The specific health beliefs and practices of immigrant populations in the U.S. pose challenges to the development of effective and culturally appropriate cancer prevention programs. In the present study we sought to understand Chinese immigrants’ recognition of cervical cancer risk factors. We found that most risk factors were recognized by less than half of our participants. Studies looking at other minority populations and the general U.S. population have shown a similar overall level of knowledge for cervical cancer risk factors. The pattern of recognition between populations, however, is somewhat varied. For certain risk factors associated with sexual activity, our Chinese immigrant respondents had very similar knowledge to studies of the general U.S. population. Recognition of multiple sexual partners as a risk factor was comparable in our study (49%) to that of the North American general population (35–60%).32–34
Recognition of a sexually transmitted disease history as a risk factor was also similar among our Chinese immigrant participants (47%), compared to the U.S. (52%).33
However, our Chinese immigrant respondents had poor recognition of the early onset of first intercourse as a risk factor (27%), compared to the North American population (39%) as a whole.33
Seventy-two percent of our participants recognized the importance of obtaining a Pap smear in preventing cervical cancer. This is particularly notable, since in a previous analysis of this population, only 60% had obtained a Pap smear in the previous two years.12
Marital status was associated with recognition of cervical cancer risk factors. Women who were never married had higher knowledge compared to those who had been previously married. Women who were never married also tended to have higher knowledge than those currently married. In a former study of Chinese immigrants from the same study population, we saw the opposite association between marital status and Pap smear history. In that analysis, immigrants who were married had 6.9 times the odds of ever having received a Pap smear compared to those who were never married. Similarly, those who were previously married had 4.3 times the odds of ever having received a Pap smear.12
The positive association of marriage and receipt of Pap smears has been documented in other minority populations, as well the general U.S. population.33,35–38
We are unaware of other studies that have examined the relationship between marital status and knowledge of cervical cancer risk factors. Since we did not hypothesize an a priori relationship between knowledge of cervical cancer risk factors and marital status, our results may be due to multiple comparisons. This relationship between marital status and knowledge of cervical cancer risk factors needs to be independently confirmed.
The relationships in our study between other sociodemographic characteristics and knowledge of cervical cancer risk factors are consistent with findings from a study of the general US population. In an analysis using the National Health Interview Survey (NHIS), investigators evaluated factors that predicted recognition of multiple sexual partners as a risk factor for cervical cancer.32
In both our study of Chinese immigrants and the NHIS study of the general US population, increasing years of education was associated with knowledge of cervical cancer risk factors. Income was also associated with knowledge of cervical cancer risk factors in the NHIS study as well as in our unadjusted analysis of Chinese immigrants. Our analysis of income is limited, however, due to a 44% non-response rate for income in our participants.
The association between knowledge of cervical cancer risk factors and Pap smear testing in our study is similar to other studies of the general U.S. population. In a study of inner city Baltimore women, those participants with higher knowledge of cervical cancer were more likely to have received adequate Pap smear testing compared to those women with lower knowledge of cervical cancer risk factors (p
A study using the National Health Interview Survey also showed that women with either knowledge of cervical or breast cancer risk factors had greater likelihood of cervical and breast cancer screening (OR 1.7; 95% CI: 1.1,2.7).40
Our results from unadjusted analysis showed similarly that women with the highest knowledge scores were more likely to have ever received a Pap smear in comparison to those women with the lowest knowledge scores (OR 2.3; 95% CI: 1.1,4.8). In our adjusted analysis, this relationship persisted, but was not statistically significant. The unadjusted analysis, however, may be more representative of the relationship between cervical cancer knowledge and Pap testing, since the variables used in the adjusted analysis including age, housing type and marital status, are potentially determinates of cervical cancer knowledge, rather than confounders in the relationship between cervical cancer knowledge and Pap testing.
Our study has potential limitations. First, we focused our study on a high-density population of Chinese Americans in the Seattle area. The generalizability of our data to less densely populated areas of Chinese American immigrants is not clear. Second, we do not know how the individuals who refused to participate or were unreachable may have affected our data. Third, since we excluded those individuals who did not speak Mandarin Cantonese or English, other more linguistically isolated dialects are not represented. Fourth, we selected the oldest woman in our survey households as participants. Younger women may have a different understanding of cervical cancer. Fifth, our study does not directly assess knowledge of human papilloma virus (HPV) as a probable cause of most cervical cancer. We chose instead to look at behaviors that affect HPV infection, such as a history of multiple sexual partners.
Our assessment of knowledge is based on a biomedical model, which may not capture culturally specific interpretations of our questions. Several of our questions about cervical cancer risk factors resonate with behaviors that are traditionally associated with gynecologic problems in Chinese culture.41
Although our Chinese participants may have correctly identified these risk factors, the reasons behind their answers may be very different from those of the general North American population. Divergent reasons for similar beliefs or knowledge can have a profound impact on preventive health behaviors, as exemplified by the Latin American community. A Los Angeles study found that Latina immigrants had far higher knowledge of several cervical cancer risk factors than either the non-immigrant Latina population or the general population. Those same Latinas who recognized these cervical cancer risk factors, however, were less likely to have had a Pap smear in the previous three years.33
Prior qualitative work helped sort out this apparent paradox. Many Latinas attributed cervical cancer risk to lifestyle choices, which were morally charged, such as having multiple sexual partners.33,42
Latinas consequently tended to avoid Pap smears, since they were associated with an admission of immoral behavior in their culture. Many Latina immigrants also attributed a diagnosis of cervical cancer to fate or punishment by God, which may further impede cancer prevention behaviors in this less acculturated population.33,43
Chinese culture has specific gender roles and perceptions of sexuality that may impact immigrants’ perceptions of cervical cancer and affect Pap smear rates.6,44
However, our results suggest that these cultural differences may not impact Pap testing in Chinese immigrants to the same degree as the Latina immigrant population. First, as previously noted, higher knowledge in our participants was associated with greater odds of ever having received a Pap test (OR 2.5; 95% CI: 1.1,5.8). Second, Chinese Americans are less likely to perceive cancer as a form of punishment or a death sentence compared to the Latina population.45
Third, we found in a recent study that a belief in fate or karma as a cause of cancer did not play a significant role in whether Chinese American women obtained Pap smears.46
There is a need for culturally and linguistically appropriate interventions to reduce cervical cancer incidence and mortality among immigrant Chinese Americans. The development of these interventions should be based on an understanding of the health beliefs and attitudes of Chinese immigrants. Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants, especially among the less educated. Future studies should clarify the roles of sexuality and sexual mores in Chinese American immigrants’ understanding of cervical cancer. Studies could also further explore the potential impact of specific beliefs about cervical cancer on preventive behaviors, such as Pap smear testing. By continuing to improve our understanding of Chinese immigrants perceptions of cervical cancer we can develop more effective and appropriate primary and secondary prevention programs.