Effects of Neighborhood Ethnic Density and Psychosocial Factors on Colorectal Cancer Screening Behavior Among Asian American Adults, Greater Philadelphia and New Jersey, United States, 2014–2019

Aisha Bhimla, PhD; Tyrell Mann-Barnes; Hemi Park, MPH; Ming-Chin Yeh, PhD; Phuong Do; Ferdinand Aczon, MD; Grace X. Ma, PhD


Prev Chronic Dis. 2021;18(9):e90 

In This Article

Abstract and Introduction


Introduction: We examined how neighborhood ethnic composition influences colorectal cancer (CRC) screening behavior in Asian American adults and explored whether associations between psychosocial predictors, including knowledge, self-efficacy, and barriers affecting CRC screening behavior, varied by level of neighborhood ethnic composition.

Methods: Filipino, Korean, and Vietnamese Americans (N = 1,158) aged 50 years or older were included in the study. Psychosocial factors associated with CRC screening, CRC screening behavior, and sociodemographic characteristics were extracted from participants' data. Neighborhood ethnic composition was characterized as the census-tract–level percentage of Asian residents. Participants' addresses were geocoded to the census tract level to determine whether they resided in an ethnically dense neighborhood. Multilevel logistic regression models were run with and without interaction terms.

Results: In mixed-effects logistic regression model 1, residing in an ethnically dense neighborhood was associated with lower odds of CRC screening (odds ratio [OR] = 0.65; 95% CI, 0.45–0.93; P = .02) after controlling for age, sex, education, ethnic group, and neighborhood socioeconomic status. Greater perceived barriers to CRC screening (OR = 0.62; 95% CI, 0.50–0.77; P < .001) resulted in significantly lower odds of obtaining a CRC screening, while higher self-efficacy (OR = 1.17, 95% CI, 1.11–1.23, P < .001) was associated with higher odds. In model 2, among those residing in a high ethnic density neighborhood, greater barriers to screening were associated with lower odds of having obtained a CRC screening (OR = 0.53; 95% CI, 0.30–0.96; P = .04).

Conclusion: We found that residing in an ethnically dense neighborhood indicated higher disparities in obtaining CRC screenings. Future studies should examine socioeconomic and cultural disparities, as well as disparities in the built environment, that are characteristic of ethnically dense neighborhoods and assess the impact of these disparities on CRC screening behaviors.


Colorectal cancer (CRC) is consistently one of the most commonly diagnosed cancers among Asian American adults.[1] Although the US population has experienced a decline in CRC incidence, national-level data indicate sharp rises in CRC incidence among Asian American subgroups, specifically Korean and Vietnamese American individuals, as well as among Filipina women.[2,3] CRC prevalence varies within populations due to a range of influences, including but not limited to heritable, environmental, behavioral, and dietary factors.[4] Literature suggests that obesity, smoking, alcohol use, and minimal physical activity are modifiable risk factors significantly associated with CRC diagnosis.[1]

Obtaining regular CRC screenings and early detection reduce the risk of negative outcomes associated with CRC, including late-stage diagnosis and death.[5] Existing literature has shown disparities in CRC screening rates between Asian American and non-Hispanic White people.[6–8] Recent screening statistics in the National Health Interview Survey indicated that Asian American adults had the lowest fecal occult blood test, colonoscopy, and sigmoidoscopy screening rates among all racial and ethnic minority groups, at 49%, compared with 65% for non-Hispanic White and 62% for Black/African American people.[5] Observed CRC screening rates are low among all Asian American ethnic groups. However, the lowest screening rates were observed among Korean Americans.[7] In a systematic review, only 25% to 50% of Korean Americans had received a CRC screening, in comparison to other Asian groups and non-Hispanic White people.[9] Several physical and psychosocial barriers to CRC screening are faced by Asian American adults, including low levels of English proficiency, low health literacy, and lack of access to care.[6,7,10–12]

Throughout the US, urbanization, migration, and immigration have contributed to population diversity and to racial and ethnic diversity in rural, urban, and suburban communities.[13] The number of Asian neighborhoods in the US increased from 412 to more than 3,000 from 1980 to 2010.[14] Asian neighborhoods consist of ethnic urban enclaves and ethnoburbs in urban and suburban areas, respectively, which have varying socioeconomic conditions.[14] Among Asian subgroups, Vietnamese, Filipino, and Korean communities tend to live in ethnically dense enclaves and ethnoburbs, which can strongly influence behavioral, social, psychological, and health-seeking behaviors within and across these communities.[13,15] Filipino, Vietnamese, and Korean people comprise the third, fourth, and fifth largest Asian racial groups in the US, respectively.[16] New Jersey has the fourth-highest population of Asian American people of all states, and Philadelphia has the tenth-highest population of Asian American people of all US cities.[17] These geographical areas have hosted immigrant enclaves, such as Little Saigon, Little Manila, Koreatown, and other Asian ethnic enclaves, with ethnic enclave areas traditionally hosting recent immigrants. Ethnoburbs serve as suburbanized areas with slightly higher socioeconomic status and stability in comparison with urban ethnic enclaves.[14]

Ethnic density, defined as the proportion of racial and ethnic minority residents in a specific area, is associated with social networks and social support within communities, factors that may contribute to health-seeking behaviors.[18] The ethnic density effect denotes that residents of areas with higher proportions of people from one's own racial and ethnic group adopt healthier behaviors.[18] Data on the protective effects of neighborhood ethnic density and health outcomes such as smoking, body mass index, and preterm birth[18] are mixed, with studies mainly reporting a lack of association. Few studies have assessed the effects of neighborhood ethnic density and ethnic enclaves on cancer screening behaviors among Asian American subgroups, including Vietnamese, Filipino, and Korean American. In a review by Fang and Tseng, a general inverse association was found in Asian neighborhoods between ethnic density and noninfectious cancer (eg, colorectal, breast) incidence, and a positive association was found between ethnic density and infectious cancer (eg, cervical, liver) incidence.[13] Ethnic density may play a critical role in individual health behaviors, attitudes, and outcomes related to CRC and CRC screening procedures, such as colonoscopy and blood stool tests.[13,19,20] Although no available literature is available specific to Asian American people and their subgroups on cancer screening behaviors, a recent study in Philadelphia found that high ethnic density and geographic segregation were associated with lower CRC screening rates in Black communities.[21]

The summation of psychosocial factors such as social support, knowledge, social influence, health beliefs, and cultural norms that influence CRC screening initiation and long-term screening adherence may cause residents of ethnically dense communities with foreign-born and US-born Asian American populations to experience nuanced barriers to CRC screening.[10,22] Considering the wide variability in previous research findings and lack of research that focuses exclusively on the experiences of Asian American people, we aimed to fill this gap in the literature and further examine the effects of ethnic density on CRC screening behaviors in Asian American populations in Philadelphia County, Pennsylvania, and in New Jersey. We also explored whether the associations between psychosocial predictors varied by level of ethnic density.