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  • br Literature has shown that the


    Literature has shown that 14003-96-4 the underutilization of CRC screening among Korean Americans is associated with their low health literacy [13,14]. Health literacy is a critical competence in assuring and promoting individuals’ health through obtaining, processing, and understanding basic health information and services needed
    to inform health decisions [15–17]. Prior research found that Korean Americans have lower levels of health literacy than non-Hispanic whites, resulting in suboptimal cancer screening [18–20]. Studies also showed that Korean Americans with limited health literacy are less likely than those with appropriate health literacy to use preventive health care services and adhere to cancer screening guidelines [21–23]. This suggests that there is the need to enhance health literacy in order to facilitate cancer screening among Korean Americans [24–26].
    A growing body of research has proposed that health literacy can be affected by online health information seeking (OHIS) [27]. As people have increasingly used Internet-enabled devices to seek health information and the Internet has become a primary medium to find and deliver health information [28], OHIS is essential to ensuring adequate health literacy and, ultimately, optimal health outcomes [29–31]. Research has shown that limited use of Internet technologies for health information seeking is related to poor health literacy [32–38]. A systematic review study also found that people who poorly evaluate online health information tend to have low health literacy [39]. Furthermore, the Health Information National Trends Survey on adults' use of cancer-related information demonstrated the positive link be-tween engaging and interpreting online health information and health literacy, implying the potential effects of OHIS behaviors on improving cancer screening outcomes [40,41].
    While the existing literature shows some evidence of the associations among health literacy, OHIS, and cancer screening, little is known about the relationship between OHIS and cancer screening, especially among Korean Americans. Moreover, the role of health literacy in such relationship remains unclear because few studies have employed theories that explain the pathways for OHIS to develop health literacy and lead to cancer screening outcomes. To fill these gaps in the body of knowledge and literature, the present study sought to examine hypothetical pathways through which OHIS influences health literacy, which, in turn, leads to CRC screening among Korean Americans. To guide establishment of the pathways, Z lines study used multi-theoretical frameworks: Health Literacy Skills Framework [42] and Cognitive Mediation Model [43].
    1.1. Conceptual framework
    1.1.1. Health literacy skills framework
    The Health Literacy Skills Framework delineates a comprehensive conceptual framework of what factors influence health literacy and, simultaneously, how health literacy relates to health outcomes [42]. Squiers andcolleagues conceptualizedthis framework to close the gap between prior theories and models in addressing a full continuum of health literacy frameworks [42]: some researchers focused only on explaining factors contributing to the acquisition and development of health literacy skills [44,45]; others attended largely to describing causal pathways linking health literacy to health outcomes [46,47]. By
     comparison, the Health Literacy Skills Framework explicates both moderators influencing the development of health literacy and mediators affecting the link between health literacy and health outcomes [42]. For example, the Health Literacy Skills Framework posits that people’s decisionalbalance— cognitiveevaluation basedon attitudes and beliefs associated with individuals’ culture and norms— functions as a mediator between health literacy and health outcomes [44]. The person needs more than adequate skill sets in acquiring and comprehending health information pertaining to a cancer and the availability of screening options. A person’s attitudes and beliefs of the screening tests also play a role in engaging in the tests. A person’s negative attitudes and beliefs may impede the person from using the screening tests [48]. Prior studies also showed the significant role of Korean Americans’ attitudes and beliefs about CRC screening in screening outcomes. A population-based studyin California found that the negative attitudes and beliefs, including fear of pain or embarrassment related toCRC screening anda lack of healthproblems for Korean Americans, were primary reasons for not utilizing CRC screening [11]. A cross-sectional study in New York City showed that low confidence in a screening test and increased perceived CRC-related severity, helplessness, and fatalism were associated with low CRC screening among Korean Americans [49]. Another study demonstrated that whether a person considers CRC screening tests to beaffordableis asignificant factor affecting CRC screening decisions [50].