the study.

CRC knowledge scores generated from 17 questions ranged from 5 to 17 with a mean score of 11.0 (Table 2). The percentage of correct answers per question ranged from 27.5% to 94.2%. Less than half (47.5%) knew that the CRC screening begins at age 50, and only 48.3% knew that there are several CRC screening options. Table 1 presents the distribution of mean CRC knowledge scores by demographic characteristics. Participants who reported to have higher educational levels, higher income, a family history of CRC, a regular physician, and a higher acculturation level tended to score higher on CRC knowledge.

Qualitative data also revealed that participants were poorly informed about CRC. Focus group participants felt that CRC was less known compared to other cancers and diseases. For example, one Korean participant shared “Everyone knows about breast cancer and liver cancer, but rarely people know about this cancer [CRC].” Similarly, most of the key informants expressed their concerns about a lack of knowledge of CRC among Chinese and Korean Americans. One community leader shared “Majority [of Chinese and Korean Americans] have heard of cancer, but very few know of colon cancer. Most of them do not know the screening guidelines.” Some key informants mentioned that Chinese and Koreans in the community were not well-informed about CRC when they were in their home country. After they immigrated to the United States, the cultural and linguistic barriers contributed to the difficulties of acquiring CRC-related knowledge. Regarding to the source of information, Chinese and Korean Americans usually received CRC-related knowledge from community education programs, doctors, families, and friends.

A quarter of participants (25.8%) had the misconception that CRC affected only older White men. The majority of participants (90%) were aware that both men and women were at risk for CRC and 67% of respondents recognized age as a risk factor. Most participants (94.2%) recognized rectal bleeding as a symptom, and 70% identified that change in bowel habit as a symptom (Table 2). Focus group findings suggested participants had some knowledge of CRC risk factors. The risk factor identified most frequently was dietary habits. However, some participants expressed misconception on susceptibility: “CRC is something that Western people often get due to their meat-heavy dietary style.” A Chinese participant shared “In my case, I don’t really like meat. Since my diet is almost vegetal based, I don’t thinks I will get CRC.” There were some concerns raised by a few participants about their change to a more “Americanized” dietary habits after coming to the United States from their home countries. They considered this might increase their risks of having CRC. Collectively, when describing the symptoms related to CRC, both Korean and Chinese participants frequently mentioned changes in bowel habits and blood in stool.

Seventy percent of the participants knew CRC begins as a growth (a polyp) in the colon or rectum. Most of the participants (86.7%) were aware that finding CRC early would save their life, and 91.7% agreed that the treatment for CRC might not be as bad if the cancer was found early. (Table 2) Focus group findings suggested that most participants were aware that as long as the cancer was detected early, it could be cured. However, no participants explained what “early detection” specifically implied and what screening tests were explicitly considered as “early detection”. Many participants were aware that polyp growth would lead to the development of CRC, however very few of them understood that removing polyps could prevent CRC. The key informant interviewees recurrently expressed their sense of community members’ fear of knowing about having cancer and receiving treatment afterwards, and they often linked cancer to “death”, “a death sentence”, or “a terminal disease.” When asked about cancer treatment, one physician shared “No, no, no. The patient doesn’t want to hear that it is cancer.” Another community leader shared that people often have misconception on cancer treatment: “If I don’t get treated, I would probably live longer than having a treatment.” Physician interviewees mentioned some of the patients were extremely poorly informed about the correct way of treating cancer and they are often “reluctant to undergo surgery,” and they thought “some sort of physical training” or “more prayer and relations with God” will cure the cancer.

Most of the participants have heard of FOBT (60.8%) or colonoscopy (78.3%) (Table 3). About 63% never received FOBT, and only 15.8% reported being up to date with FOBT. More than half (58.3%) of the participants reported never having had a colonoscopy, and only 28.3% reported up to date. Regarding self-efficacy related to Health Belief Model, less than one third of participants (30.8%) reported being confident or very confident to complete a FOBT and less than half (47.5%) of the participants felt confident or very confident to complete a colonoscopy. Participants who were aware of or had participated in CRC screening tended to score higher on CRC knowledge compared with those who were not aware of or had not participated in any screening before.

Table 4 presents the multiple logistic regression models between CRC knowledge and screening variables after adjusting for potential covariates. Participants who had higher knowledge scores were more likely to report having heard of a colonoscopy (OR = 1.45, 95% CI: 1.12, 1.87), ever had colonoscopy (OR = 1.35, 95% CI: 1.06, 1.64), confidence in completing a colonoscopy (OR=1.22, 95% CI: 0.98, 1.52), and confidence in completing a FOBT (OR = 1.27, 95% CI: 1.01, 1.60) than those who had lower knowledge scores. Focus group findings suggest that awareness about CRC screening among Chinese and Korean participants was generally limited. One Chinese participant shared “People in my age have very low awareness about the screening. It seems that few people actively do the cancer screening.” Another Korean participant shared “Koreans do not have awareness about CRC. When I used to live in Korea, I did not know about CRC screening. In America I have been told to get CRC screening because of diet. Even now I do not understand the severity of CRC.” Questions and concerns about FOBT and colonoscopy were frequently raised during the focus group sessions. Particularly, many Chinese confused FOBT with visual stool examination and parasite stool test. In addition, both Chinese and Korean participants repeatedly stated their discomfort towards having a colonoscopy due to the tedious and painful preparation process and the possible adverse side effects. Some of them also shared about the negative experiences they personally had or their families and friends used to encounter. Physicians and community leaders recurrently mentioned that Chinese and Koreans lacked knowledge about existing resources and free services for CRC screening in the community. Some interviewees explained that the gap might be caused by lack of efforts in disseminating CRC screening information in the community.