Miyong Kim

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (17)11.5 Total impact

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    ABSTRACT: Background: Little is known about the magnitude and impact of health literacy on chronic disease management among people with limited English skills. Moreover, no study has focused on the relationship between high blood pressure (HBP) -specific health literacy with multiple HBP-related outcomes. The purpose: To examine the effect of high blood pressure -specific health literacy on factors related to self-care skills, including BP knowledge, health care utilization, and BP outcomes in first-generation Korean American seniors with HBP. Methods: Baseline data from an ongoing health literacy -focused self-care behavioral education intervention program for Korean American seniors with high blood pressure were utilized. Eligibility criteria for entry into this community-based, prospective controlled trial were: 60 years of age or older; systolic BP (SBP) > 140 mm Hg and/or diastolic BP (DBP) > 90 mm Hg on two separate occasions or being on antihypertensive medication; and self-identification as a Korean American senior. Results: 440 first-generation Korean American seniors with HBP were enrolled (69.5% females; mean age, 70.9 5.5 yr). Multivariate regression analysis showed that the HBP-specific health literacy score was significantly and positively associated with the three predictors, HBP knowledge, depression, and health care utilization (adjusted R2 =.52), after controlling for the demographic variables gender, years of education, and years in the US. HBP-specific health literacy however was not independently associated with BP level or BP control status. Conclusion/Discussion: The findings of this study indicated that health literacy is essential to self-management in HBP, since several important precursors of self-care behavior such as HBP knowledge, mood state, and health care utilization were positively related to HBP -specific health literacy. Our findings also highlight the need for measuring and integrating disease-specific health literacy into the self-management of chronic illnesses, such as high blood pressure, in the Korean immigrant population.
    141st APHA Annual Meeting and Exposition 2013; 11/2013
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    ABSTRACT: Adequate self-care is crucial for blood pressure control. A number of hypertension (HBP) self-care instruments are available, but existing tools do not capture all the critical domains of HBP self-care and have limited evidence of reliability and validity. The purpose of this study was to develop and validate a new tool-the HBP Self-Care Profile (HBP SCP)-in a sample of inner-city residents. The HBP SCP encompasses comprehensive domains of HBP self-care behaviors. Guided by 2 validated theoretical approaches-Orem's self-care model and Motivational Interviewing-the HBP SCP includes 3 scales that can be used together or independently: Behavior, Motivation, and Self-efficacy. The sample included 213 English-speaking inner-city residents with HBP (mean age, 68.6 years; 76.1% women; 81.7% African American). Item-total correlations ranged from 0.20 to 0.63 for Behavior, 0.46 to 0.70 for Motivation, and 0.40 to 0.74 for Self-efficacy, meeting the cutoff set a priori at 0.15. Internal consistency reliability coefficients ranged from 0.83 to 0.93. Concurrent and construct validities of the HBP SCP were achieved by significant correlations between HBP SCP scales and theoretically selected instruments (P < .05 for all correlation coefficients). The HBP SCP-Behavior scale also successfully discriminated between those with or without blood pressure control (P < .05). The reliability and validity of the HBP SCP were supported in this sample of inner-city residents with HBP. The high reliability estimates and strong evidence of validity should allow researchers to use the HBP SCP to assess and identify gaps in HBP self-care behavior, motivation, and self-efficacy. Future research is warranted to evaluate the HBP SCP in diverse ethnic and age samples of hypertensive patient populations.
    The Journal of cardiovascular nursing 10/2013; 29(3). DOI:10.1097/JCN.0b013e3182a3fd46 · 1.81 Impact Factor
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    ABSTRACT: OBJECTIVES: To determine the level of agreement between dementia rating by trained community health workers (CHWs) based on the Clinical Dementia Rating (CDR) and the criterion standard: physician diagnosis. DESIGN: Cross-sectional validation study. SETTING: Community gathering places such as ethnic churches, senior centers, low-income elderly apartments, and ethnic groceries in the Baltimore-Washington metropolitan area. PARTICIPANTS: Ninety community-dwelling Korean-American individuals aged 60 and older. MEASUREMENTS: The CDR is a standardized clinical dementia staging instrument used to assess cognitive and functional performance using a semistructured interview protocol. Six CHWs trained and certified as CDR raters interviewed and rated study participants. A bilingual geriatric psychiatrist evaluated participants independently for dementia status. RESULTS: CHWs rated 61.1% of the participants as having mild cognitive impairment (MCI; CDR = 0.5) or dementia (CDR≥1), versus 56.7% diagnosed by the clinician. A receiver operating characteristic (ROC) curve analysis demonstrated good predictive ability of CDR rating by trained CHWs (area under the ROC curve = 0.86, 95% confidence interval = 0.78-0.93, sensitivity = 85.5%, specificity = 88.6%) in detecting MCI and dementia. CONCLUSION: The findings provide preliminary evidence that trained CHWs can effectively identify community-dwelling elderly Korean adults with MCI and dementia for early follow-up assessment and care in a community with scarce bilingual caregivers and programs.
    Journal of the American Geriatrics Society 06/2013; 61(7). DOI:10.1111/jgs.12309 · 4.22 Impact Factor
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    ABSTRACT: Background/Significance: Recent immigrants, including Korean Americans (KA), face an unequal cancer burden related to the significant language and cultural barriers they face in attempting to navigate the US healthcare system. Limited health literacy, closely associated with limited English language proficiency, strongly predicts inadequate utilization of healthcare resources among immigrants. Objective/Purpose: Based on a strong partnership built over the past ten years, this academic-community collaborative team developed and tested a health literacy-focused intervention in non-adherent KA women (N=560). Methods: Using a cluster-randomized study design, the intervention was delivered to 278 KA women by trained community health workers (n=13) from 11 ethnic churches in the Baltimore-Washington metropolitan area. The intervention consisted of computerized health messages tailored to the level of health literacy and individual risk factors, health literacy skills training, and navigation assistance. The comparison group (n=282 from 13 churches) received publicly available educational brochures. Results: 57% of those in the intervention group received cancer screening compared to 10% in the comparison group at 6 months (p< 0.01 for both cancers). Between-group differences in improvements in health literacy scores were also significant (p< 0.001). Preliminary analysis showed that participating in the intervention significantly improved psychological outcomes such as cancer knowledge, decisional balance, and self-efficacy in the expected directions. Conclusion: While previous interventions have primarily focused on accommodating women's needs rather than developing their skills, our findings support the use of health literacy as part of an intervention approach in improving cancer screening behaviors among women with limited English skills.
    140st APHA Annual Meeting and Exposition 2012; 10/2012
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    ABSTRACT: Based on substantial formative research, the authors developed and implemented a year-long corner store-based program in East Baltimore focusing on Korean American (KA) stores. To understand acceptability of the intervention by storeowners, the authors examined the motivating factors for program participation, barriers to program implementation, perceived effectiveness of intervention materials, and perceptions about the program. Data collection methods included in-depth interviews with seven corner store owners, field notes by interventionists, and a follow-up survey. Stores varied considerably in terms of owners' perceptions about the program, supportive atmosphere, and acceptability of intervention strategies. The storeowners who showed strong or moderate support for the program were more likely to sustain the stocking of promoted foods such as cooking spray and baked or low-fat chips after the program was completed as compared to less supportive stores. The level of support and active participation of storeowners can greatly influence the success of corner store-based nutrition interventions.
    Health Promotion Practice 05/2011; 12(3):472-82. DOI:10.1177/1524839910364369 · 0.55 Impact Factor
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    ABSTRACT: Aims: While the need for understanding the issue of health literacy among ethnic minority groups with limited English skills is rapidly increasing in the United States, it is difficult to find valid and useful health literacy tools for certain linguistic minorities. To date, most health literacy research has focused on English- or Spanish-speaking populations, with no health literacy tests available for other linguistic subpopulations. Methods: We present a study that was designed to validate the Korean translation of Rapid Estimate of Adult Literacy in Medicine (REALM) and Test of Functional Health Literacy in Adults-Short form (S-TOFHLA), the two most popular health literacy tests. Korean REALM and S-TOFHLA were administered to 98 Korean American (KA) women, together with REALM-English. Results: Participants were first-generation immigrant women who were born and educated in Korea. Both Korean REALM and S-TOFHLA resulted in a negatively-skewed distribution. Reliability coefficients yielded 0.80 for REALM-Korean, 0.64 for the numeracy, and 0.79 for the reading comprehension sections of S-TOFHLA, respectively. REALM-English yielded well-distributed groups with a reliability coefficient of .98. REALM-English had statistically significant correlations with Korean REALM and S-TOFHLA (Spearman’s rho=0.30 and 0.22, respectively). To test construct validity, the level of health literacy was compared in relation to the woman’s age, education, and years of residence in the United States. The proportion of women with higher levels of health literacy tended to be greater among younger (<50 years) and more educated (>high school) women, though none of the literacy tests were correlated with age. Educational level was statistically significantly correlated with REALM-English and Korean S-TOFHLA (Spearman’s rho=0.39 and 0.25), but not with REALM-Korean. The length of residence in the United States was not associated with health literacy in this sample. Conclusions: The translation of REALM and S-TOFHLA into the Korean language did not lead to a valid assessment of health literacy. A more systematic approach is needed to assess health literacy in immigrants with limited English skills, particularly those with a phonetic primary language. Meanwhile, REALM-English could be used as a crude health literacy test for individuals with some English skills.
    CANS 2010 State of the Science Congress on Nursing Research; 09/2010
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    ABSTRACT: Aims: Health literacy has long been identified as a major barrier against reaching optimal benefits of health promotion. Even after holding both education and socioeconomics constant, knowledge of one’s disease and of the skills necessary to be successful in maintaining health are often strongly correlated with health literacy. Currently, most health literacy assessments aim for testing one’s general health literacy skills without tailoring any disease specific context. The purpose of this study was to address the need for improvement in health literacy tools for individuals with chronic illness, we have developed a couple disease-specific health literacy assessments. In this paper, we will use the psychometric data from an instrument project--a diabetes-specific health literacy assessment for Korean Americans, DISHLA-K. Methods: DISHLA-K was developed for a randomized pilot study designed to improve health literacy and glucose control in Korean Americans with type 2 diabetes mellitus (T2DM). Modeling on the Rapid Estimate of Adult Literacy in Medicine, the new instrument, DISHLA-K, included a reading test with 82 key English words related to diabetes management that were generated by a committee consisting of experts and community members; and 2) a matching test asking patients to relate each word on the list to corresponding meaning in Korean. In addition, we modified published health literacy tests, numeracy section of the Test of Functional Health Literacy in Adults and New Vital Sign, in order to make them more applicable to patients with T2DM. In order to test construct validity of the instrument, we correlated scores on the DISHLA-K with theoretically-relevant variables including education, diabetes knowledge, and glucose control. In addition, we tested the sensitivity of the DISHLA-K in capturing changes in the level of health literacy as an outcome of the intervention. Results: Content validity of DISHLA-K was assessed by focus groups involving Korean patients with T2DM, bilingual researchers, and diabetes experts. Psychometric assessment of DISHLA-K was done on 79 patients who completed the intervention study. Participants were in their 50s with a mean (±SD) age of 56.4 (±7.9) yrs. Less than half (44.3%) were female, 48.1% had received a higher level of education (> high school), and 53.2% had been in the United States for more than 20 years. At baseline, DISHLA-K, modified numeracy test, and New Vital Sign yielded acceptable reliability coefficients (0.78-0.98). DISHLA-K significantly correlated with the level of education (r=.58), diabetes knowledge (r=.49), and hemoglobin A1C (r=.63) at bivariate level. Functional literacy tests also revealed similar results. As compared to the control group, the intervention group that received the health literacy-focused educational program achieved significantly higher health literacy scores based on DISHLA-K at 6 month follow-up (p=.026). Conclusions: DISHLA-K demonstrated strong evidence of reliability and validity in this sample of Korean patients with T2DM. The utility of DISHLA-K as an outcome measure of an intervention designed to improve health literacy was successfully supported by this study. Cross-validation of this tool is warranted in populations with diverse backgrounds.
    CANS 2010 State of the Science Congress on Nursing Research; 09/2010
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    ABSTRACT: Aims: The purpose of this paper is to review and critically evaluate the current state of the science in health literacy measures- specifically as it relates to the conceptual underpinnings and context of health literacy. Furthermore, the review assesses how well measures are able to capture health literacy in populations with limited English proficiency, a sub-group that has been known to be at high risk for limited health literacy. Methods: To gain insight into the current state of the science, PubMed, PsycINFO and SCOPUS data-bases were searched for health literacy measurement studies from 1975 to 2007. Keywords used alone and in combination included: health literacy, instrument, measure, scale, assessment, and tool. Additionally, reference lists of all eligible studies were reviewed and experts in the field were contacted. Health literacy measures were reviewed and evaluated based on conceptual underpinning, context, psychometric properties, and sensitivity to capture health literacy among populations with limited English proficiency. Results: There were 13 known measures of health literacy, four of which are shortened versions of original measures. The psychometric properties of the measures varied (Cronbach’s alpha = 0.57-0.98). Four overarching conceptual domains were found in the measurement of health literacy: print literacy, oral literacy, numeracy and cultural/ contextual knowledge. However, none of the measures were comprehensive, measuring at best only three out the four domains. The majority (8) of the health literacy measures are global in nature, while both the direction and trends are moving toward measures that capture health literacy in a specific context. Few measures are sensitive to people with limited English skills, and none have been translated into languages other than English and Spanish. Additionally, validations of all the measures have come from samples comprised of mainly Caucasians, African Americans, and Hispanic Americans. Conclusions: These findings may result in faulty health literacy measures, specifically among ethnic minority populations. Future work in health literacy instrumentations should focus on comprehensiveness in order to capture the essential underlying conceptual domains. Additional future validation studies should consider sampling from more ethnically diverse populations. Furthermore, the phonetic structure of the participants’ primary language should be considered when validating these tools. Lastly, future studies should also examined if currently available tools are sensitive enough to capture variability among those with very limited English proficiency.
    CANS 2010 State of the Science Congress on Nursing Research; 09/2010
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    ABSTRACT: Despite well-known benefits of health care utilization for the effective management of chronic diseases, the underlying mechanism of understanding health care utilization in ethnic minority population has not been systematically explored. The purpose of this paper is to examine the predictive ability of a health care utilization model by analyzing the interplay between predisposing, enabling, and need factors. The sample consisted of hypertensive Korean American immigrants (KAIs) 40-64 years of age who participated in a self-help intervention for high blood pressure care (SHIP-HBP). Using structured questionnaires, data were collected from 445 KAIs at baseline and analyzed with path analysis. Insurance status and relevant medical history were not just strong direct effects but also carried the most total effect on the health care utilization of these patients. Life priorities, years of residence in the US and perceived income level exerted indirect effects through the participants' insurance status. Our statistical analysis indicated a good fit for the proposed model (x (2) = 28.4, P = 0.29; NFI = 0.91; CFI = 0.99; RMSEA = 0.02). Overall, the model explained 18% of the variance in health care utilization of hypertensive KAIs. These findings strongly support a need to improve access to health care for KAIs by introducing a variety of community resources and building sustainable community infrastructures.
    Journal of Immigrant and Minority Health 09/2009; 12(4):513-9. DOI:10.1007/s10903-009-9276-1 · 1.16 Impact Factor
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    ABSTRACT: While corner store-based nutrition interventions have emerged as a potential strategy to increase healthy food availability in low-income communities, few evaluation studies exist. We present the results of a trial in Baltimore City to increase the availability and sales of healthier food options in local stores. Quasi-experimental study. Corner stores owned by Korean-Americans and supermarkets located in East and West Baltimore. Seven corner stores and two supermarkets in East Baltimore received a 10-month intervention and six corner stores and two supermarkets in West Baltimore served as comparison. During and post-intervention, stocking of healthy foods and weekly reported sales of some promoted foods increased significantly in intervention stores compared with comparison stores. Also, intervention storeowners showed significantly higher self-efficacy for stocking some healthy foods in comparison to West Baltimore storeowners. Findings of the study demonstrated that increases in the stocking and promotion of healthy foods can result in increased sales. Working in small corner stores may be a feasible means of improving the availability of healthy foods and their sales in a low-income urban community.
    Public Health Nutrition 05/2009; 12(11):2060-7. DOI:10.1017/S1368980009005242 · 2.48 Impact Factor
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    ABSTRACT: The purpose of this paper is to review and critically evaluate the current state of the science in health literacy measures- specifically as it relates to ethnic minority populations with limited English proficiency, a sub-group that has been known to be at high risk for limited health literacy proficiency. To gain insight into those limitations, PubMed, PsycINFO and SCOPUS data-bases were searched for health literacy measurement studies from 1975-2007. Keywords used alone and in combination included: health literacy, instrument, measure, scale, assessment, tool. Additionally, reference lists of all eligible studies were reviewed and experts in the field were contacted. Health literacy measures were evaluated based on its psychometric properties, comprehensiveness, and cultural sensitivity. There are 11 known measures of health literacy, four of which are shorten versions of an original measure. The psychometric properties of the measures varied (Cronbach's alpha = 0.57-0.98). None of the measures were comprehensive, measuring only three out the six dimensions of health literacy at best. Furthermore few are sensitive to people with limited English skills, and none have been translated into languages other than English and Spanish. These findings may result in faulty measures of health literacy, specifically among ethnic minority populations. Future work in health literacy instrumentations should focus on addressing those gaps.
    136st APHA Annual Meeting and Exposition 2008; 10/2008
  • Miyong Kim, Hae-Ra Han, Kim Kim
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    ABSTRACT: Adequate management of chronic diseases such as hypertension and diabetes is a difficult daily challenge for every patient. However, it is more burdensome for underserved minority populations since many of them suffer from insufficient resources and stiff barriers. In particular, recent immigrant groups such as Korean Americans (KA) are facing with linguistic, cultural and system associated barriers. Our years of community needs and asset assessments have led us to develop a community-based system of support to address significant health disparities in chronic disease management experienced by KA. Following descriptive phase of our program development, we have utilized a variety of intervention strategies including culturally tailored education, telephone counseling by bilingual nurses, and self-monitoring of BPs using tele-health. In addition, we have paid a close attention to making these programs sustainable by putting much effort in building a lasting community infrastructure. The approach has yielded several important resources and system to sustain key elements of our intervention within the community such as a pool of trained community health workers and establishment of an academic-community partnered chronic disease management program for underinsured KA. One of the key ingredients of our achievement was a tracking and documenting the process and outcome of our research projects. The documentation was instrumental in changing a couple of important health policies for chronic disease management in patients from the traditionally underserved community in Maryland. In this paper, we highlight the policy change processes that were driven by our evidence-based research.
    135st APHA Annual Meeting and Exposition 2007; 11/2007
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    ABSTRACT: This on-going smoking cessation project started in August 2002 based on a series of in-depth descriptive studies among Korean Americans in Maryland. These studies identified disproportionally high rates of current smoking among Korean men. Our previous environment assessment also revealed unusually high tolerance toward male smoking by family members and business owners. Therefore, we have put intense effort into developing and implementing culturally sensitive smoking cessation programs for individual smokers. Specifically, we developed an intervention program that consists of the following: (1) behavioral education-based, standardized 2-hour weekly smoking cessation classes for 4 weeks with weekly follow-up calls; and (2) long-running anti-tobacco media campaign in the Korean language. This individually focused intervention program has been offered to Korean smokers since 2003. A coalition of 8 organizations in Baltimore, Maryland and Washington D.C. area has worked together with university researchers to implement a state-wide media campaign via advertisements in local, ethnic newspapers, while utilizing other means of innovative approach targeting family members and youth groups. In addition, a community-wide coalition effort has been in place in order to address community behavior and attitudes about smoking including secondhand smoking. In particular, we have built an active partnership with mainstream antismoking organizations and policy makers to change policy on environmental smoking. This paper highlights essential steps that have been taken in order to achieve successful smoking related policy changes including indoor smoking policy in both Howard and Montgomery Counties in Maryland, U.S.
    135st APHA Annual Meeting and Exposition 2007; 11/2007
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    ABSTRACT: Title VI of the Civil Rights Act stipulates that any agency receiving federal funding needs to provide interpreters for persons with limited English proficiency. A series of community surveys and focus groups conducted by the Korean Resource Center (KRC), in collaboration with the Johns Hopkins University Korean American Health Research Initiative, revealed a strong and urgent need for adequate interpretive services for Korean Americans (KA) in Maryland. In response to this significant problem, the KRC-Hopkins team developed a program to train indigent bilingual speakers to function as medical interpreters. A total of 12 volunteers underwent our two-day training sessions. Training topics included: 1) code of ethics, 2) principles of medical interpretation, 3) medical terminology, and 4) cultural competency. This unprecedented program was publicized to mainstream care providers as well as to the KA community. Overall evaluation of this on-going program can be summarized as a limited success. While five mainstream healthcare agencies have sporadically utilized the service to meet the needs of their KA patients, most agencies still rely on traditional approaches of translation using untrained Korean staff or KA family members. Focus group interviews with health providers revealed that the major barrier to implementing this policy is no financial incentives given to the provider who utilizes trained medical interpreters. Rapidly rising medical cost in the U.S. along with complicated medical reimbursement system hinges the implementation of this policy which can result in inadequate healthcare utilization among non-English speaking minority populations.
    135st APHA Annual Meeting and Exposition 2007; 11/2007
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    ABSTRACT: Today's Korean American elderly are predominantly first-generation immigrants who face stern challenges of acculturation, which is often associated with depression. Social support has been identified as an effective personal resource for alleviating acculturative stress and achieving better mental health outcomes. The purposes of this study were to describe available sources of social support utilized by Korean elders and to examine the relationships among acculturative stress, social support, and depression. In particular, social support was operationalized as an integrative concept encompassing the size of the social network, satisfaction with the support received, and appraisals of the level of social support. This study was a secondary data analysis of an existing survey of 205 elderly Korean immigrants (>or=60 years) in a major metropolitan city on the East coast. Adult children were found to be the main source of support utilized by elders, even when the elder had a living spouse. Hierarchical multiple regression analysis revealed that higher acculturative stress and lower social support were associated with higher depression scores after demographics and health status were controlled for, whereas network size and satisfaction with support were not. Future interventions should address the cultural/social needs of these immigrants, not only by reinforcing their existing social network but also by providing additional support for their family members to prevent social isolation and depression in the population.
    Journal of Cross-Cultural Gerontology 03/2007; 22(1):115-27. DOI:10.1007/s10823-006-9022-2
  • Miyong Kim, Hae-Ra Han, Linda Phillips
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    ABSTRACT: Metric equivalence is a quantitative way to assess cross-cultural equivalences of translated instruments by examining the patterns of psychometric properties based on cross-cultural data derived from both versions of the instrument. Metric equivalence checks at item and instrument levels can be used as a valuable tool to refine cross-cultural instruments. Korean and English versions of the Center for Epidemiological Studies-Depression Scale (CES-D) were administered to 154 Korean Americans and 151 Anglo Americans to illustrate approaches to assessing their metric equivalence. Inter-item and item-total correlations, Cronbach's alpha coefficients, and factor analysis were used for metric equivalence checks. The alpha coefficient for the Korean-American sample was 0.85 and 0.92 for the Anglo American sample. Although all items of the CES-D surpassed the desirable minimum of 0.30 in the Anglo American sample, four items did not meet the standard in the Korean American sample. Differences in average inter-item correlations were also noted between the two groups (0.25 for Korean Americans and 0.37 for Anglo Americans). Factor analysis identified two factors for both groups, and factor loadings showed similar patterns and congruence coefficients. Results of the item analysis procedures suggest the possibility of bias in certain items that may influence the sensitivity of the Korean version of the CES-D. These item biases also provide a possible explanation for the alpha differences. Although factor loadings showed similar patterns for the Korean and English versions of the CES-D, factorial similarity alone is not sufficient for testing the universality of the structure underlying an instrument.
    Journal of Nursing Measurement 03/2003; 11(1):5-18. DOI:10.1891/106137403780954930
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    ABSTRACT: With the current wave of Asian immigration to the United States, awareness of their use of traditional medicine, often in combination with Western medicine, is an increasingly salient issue for health care professionals. This paper describes the use of traditional and Western medicine by Korean American elderly and factors that are associated with their health-seeking behaviors and health service utilization. Data were obtained from a convenience sample of 205 Korean elderly immigrants through interview. The findings revealed that health service utilization among Korean American elderly covered a broad spectrum of health resources, including the use of Western medicine, the traditional Korean medicine (hanbang), or both Western and traditional clinics. In addition, health insurance status and the source of health care were found to relate to the types of health service that Korean American elderly chose to utilize. Better understanding of patterns of health service utilization may improve the quality of health care by increasing health providers' cultural sensitivity and facilitating adequate communication between Asian immigrant clients and their care providers. Implications for research and practice are discussed.
    Journal of Community Health 05/2002; 27(2):109-20. DOI:10.1023/A:1014509200352 · 1.28 Impact Factor