Ethnic differences in choices of health information by cancer patients using complementary and alternative medicine: an exploratory study with correspondence analysis

Abstract

This study examined patterns in the use of health information among Caucasian, Japanese, and non-Japanese Asian Pacific Islander cancer patients in Hawaii and explored the relation of ethnicity and educational level to choices of health information sources. Information from 140 cancer patients, most of whom were users of complementary and alternative medicine (CAM), was analyzed using correspondence analysis. Three clusters of health information pertinent to the three ethnic groups emerged from the data. The results of this study revealed that Caucasian patients preferred objective, scientific, and updated information obtained through medical journals or newsletters from research institutions, telephone information services, and the internet. Japanese patients relied on media and commercial sources including television, newspapers, books, magazines and CAM providers. Non-Japanese Asians and Pacific Islanders used information sources involving person-to-person communication with their physicians, social groups, and other cancer patients. A higher educational level was closely related to a cluster of health information stressing objective, scientific and updated information, while a lower educational level was associated with interpersonally communicated information. The three ethnicity-specific patterns of health information use remained relatively stable at different educational levels, implying that the effect of patients’ ethnicity overrides their educational level in shaping their choices of health information. The results of this study indicate the importance of recognizing cancer patients’ culturally developed world views when understanding their health information-seeking behavior. For medical practice, these findings indicate the need for healthcare providers to assist cancer patients to obtain accurate health information in a culturally sensitive way.

Introduction

Cancer patients use various sources of health information to gain knowledge about their illness and prognosis, treatment options and side effects, ways to prevent recurrence, and psychological resources for coping (Cassileth, Zupkis, Sutton-Smith, & March, 1980; Fallowfield, Ford, & Lewis, 1994). These include, but are not limited to, healthcare providers (e.g., physicians and nurses), publications (e.g., books and magazines), phone assistance (e.g., Cancer Information Service), newspapers, television, radio, and word of mouth (Carlsson, 2000; Freimuth, 1993; Guidry, Aday, Zhang, & Winn, 1998; Ward, Anderson, Pundik, Redrick, & Kaufman, 1993; Worsley, 1989). Worsley (1989) categorized sources of health information into three major groups, “formal sources” (healthcare providers), “informal sources” (friends and relatives), and “commercial and media sources” (TV commercials, newspaper, and magazine articles). In a different approach, Carlsson (2000) distinguished an “active information-seeking strategy” (internet, medical books, narratives, and telephone information lines) and a “passive information-seeking strategy” (television, radio, newspapers, other cancer patients, and friends).

Demographic variables associated with information-seeking behavior include age (Carlsson, 2000; Turk-Charles, Meyerowitz, & Gatz, 1997; Worsley, 1989), gender (Freimuth, 1993; Rimer, Catoe, Graves, Burklow, & Anderson, 1993), education (Brown et al., 1993; Carlsson, 2000; Freimuth, 1993; Guidry et al., 1998; Jubelirer, Linton, & Magnetti, 1994; Turk-Charles et al., 1997; Ward et al., 1993), and ethnicity (Freimuth, 1993; Guidry et al., 1998; Rimer et al., 1993; Ward et al., 1993). The latter appears to be a critical contributor in shaping health information-seeking behavior although all ethnic groups perceive healthcare professionals as the most helpful source of information (Freimuth, 1993; Guidry et al., 1998; Rimer et al., 1993; Ward et al., 1993; Pennbridge, Moya, & Rodrigues, 1999). For example, Caucasian patients were more likely to use printed materials such as books and reference materials, whereas African-American patients tended to rely on pamphlets and television when seeking information about treatment options and side effects (Guidry et al., 1998). Use of the Cancer Information Service was dominated by Caucasians and underutilized by racial and ethnic minorities (Freimuth, 1993; Rimer et al., 1993; Ward et al., 1993). Educational background may also influence people's health information-seeking behavior in combination with ethnicity (Brown et al., 1993; Carlsson, 2000; Guidry et al., 1998; Jubelirer et al., 1994; Turk-Charles et al., 1997). For example, higher educational attainment may be responsible for the greater use of newspapers among Asians and Pacific Islanders (APIs) (Ward et al., 1993). Recently, with the advancement of information technology, the use of the internet as a source of health information has been increasing (Elliott & Elliott, 2000), particularly among cancer patients with higher education and younger age (Carlsson, 2000; Harris, 1998; Pennbridge et al., 1999). Whereas computer penetration and on-line access has been low among Hispanic- and African-Americans (24%), it has been high among APIs (51%). However, a breakdown for the individual ethnic groups within APIs is not available (National Telecommunication and Information Administration, 2000).

The significant influences of culture on health behaviors have been discussed by scholars of various fields (Helman,1994; Kreps & Kunimoto, 1994; Spector, 2000). Although multiple definitions of ‘culture’ exist, many agree that the concept of culture refers to a set of guidelines, which include values, beliefs, attitudes, and behaviors, shared by members of a particular group (Ember & Ember, 1985; Helman, 1994; Matsumoto, 2000). The choice of guidelines is often influenced by individuals’ membership in various cultural groups defined by nationality, ethnicity, age, gender, and socioeconomic status (Kreps & Kunimoto, 1994). Internal locus of control (Rotter, 1954), which is the belief that individuals have control over events happening in their environments, is one concept that characterizes a tendency of individuals with Western cultural backgrounds who hold individualistic values (Dyal, 1984; Hamid, 1994). Individuals with non-Western cultural backgrounds, who generally cherish interpersonally oriented cultural values (Markus & Kitayama, 1991; Triandis, 1989), have been often described as possessing spiritual–social (Edman & Kameoka, 1997) or fatalistic (Domino & Lin, 1991; Domino & Lin, 1993) attributions to illness. This cognitive style is likely to be shaped by a world view that is “less dialectical, logical, or linguistic in character, less analytical, more synthetic, or more sensitive to family or community consensus than to individual autonomy, more virtue-based than principle-based” (Pellegrino, 1992, p. 14).

The present study explored patterns of health information use among cancer patients of diverse ethnicity in Hawaii. Fifty-one percent of the state's population are APIs, including Hawaiian/part-Hawaiian, Japanese, Chinese, Filipino, Korean, and Samoan (Hawaii State DBEDT's Research and Economic Analysis Division, 2000). With 17% of the state's population reporting exclusively Japanese ancestry and an additional 8% reporting some Japanese ancestry, Japanese-Americans represent the largest API group. Immigration from Japan to Hawaii occurred primarily during 1868–1924, when more than 200,000 Japanese came to work on plantations (Nordyke, 1989). Japanese-Americans have been considered unique because of their rapid acculturation into mainstream America during and after World War II (Kitano, 1969). The pressure to assimilate and demonstrate their loyalty as “good Americans” during the war accelerated Japanese-Americans’ becoming very American (Ina, 1997). Compared to other APIs, more Japanese-American families speak only English and a smaller percentage is foreign-born (Uba & Sue, 1991). A number of cultural concepts are important to understanding behavioral patterns among Japanese-Americans. Confucianism which has greatly influenced Japanese culture (DeVos, 1985; Johnson & Marsella, 1978; Kitano, 1969; Marsella, 1993), emphasizes conformity, obedience, and the importance of legitimacy and authority associated with social roles and hierarchy. Therefore, Japanese-American patients, particularly elders, often defer to their physicians for medical decision-making (Saldov, Kakai, McLaughlin & Thomas, 1998), an accepted practice in traditional Japanese culture. At the same time, Japanese-Americans’ enryo, “modesty in the presence of one's superior” (Kitano, 1969, p. 102) or “denial of self-importance” (Johnson, 1985, p. 123), discourages assertiveness in front of authorities such as physicians.

The major objective of this study was to investigate ethnic differences in health information-seeking behaviors among cancer patients in Hawaii who had participated in a survey on complementary and alternative medicine (CAM). In addition, we explored a possible association between patients’ education and ethnicity and choice of health information.