We previously completed a survey of Vietnamese women in Seattle during 2002. This earlier survey found that 71% of women without a history of hysterectomy had been screened for cervical cancer at least once and 68% had been screened in the last three years (Taylor et al. 2004b
). In the five years since our prior survey, Pap testing rates have increased substantially. Specifically, in 2006–2007, we found that 92% of women without a history of hysterectomy had ever received a Pap smear and 82% had received a recent Pap smear (in the last three years). Over the last five years, Seattle’s Vietnamese community has been the focus of cervical cancer control efforts by the National Breast and Cervical Cancer Early Detection Program, as well as a community clinic system serving limited English speaking Asian Americans. Our findings indicate that these efforts may have been successful in increasing Pap testing levels among Vietnamese women.
This study identified sub-groups of women who could usefully be the focus of future cervical cancer control efforts in Vietnamese communities. For example, over one-quarter of never married women had not received a Pap smear, and the odds of ever having been screened were about four times higher among currently/previously married women than among never married women in our backward elimination model. Similarly, the odds of Pap test receipt on at least one occasion were estimated to be four times higher among women who had been in the US for at least 20 years than those who had been in the US for less than 10 years.
Current cervical cancer screening guidelines specify that women aged 70 years and older who have had three or more normal Pap smears and no abnormal Pap smears in the last 10 years may choose to stop cervical cancer screening. They also specify that screening is not necessary after hysterectomy with removal of the cervix (Saslow et al. 2002
). Therefore, it is not surprising that women in their seventies had lower levels of recent Pap testing than younger women, and women with a history of hysterectomy had lower levels of recent Pap testing than women without a history of hysterectomy. Interestingly, nearly three-quarters of our respondents with a history of hysterectomy did report a recent Pap smear. While a proportion of these women may have received a hysterectomy without removal of the cervix, this finding suggests that some physicians may be performing unnecessary Pap testing.
Some authors have speculated that traditional health beliefs may act as barriers to utilization of preventive health services (Jenkins et al. 1996
). A majority of our respondents believed cervical cancer can be prevented by traditional Vietnamese washing procedures and proper observance of the sitting month; however, these beliefs were not important correlates of Pap testing behavior. Nonetheless, it is important that health educational programs for Vietnamese and other immigrant groups recognize communities’ cultural beliefs and incorporate them into intervention programs. Indeed, decontextualization of a health problem from the belief systems and daily routines of the target population may diminish the effectiveness of health education efforts (Hubbell et al. 1995
Levels of knowledge about Pap testing were relatively high and over 80% of our participants knew that Pap testing is necessary for asymptomatic women, Pap testing is necessary for sexually inactive women, and Pap testing is necessary for post-menopausal women. Our multivariable analyses of knowledge/beliefs and Pap testing suggest that educational programs might usefully focus on the role of Pap testing in the prevention of cervical cancer and the necessity of Pap testing for all women.
Our summary multivariable analyses indicate that health care factors are the most important determinants of cervical cancer screening participation. Findings with respect to physician–patient communication about Pap testing were very similar to those reported from a recent study of Vietnamese women in California and Texas. Specifically, Nguyen and colleagues found that women who had requested a Pap test were nine times more likely to have ever been screened than women who had never requested the test, and women who had received a physician recommendation were eight times more likely to have ever been screened than those who had not received a recommendation (Nguyen et al. 2002
Previous research has consistently demonstrated that women of Southeast Asian descent who have a female doctor are more likely to receive cervical cancer screening than those who have a male doctor (McPhee et al. 1997a
; McPhee et al. 1997b
; Nguyen et al. 2002
; Taylor et al. 1999
; Taylor et al. 2004a
). However, previous findings with respect to physician ethnicity have been inconsistent (McPhee et al. 1997a
; McPhee et al. 1997b
; Nguyen et al. 2002
; Taylor et al. 2004a
). In this study, multivariable analyses indicated that women with a male Vietnamese doctor were no more likely to have been recently screened than those with no regular doctor. However, screening rates among women with a female Vietnamese physician were comparable to those among women with a non-Vietnamese physician. Low levels of Pap smear use among Vietnamese male physicians may be attributable to a lack of emphasis on prevention during medical training in Vietnam, as well as a cultural sensitivity to personal modesty issues among female patients (Lai et al. 2004
). If male Vietnamese physicians are uncomfortable performing Pap tests, they could be advised to refer their patients to an appropriate provider. Finally, our results suggest that positive associations between physician-patient racial/ethnic concordance and quality of care cannot be assumed (Cooper and Powe 2004
Coyne and colleagues conducted a literature review of factors associated with cervical cancer screening among women in the US. This review found that individual barriers to screening, as well as their relative importance, differ markedly between population subgroups. For example, Spanish-speaking Latina women are more likely to report that they find Pap smears embarrassing and frightening than do English-speaking Latina women. As might be expected, logistic issues such as transportation, childcare, and concern about using scarce resources for unnecessary tests are most important among socially disadvantaged and racial/ethnic minority women. For the female population as a whole, these authors concluded that the most important barriers to Pap testing are perceptions that it is unnecessary, fear of embarrassment, and lack of physician recommendation (Coyne et al. 1992
A group of researchers recently described perceived barriers to cervical cancer screening from the perspectives of women, men, and healthcare providers in five Latin American countries (Ecuador, El Salvador, Mexico, Peru, and Venezuela). The main barriers were accessibility and availability of quality health services, medical facilities that lacked comfort and privacy, the financial costs of screening, and levels of courtesy among providers (Agurto et al. 2004
Similarly, the following have been reported to be barriers to Pap testing among Mexican women from urban (Mexico City) and rural (the State of Oaxaca) areas of the country: Problems in doctor/medical institution-patient relationships, long waits for sample collection and receiving results, and perceived high costs for care (Lazcano-Ponce et al. 1999
The recently completed Vietnamese REACH for Health Initiative evaluated a multifaceted cervical cancer control intervention program for Vietnamese women in Santa Clara County, California (Nguyen et al. 2006
). Intervention components included continuing medical education sessions for Vietnamese physicians (Lai et al. 2004
; Nguyen et al. 2006
). Doctors who participated in the educational sessions were asked to complete pre-education and post-education surveys. Results showed that the sessions were effective in improving knowledge about cervical cancer and Pap testing (Lai et al. 2004
). Indirect evidence, from surveys of women, also suggested that levels of physician recommendation for cervical cancer screening increased as a result of the continuing medical education sessions (Nguyen et al. 2006
During 1998–2002, the cervical cancer incidence rate among Cambodian women in California and Washington was 15.0 per 100,000 women, compared to 7.7 per 100,000 among non-Latina white women (Kem and Chu 2007
). Additionally, the incidence rate among Hmong women in California during 1996–2001 was 33.7 per 100,000 (Yang et al. 2004
). While these other Southeast Asian groups come from the same geographic area and have similar immigration histories to the Vietnamese, there are many cultural differences. Therefore, it is important that future efforts to increase Pap testing focus on these communities.
The reported study has several limitations that warrant discussion. Our findings with respect to Pap testing rates may not be applicable to all geographic areas. For example, we documented relatively high rates of health insurance coverage, compared to other studies (Nguyen et al. 2002
; Nguyen et al. 2006
). Only households with listed telephone numbers were eligible for the study. Also, survey respondents may have had different preventive behavior patterns than those who were unreachable or refused participation. Finally, Pap testing self-reports may be faulty due to inaccurate recall or desirability bias. Since racial/ethnic minority women tend to over-report screening test receipt when compared to non-Latina white women, it is possible that our study over-estimated levels of Pap testing use (McPhee et al. 2002