br Cognitive mediation model br This study also
1.1.2. Cognitive mediation model
This study also employed the Cognitive Mediation Model as another conceptual framework to better explain the pathways linking OHIS to health literacy. Whereas the Health Literacy Skills Framework is useful in explaining factors (e.g., OHIS) contributing to the development of health literacy and the link between health literacy and health outcomes through mediators (e.g., decisional balance), it 52128-35-5 is limited in explaining the process of the development of health literacy. The Cognitive Mediation Model posits that people’s various motivations influence their knowledge develop-ment through attention to information and information elabora-tive processing . Particularly, with the Cognitive Mediation Model, Jiang and Beaudoin  showed the associations among health-related motivations (e.g., cancer history), OHIS behaviors, information overload, and health literacy using a population-based data. Their study found that OHIS behaviors were positively associated with health literacy, mediated by perceived information overload—people’s limited capacity to process information— highlighting an inverse association between information overload and health literacy .
Taken together, this study hypothesized the following pathways as shown Fig. 1:
H1. OHIS is positively associated with health literacy.
H1a. OHIS is positively associated with information overload.
Fig. 1. Hypothetical Paths from OHIS to Health Literacy to CRC Screening.
H1b. Information overload is inversely associated with health literacy.
H2. Health literacy is positively associated with CRC screening.
H2a. Health literacy is positively associated with decisional balance.
H2b. Decisional balance is positively associated with CRC screening.
2.1. Research design and data collection
A cross-sectional survey design was employed in this study. Convenience sampling was conducted to recruit Korean Ameri-cans. The inclusion criteria of the study were individuals who self-identified as Korea Americans, aged 50–75, and resided in the metropolitan area in the Southeastern U.S. The recruitment occurred between May 2015 and February 2016 through advertise-ments via a local ethnic radio station, religious organizations, senior day care centers, and referrals. Those who were interested in the study contacted the research team via phone, email, or in-person and were screened according to the inclusion criteria. Those who met the inclusion criteria selected a time and place (i.e., home, a church, a senior day care center, or a local community center) for data collection using a self-reported survey based on their preference and convenience. A total of 433 Korean Americans met the criteria and participated in the survey which collected information about sociodemographics, a history of cancer for self and family, regular annual medical check-ups, OHIS behaviors, information overload, general health literacy, decisional balance (i.e., attitudes and beliefs about CRC screening), and CRC screening history (FOBT, sigmoidoscopy, and colonoscopy). Among 433 participants, 240 participants who reported experiences of seeking health-related information through the Internet were selected for data analyses to test the study hypotheses. An institutional review board approved proton study.
2.2. Instruments and measures
CRC screening history was a dependent variable of the study. In particular, completion of each of FOBT, sigmoidoscopy, and colonoscopy was used as a dependent variable in each model. For example, participants’ completion of colonoscopy was measured with one item: “Have you ever received colonoscopy?” To this question, a ‘yes’ response was denoted as 1 and ‘no’ was 0. The selection of ‘no’ indicates that a participant had never had colonoscopy.
Decisional balance was used as a mediating variable in all three models to measure attitudes and beliefs about each of the three CRC screening tests. This study adopted a 18-item decisional balance scale used by Costanza and colleagues . The scale consisted of seven items with a positive statement and eleven items with a negative statement. For example, a positive statement includes: “Having colonoscopy screening gives me peace of mind about my health”; a negative statement includes: “Screening causes me a lot of worry or anxiety about getting colonoscopy.” A ‘yes’ response was denoted as 1 and ‘no’ was 0. The scores summing up all ‘yes’ (=1) responses were used in the analyses and standardized ranging from 0 to 1. The total decisional balance
score for colonoscopy, FOBT, and sigmoidoscopy, respectively, demonstrated moderate internal consistency with an alpha coefficient of 0.772, 0.743, and 0.768.