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Language and Culture Appropriate Approaches Needed to Improve Health Education to Reduce Disparities among Korean American Immigrants Living in Los Angeles

This study aimed to determine the disparities associated with health awareness and access to health education among Korean American residents living in the Los Angeles area. In particular, this research focused on gathering data on how Korean American immigrants perceive health information and what major barriers prevent them from gaining access to healthcare. In total, 421 Korean Americans living in Los Angeles participated in this study. The constructed 13-item questionnaires were provided in a pen and paper or online version in Korean or English. The quantitatively evaluated data revealed the status of exercise, smoking, access to healthcare, health interest, alcoholic consumption et al. in female and male subjects. Our study found that older age groups chose the paper survey option rather than the online version. They also preferred the Korean-translated survey over the English one. These findings suggest that careful consideration on language and format is required when assessing healthcare access in older generation Korean Americans. The major health concern of the paper survey group was also cancer prevention.


Introduction
As the United States becomes more linguistically and culturally diverse, there is a greater need for effective health communication interventions that target diverse and the most vulnerable populations (Barrera et al., 2013). Southern California, particularly Los Angeles and the Orange County area, has the highest concentrated Korean population in the U.S.; making up 25% of all Koreans residing in America. A majority of Koreans are concentrated around the Koreatown area. Koreatown is also the most densely populated district, by population, in LA county, with an average of 42,611 people per square mile. However, research activities with special efforts on collecting health information on ethnic minority populations, particularly Korean Americans, are currently lacking.
Evidence of healthcare disparities in Korean Americans has been previously reported (Shin et al., 2018, Jun andNan, 2017). In an effort to overcome these disparities in Koreans and Korean Americans living in Los Angeles, our study focused on understanding the main obstacles in the way of delivering health messages and screening. We paid special focus on methods that retain the essential elements of original health interventions while also addressing the different linguistic needs and cultural perspectives of the target population. The results of our study report disparities in the receipt of health information and accessibility within a sample of Korean American immigrants.
The goal of this study was to develop tools using our "Korean Community Health Survey" that could potentially capture research survey data. Ultimately, we hope that the tools developed from this project will lead to the development of efficient methods for identifying factors that contribute to lower healthcare awareness and accessibility among Korean Americans in Los Angeles. By doing so, we can establish guidelines to increase health awareness and cancer screening rates, which will eventually reduce cancer risk, in Korean Americans.

Methods
The study protocol was approved by Cedars-Sinai Medical Center institutional review board (Pro00048053).
In an effort to promote health awareness in Koreans and Korean Americans living in Los Angeles and understand their main health concerns and challenges in receiving proper care, we conducted a survey as part of our initiative step. Our "Korean American Health Survey" was designed for people of Korean descent who are over the age of 18, with no upper limit on age. The survey was administered over a three-week period for the pen and paper survey and ten days for the online version in May 2017. In total, there were 532 participants, of which 421 completed a pen and paper

© 2018 Published by IJIRMS Publication
survey and 111 completed the online survey. Aside from general health questions, the surveys were completely anonymous and did not ask for any personal information. Participants were recruited from street sides, local businesses (office and company), community clinics, churches, restaurants, coffee shops, schools et al.
The survey consisted of 13 questions, which took approximately 2 minutes to complete. Participants were asked in-person and selfadministered the in-person survey (Korean or English). The online survey was prepared in English only, due to limitations on the survey platform, Survey Monkey. Information sheets were provided to participants prior to the survey. The Community Advisory board members and study staff helped deliver messages regarding the survey goals, procedures, and methods.

Results and Discussion
Results from the pen and paper survey format In total, 421 participants were selected using a simple random sampling method. A constructed 13-item questionnaire was distributed to all subjects. According to self-reported data, among these 421 participants, 54% were female and 46% were male. Most participants (53%) were aged between 50-64 years old. The next largest age group in the participants (23%) was aged 65 years and over, followed by those between 30-39 years old (16%). A rapid decline in participation was observed in the young adult age group (19-28 years old) and middle-aged group (40-44 and 45-49 years old). The average heights and weights of Korean males and females in Los Angeles were 5 ft 7 in, 159 lbs, and 5 ft 3 in, 121.5 lbs, respectively.
Most of the participants (58%) reported either exercising no amount in the past seven days or exercising at least 30 minutes 1-2 days a week. A minority (26%) reported to exercising at least 30 minutes 3-6 days a week, and the fewest number of participants reported exercising at least 30 minutes every day (16%). Most of the participants (89%) reported not smoking, and a smaller majority (67%) stated that they do no consume alcohol. The average number of years that participants have lived in the U.S. varied widely, from less than 5 years to over 36. Only 10% were reported to be born in the U.S. Health insurance coverage among participants was diverse: Medicare (20%), Medi-Cal (23%), employer-sponsored insurance (25%), or self-employed insurance (17%). A small number were reported to be uninsured (11%).
More than half the participants reported visiting a private doctor's office when sick, needing medical advice, or acquiring a routine check-up. Some (9%) reported seeking acupuncture when sick. Most participants (24%) reported that their major concerns were cancer prevention, this was followed by diabetes (21%) and heart disease (19%). Although a majority of participants (84%) reported having heard of Cedars-Sinai Medical Center, many were not aware of what kinds of treatments and services were available. Roughly half of the participants were interested in being involved in future clinical research.

Results from online survey format
In total, 111 participants were recruited for the online survey. Approximately 59% were female and 41% were male. Most male participants were aged 18-29 (59%). The second largest age groups were 30-39 and 40-44 (17%, 17%). However, a rapid decline was observed in the age groups 45-49 (4%) and 50-64 (2%). For females, the majority of participants were from the same age group as males, 18-29 (54%). Females from age groups 30-39, 40-44, 45-49, and 50-64 were all similar in participation rates; 11%, 12%, 11%, and 12%, respectively. The online survey had no participants in the age group of 65+. The average heights and weight of males and females were 5 ft 8 in, 159 lbs, and 5 ft 3 in, 129 lbs, respectively. About 34% of females and 30% of males reported walking at least 30 min/day for 1-2 days/week. More males (46%) reported walking at least 30 min/day 3-6 times/week compared to females (34%). A similar percentage of females and males reported walking every day for at least 30 min/day; 18% and 22%, respectively.
The main health concern among this group was back pain (21%), followed by heart disease (16%) and cancer prevention (15%). Some participants reported being concerned about diabetes (11%), dementia (6%), arthritis (6%), and cancer therapy (2%). A majority of participants (70%) reported having heard of Cedars-Sinai Medical Center, but many were unaware of the services provided. A large proportion (61%) reported that they did not want to be involved in clinical research.

Paper survey participants walk less than online survey participants
A majority of paper survey participants did not walk the recommended walking amount; 34% of females and 30% of males reported not walking at all for at least 30 min. In contrast, only 14% of females and 2% of males in the online survey group reported not walking at all. In general, the online survey group presented a higher rate of exercise; of all online participants, 18% of female and 22% of male subjected reported walking at least 30 min every day. Although the number of participants who walked every day was not significantly different, a greater number of online survey participants (34% female and 46% male) walked at least 30 min for 3-6 days/week compared to paper survey participants (27% females and 25% males). Both surveys exhibited similar patterns for participants who walked at least 30 min for 1-2 days/week.

Online survey group showed more alcoholic consumption
Of all paper survey participants, 78% of females and 54% of males were non-drinkers. Approximately 22% of females reported consuming less than 14 drinks/week. Of the male drinkers, 6% reported being heavy drinkers (more than 14 drinks/week) and 40% were light drinkers (less than 14 drinks/week). A significantly higher proportion of online survey participants reported higher amounts of drinking. Of the total online survey group, 48% of females and 41% of males were non-drinkers. There were less heavy drinkers, but a higher percentage of males (57%) and females (52%) were light drinkers (Figure 1).  Major health concern of the paper survey group was cancer prevention One of interesting observations was that age ranges are dramatically different between pen and paper vs. online surveys ( Figure 2). Among some common health problems, cancer prevention was the major health concern (25 % of all participants) in paper survey. It was followed by diabetes (21 %) and heart disease (19%). In contrast, participants in the online survey groups reported back pain as their major concern (21%), followed by heart disease (16%) and cancer prevention (15%) (Figure 3).

© 2018 Published by IJIRMS Publication
Interestingly, both surveys showed that a majority of participants were not interested in clinical research; 55% of paper survey participants and 61% of online survey participants reported not being interested in clinical research ( Figure 4). These factors should be carefully considered for future studies with Korean American immigrants (Lee, 2015).
In addition, this study showed that we may not get a strong response from males over 45 years old if using an online survey. We found that subjects who completed the paper survey did not walk enough; about 30% of males and 34% of females. The online survey group was generally younger and showed more alcohol consumption.
It should be noted that paper survey participants preferred the Korean version of the survey, regardless of English-speaking skills. It suggests the importance of language and comfort when obtaining health messages. Even those who did not have any language barriers thought that a culturally comfortable environment is critical for efficient message delivery. These findings suggest that language-based and culturally-appropriate questionnaires will enhance the effectiveness of health information delivery and survey-based future studies.

Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.