Lingala et al.

BMC Dermatology 2014, 14:13

http://www.biomedcentral.com/1471-5945/14/13

RESEARCH ARTICLE

Open Access

Low rate of dermatology outpatient visits in

Asian-Americans: an initial survey study for
associated patient-related factors
Bharathi Lingala, Shufeng Li, Ashley Wysong, Allison K Truong, David Kim and Anne Lynn S Chang*

Abstract
Background: Asian-Americans represent the fastest growing minority group in the United States, but are
under-represented patients in outpatient dermatology clinics. At the same time, skin cancer rates in individuals of
Asian descent are increasing, but skin cancer detection appears to be delayed in Asian-Americans compared to white
individuals. Some health-care provider related factors for this phenomenon have been reported in the literature, but
the patient-related factors are unclear.
Methods: This exploratory study to identify patient-related factors associated with dermatology visits in Asian-Americans
was performed after Institutional Review Board (IRB) approval. An anonymous, online survey utilizing validated items was
conducted on adults who self-identified as Asian-American in Northern California. Univariate and multivariate logistic
regression for dermatology visits as indicated by responses to the question of ever having had skin checked by a
dermatologist were performed on survey responses pertaining to demographic information, socioeconomic factors,
acculturation, knowledge of melanoma warning signs and SSE belief and practice.
Results: 89.7% of individuals who opened the online survey completed the items, with 469 surveys included in
the analysis. Only 60% reported ever performing a SSE, and only 48% reported ever having a skin examination by
a dermatologist. Multivariate models showed that ever performing SSE (p < 0.0001), marital status (p = 0.02), family
history of skin cancer (p = 0.03) and generation in the United States (p = 0.02) were significant predictors of the primary
outcome of ever had skin checked by a dermatologist.
Conclusions: Identification of patient-related factors that associate with dermatology clinic visits in Asian-Americans is
important so that this potential gap in dermatologic care can be better addressed through future studies.
Keywords: Dermatology, Skin cancer, Early detection, Acculturation, Asian-Americans, Skin self-examination,
Dermatology visits, Prevention, Ethnic skin

Background
According to the 2012 United States Census Bureau,
Asian-Americans currently represent the fastest growing
minority group [1]. However, data from the National
Ambulatory Medical Care Survey (NAMCS) in 2010
showed that Asian-American represent only 1.07% of
ambulatory care visits to dermatologists even though
they comprise 3% of the American population. This is
potentially concerning as the overall incidence rate of
melanoma appears to be rising at 2.4% per year from
* Correspondence: [email protected]
Department of Dermatology, Stanford University, Pavilion C, 2nd Floor, 450
Broadway St, Redwood City 94063, CA, USA

19992006 in the U. S. in all races [2,3], a trend also

seen in worldwide populations where Asians are the majority [4-6]. In the U. S., data from the National Cancer
Institute Surveillance, Epidemiology and End Results
Program (SEER) database 20072011 showed age-adjusted
new melanoma cases per 100,000 persons was 8.1 for
Asian/Pacific Islanders (52.3 for whites). However, Asians
and Pacific Islanders had a higher rate of thicker and
distant melanomas compared to whites and Hispanics
[2,7-10]. Asians/Pacific Islanders in the U.S. also had lower
5-year survival rates than whites [2].
Factors related to delayed diagnosis could be either
patient-related or provider-related. Provider-related factors

2014 Lingala et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Lingala et al. BMC Dermatology 2014, 14:13

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Page 2 of 7

Table 1 Characteristics of study participants, with n = 469

responses included unless otherwise indicated

Table 1 Characteristics of study participants, with n = 469

responses included unless otherwise indicated (Continued)

Demographic and socioeconomic factors

Ever performed skin self-examination (SSE)

Number (%)

Age in years, mean (SD)

37.2 15.9

Gender

Never

159 (34%)

1-3 times

144 (31%)

Male

147 (31%)

4-6 times

39 (8%)

Female

322 (69%)

7-9 times

5 (1%)

Single

240 (51%)

Married

187 (40%)

Marital status

10 or more times

94 (20%)

Not sure

28 (6%)

Ever had skin checked by dermatologist

Separated, Divorced, Widowed

28 (6%)

Never

237 (51%)

Domestic union (living together)

14 (3%)

1-3 times

155 (34%)

4-6 times

38 (8%)

Education
High School

34 (7%)

College

249 (53%)

Graduate or Professional

180 (38%)

Grade school or no formal education

6 (1%)

Annual household income (n = 441, missing data n = 18)

7-9 times

5 (1%)

10 or more times

23 (5%)

Not sure

11 (2%)

Self-assessed risk for getting skin cancer during lifetime, n = 465

Mildly agree

185 (40%)

< $25,000

67 (15%)

Mildly disagree

$25,000 - $50,000

77 (17%)

Neither agree nor disagree

72 (15%)

$50,001 - $75,000

73 (17%)

Strongly agree

144 (31%)

$75,001 - $100,000

62 (14%)

> $100,000

162 (37%)

Has health insurance

419 (89%)

Strongly disagree

Generation in the United States

First generation (born outside US)

160 (39%)

Second Generation

175 (43%)

Third Generation

41 (10%)

Fourth Generation

26 (6%)

Fifth Generation

8 (2%)

Self-rated acculturation, n = 410 (missing response n = 59)

Very Asian

46 (11%)

Mostly Asian

72 (18%)

Bicultural

159 (39%)

Mostly Westernized

88 (21%)

Very Westernized

45 (11%)

Additional parameters
Personal history of skin cancer

8 (1.7%)

Family history of skin cancer

19 (4.1%)

Co-worker or friend with history of skin cancer

116 (25%)

Has heard of ABCDEs of melanoma

79 (16.8%)

Belief in skin self-examination (n = 466, missing response n = 3)

Disagree

82 (18%)

Neutral

97 (21%)

Agree

287 (61%)

23 (5%)

Skin burns when exposed to strong sunshine without protection,

n = 460
Not at all

Acculturation, n = 410

41 (9%)

32 (7%)

Somewhat

203 (44%)

Very little

118 (26%)

Yes (red, painful burn)

107 (23%)

Skin tans when exposed to strong sunshine without protection,

n = 452
Not tan at all - I just burn

15 (3%)

Tan Slightly

86 (19%)

Tan deeply

140 (31%)

Tan moderately

211 (47%)

Number of blistering sunburns in lifetime, n = 468

0

206 (44%)

1-2

168 (36%)

3-4

65 (14%)

5 or more

29 (6)

reported include a lowered index of suspicion among clinicians and different anatomic sites leading to advanced
stages at presentation and a poorer prognosis [2]. Patientrelated factors are less clear. One hypothesis is that AsianAmericans visit dermatology clinics at a lower rate than
other races, as suggested by the NAMCS data. Although
there is data on patient characteristics such as personal
skin cancer history, skin type, psychosocial factors that

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Table 2 Univariate and multivariate analyses on the primary outcome variable of ever had skin checked by
a dermatologist
Demographic and socioeconomic factors

Univariate OR (95% CI)

Multivariate OR (95% CI)

Age (1 year)

1.02 (1.01 - 1.04)

<0.0001

1.00 (0.97 - 1.03)

0.89

Gender (Female (ref = Male))

1.63 (1.09 - 2.43)

0.02

1.17 (0.62 - 2.21)

0.64

Marital status
Ref

Single

Ref

Married

2.02 (1.37 - 2.97)

Separated, Divorced, Widowed

3.90 (1.65 - 9.22)

<0.001

2.52 (1.06 - 5.99)

3.05 (0.65 - 14.3)

Ref

Ref

0.09

Education
High School
College

1.12 (0.55 - 2.31)

Graduate/Professional School

1.00 (0.48 - 2.10)

0.83

1.84 (0.55 - 6.11)

1.62 (0.46 - 5.72)

Ref

Ref

0.60

Annual household income

< $25,000
$25,001-50,000

1.61 (0.79 - 3.28)

$50,001-75,000

3.24 (1.59 - 6.61)

$75,001-100,000

2.98 (1.43 - 6.23)

3.33 (1.10 - 10.07)

> $100,000

2.68 (1.44 - 4.99)

2.19 (0.86 - 5.62)

Has health insurance

0.77 (0.38 - 1.57)

1.83 (0.65 - 5.14)

0.004

0.47

3.01 (1.03 - 8.79)

0.62 (0.21 - 1.84)

0.21

0.39

Acculturation
Generation in the United States
Ref

First Generation (born outside US)

Second Generation

1.92 (1.23 - 2.99)

Third Generation

3.68 (1.77 - 7.65)

Fourth or more Generation

2.99 (1.37 - 6.52)

Ref
<0.0001

1.83 (0.92 - 3.61)

0.40

1.52 (0.45 - 5.15)

1.63 (0.52 - 5.04)

Self-rated acculturation
Ref

Ref

2.52 (1.12 - 5.67)

0.94 (0.34 - 2.56)

Very Asian
Mostly Asian
Bicultural

2.15 (1.03 - 4.47)

Mostly Westernized

4.82 (2.17 - 10.67)

0.001

1.09 (0.37 - 3.22)

1.81 (0.59 - 5.58)

Very Westernized

3.76 (1.52 - 9.34)

1.83 (0.48 - 6.92)

0.44

Additional parameters
Personal history of skin cancer

7.71 (0.94 - 63.11)

0.06

Family history of skin cancer

3.92 (1.27 - 12.05)

0.02

5.67 (0.94 - 34.08)

NR*
0.06

Co-worker or friend with history of skin cancer

2.37 (1.52 - 3.69)

0.001

1.05 (0.54 - 2.05)

0.89

Has heard of ABCDEs of melanoma

1.78 (1.08 - 2.94)

0.03

1.20 (0.57 - 2.53)

0.64

Belief in SSE
Ref

Disagree
Agree

2.44 (1.45 - 4.12)

Neutral

1.05 (0.56 - 1.97)

Ever performed SSE

4.28 (2.79 - 6.59)

Ref
<0.0001

1.29 (0.50 - 3.32)

0.23

1.98 (0.84 - 4.67)

<0.0001

2.99 (1.54 - 5.80)

0.0099

1.18 (0.28 - 5.00)

0.0012

Self-assessed risk for getting skin cancer during lifetime, n = 465

Strongly disagree

Ref

Mildly agree

1.34 (0.54 - 3.35)

Mildly disagree

1.58 (0.54 - 4.61)

Ref

1.72 (0.33 - 8.98)

0.13

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Table 2 Univariate and multivariate analyses on the primary outcome variable of ever had skin checked by
a dermatologist (Continued)
Neither agree nor disagree

1.17 (0.43 - 3.15)

0.60 (0.13 - 2.76)

Strongly agree

2.69 (1.06 - 6.82)

1.99 (0.45 - 8.73)

Skin burns when exposed to strong sunshine without protection

Not at all

Ref

Ref

Somewhat

1.46 (0.67 - 3.17)

1.37 (0.43 - 4.40)

Very little

1.70 (0.76 - 3.81)

Yes (red, painful burn)

1.52 (0.67 - 3.45)

0.54

2.53 (0.76 - 8.46)

0.05

0.77 (0.22 - 2.74)

Skin tans when exposed to strong sunshine without protection

Not tan at all - I just burn

Ref

Ref

Tan Slightly

1.61 (0.51 - 5.12)

Tan deeply

2.45 (0.80 - 7.55)

Tan moderately

1.76 (0.58 - 5.34)

0.20

0.37 (0.06 - 2.25)

0.85 (0.15 - 4.84)

0.13

0.57 (0.10 - 3.15)

Number of blistering sunburns in lifetime

Ref

Ref

1-2

1.13 (0.75 - 1.71)

1.28 (0.67 - 2.43)

3-4

1.30 (0.74 - 2.28)

5 or more

1.28 (0.57 - 2.85)

0.78

1.32 (0.58 - 3.01)

0.73

1.92 (0.49 - 7.49)

*Not included in multivariate analysis due to small number of skin cancers (n = 8).
Multivariate analysis was based on n = 324 unless otherwise indicated.
Bolded numbers indicate significance at a level P<0.05.

associate with clinical skin examinations [11], there is no

data in Asian or Asian-American populations. Furthermore, cutaneous examination by a dermatologist is known
to impact skin cancer stage at initial presentation [12-17].
This study examines factors that correlate with ever
having skin checked by a dermatologist in a Northern
California Asian-American population. Because of the
overwhelmingly outpatient nature of dermatology, having
skin checked by a dermatologist almost always occurs in
the setting of an outpatient dermatology clinic visit. In
addition, we acknowledge that the guidelines for frequency and utility of dermatologists cutaneous examinations particularly in asymptomatic people of color
continues to be debated due to the lack of high quality
evidence for this practice [3,15-18].

Methods
The study was approved by the Stanford Human Subjects
Panel and the need for a written consent was waived as the
study was anonymous and voluntary. An online survey
study of adults in Northern California who self-identified
as Asian-American was performed and included items on
demographic information, socioeconomic factors, acculturation, belief in SSE, having heard of melanoma warning
signs, SSE practices and ever having skin checked by
dermatologist. Survey items were adapted from previously
published skin cancer survey instruments [19] and previously published acculturation tools [20-22]. Additional
file 1: Figure S1 shows the actual survey instrument,

with items used in the study analysis highlighted. Because

of the many languages spoken within the Asian population in northern California, the survey was available in
English only. To minimize bias toward Asian-Americans
with access to dermatologic care, this study was conducted completely online rather than at dermatology
clinics. The survey was placed online via the Stanford
University Surveyor Web site. The web site address was
distributed to leaders of Northern California community
groups that were likely to contain a large portion of
Asian-Americans for circulation among community group
members to identify participants for this study. These
group members were all adults. Because of technical limitations, we could not prevent individuals who were under
18 years of age or not Asian-American from accessing the
survey. These individuals were excluded prior to statistical
analysis (see Results section).
Because of the online format, a conventional response
rate could not be calculated. However, we did track the
number of participants who completed the survey divided by the number of clicks (hits) from unique Internet
Protocol (IP) addresses for this web site regardless of
whether any survey items were completed.
Characteristics of the study subjects were summarized
using descriptive statistics. Clinically meaningful variables
were chosen for analysis and based on review of the medical literature [23-25]. Univariate and multivariate logistic
regressions were performed on the primary outcome variable of ever had skin checked by a dermatologist.

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A final multivariate analyses model on the primary

outcome variable of ever had skin checked by a dermatologist was generated after checking for multicollinearity or interactions between any two variables,
then applying stepwise selection, plus the variables of
interest. Of note, while generation in the United States
and self-rated acculturation did not meet the threshold
for collinearity, there was a significant association between these two variables. Hence, only generation in
the United States was included in the final model. All
statistical analyses were conducted using SAS statistical
software package (Version 9.1, SAS Institute, Inc., Cary,
North Carolina).

Results
Of the 564 individuals who visited the survey website,
506 (89.7%) completed the survey. To ensure an AsianAmerican population, individuals who self-identified as
only white (n = 27) or other (n = 10) were excluded
from the study. The final study sample included 469 individuals. Table 1 shows the demographic characteristics of this group. The most common self-identified
races in the study sample were Chinese (39%), Japanese
(18%), Taiwanese (8%), Filipino (7%), Korean (7%), and
Vietnamese (6%). Other groups represented (<6% each)
include Pacific Islander, Thai, Laotian, Cambodian, AfricanAmerican, and Caucasian (individuals were allowed
to select more than one race or ethnicity to allow for
mixed race). Thirty-four percent of individuals were
born outside of the United States (first-generation), while
37%, 9%, 6%, and 2% self-identified as second, third, fourth,
and fifth generation Americans, respectively. To further assess the degree of cultural identification, respondents were
also asked to self-rate their acculturation, with 15% identifying their acculturation as mostly Asian, 10% as very
Asian, 34% as bicultural, 19% as mostly westernized,
and 10% as very westernized.
Overall, only 48% of respondents reported ever having
their skin checked by a dermatologist. Univariate analyses on the primary outcome of ever had skin checked
by a dermatologist are presented in Table 2. In multivariate analysis, the only variable significantly associated
with ever having skin checked by dermatologist was
ever performed a skin self-examination, (p < 0.0012)
(Table 2). Only 60% of respondents had ever performed
an SSE. In multivariate analysis, a family history of skin
cancer and ever having skin checked by dermatologist
showed a trend toward significance (p = 0.06).
To explore predictors of having skin checked by a
dermatologist, multiple multivariate analyses varying
the variables were performed, after accounting for multicollinearity or interaction (results shown in Table 3).
Significant predictors of having skin checked by a dermatologist included Ever Performed SSE (p < 0.0001), marital

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Table 3 Final multivariate analyses model on the primary

outcome variable of ever had skin checked by a
dermatologist
Characteristic

Multivariate OR (95% CI)

Education
High School

Ref

College

2.19 (0.80 - 6.00)

Graduate/Professional School

1.64 (0.57 - 4.74)

0.24

Annual household income

< $25,000

Ref

$25,001-50,000

1.93 (0.79 - 4.72)

$50,001-75,000

3.19 (1.24 - 8.23)

$75,001-100,000

3.70 (1.41 - 9.71)

> $100,000

2.60 (1.13 - 6.02)

0.07

Has health insurance

0.55 (0.22 - 1.41)

0.22

Ever performed SSE

3.32 (1.95 - 5.65)

<0.0001

Marital status
Single

Ref

Married

2.04 (1.13 - 3.70)

Separated, Divorced, Widowed

3.56 (1.01 - 12.61)

Family history of skin cancer

6.50 (1.15 - 36.69)

0.02

0.03

Generation in the United States

First Generation (born outside US)
Second Generation
Third Generation
Fourth or more Generation

Ref
2.11 (1.20 - 3.72)

0.02

2.21 (0.85 - 5.80)

3.14 (1.17 - 8.42)

This model was selected after checking for multi-collinearity or interactions

between any two variables, then applying stepwise selection, plus the variables of
interest. Analysis based on n = 349 responses.
Bolded numbers indicate significance at a level P<0.05.

status (p = 0.02), generation in the United States (p = 0.03),

and family history of skin cancer (p = 0.03).

Discussion
The rates of ever had skin checked by dermatologist
in our Asian-American study population are difficult to
directly compare with other minority groups. Perhaps
the most similar study in the literature was an online
survey of Hispanics living in the United States, which
showed only 9.2% had a total cutaneous examination
[10]. As the overall purpose of our study was to examine patient-related factors associated with dermatologic
clinic visits, our current survey did not ask if a patient
had a total cutaneous examination, only whether they
ever had skin checked by dermatologist. This would
likely include skin checks for benign skin disease as
well as skin cancer surveillance, hence, accounting for
our higher percentage of individuals ever having skin
checked by dermatologist compared to total cutaneous

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examinations reported in other studies. It is also difficult

to directly compare our study with existing studies in
other minority groups due to differences in geographic
locales and survey methods.
The study participants were similar to the local AsianAmerican community with respect to household income,
education and health insurance status. For instance, the
median household income for single race Asian households in Santa Clara County, the location of our institution, was $68,780 (by the U.S. Census, 2009); for our
study, 50% of participants reported incomes above $75,000.
For education level in single race Asians in Santa County
Clara County, 50% have a bachelors or some college degree; this is 53% in our study. For health insurance in single
race Asians in Santa Clara County, 17.2% did not have
health insurance; 11% in our survey did not. Hence, this
study is likely generalizable to the local Asian-American
community.
This study was conducted only in English (due to the
large number of languages spoken by Asian-Americans
in Northern California) and is therefore biased in favor
of those proficient in English. In addition, this study
was performed online, hence accessible only to those
with computer literacy and Internet access. Finally, the
Asian-American community is very heterogeneous and
therefore, this study does not necessarily represent the
demographic and clinical factors and practices of each
subgroup.
Finally, SSE and cutaneous examinations by dermatologists have been significantly linked in previous studies
that did not primarily focus on Asian-Americans [26].
Nevertheless, the ideal frequency of SSE and cutaneous
examinations in asymptomatic persons of any race has not
been established, in part due to the lack of high quality
studies to support these measures [3,15-18]. Nevertheless,
a recent expert opinion article by Agbai et al. in persons of
color did suggest monthly self-skin examinations, though
no recommendations were made for cutaneous examinations by dermatologists [3].

Conclusion
Future research is needed to determine the optimal frequency of skin examinations in Asian-Americans and
whether increased dermatology clinic visits lead to earlier
detection of skin cancers in Asian-Americans.
Additional file
Additional file 1: Figure S1. Survey instrument with items included in
the analysis highlighted in yellow.

Competing interests
The authors have no competing interests to declare.

Page 6 of 7

Authors contributions
BL contributed to conception, design, statistical analysis and data interpretation.
AW and AC contributed to the conception, design, data acquisition, statistical
analysis, data interpretation, manuscript draft and revision. SL contributed to
design, statistical analysis, data interpretation, manuscript draft and revision.
AT contributed to data interpretation and manuscript draft and revision. DK
contributed to data acquisition and manuscript draft. All authors read and
approved the final manuscript.
Authors information
Anne Lynn Chang is an Assistant Professor of Dermatology at Stanford
University School of Medicine. She is Director of the Stanford Dermatology
Adult Dermatological Clinical Trials, the Advanced Basal Cell Carcinoma
Clinic and a member of the Stanford Cancer Institute.
Bharathi Lingala and Shufeng Li are co-first authors.
Received: 26 May 2014 Accepted: 22 July 2014
Published: 2 August 2014
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Cite this article as: Lingala et al.: Low rate of dermatology outpatient
visits in Asian-Americans: an initial survey study for associated patientrelated factors. BMC Dermatology 2014 14:13.

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