One of the most critical issues in cervical cancer prevention among Vietnamese American women over the past two decades is the persistently low Pap screening rate despite significantly high incidence rate of cervical cancer. Specific challenges and barriers to obtaining screening need to be examined and addressed in this underserved population. Although previous studies in the western region of the USA laid the groundwork for interventions [
23–
26], they rarely addressed both individual and system barriers that are associated with cervical cancer screening behaviors among Vietnamese women in a single study with a large sample size (
n = 1450). In addition, geographic differences may be important to consider, as geographic variations may exist regarding access to healthcare providers and/or healthcare staff who can provide bilingual services. Gresenz et al. (2009) have demonstrated that the considerable language obstacles that exist within some immigrant populations can serve as critical barriers to healthcare and uptake of screening tests [
27].
Findings from this population suggest that younger Vietnamese women are less likely to have ever had a Pap smear compared to their older (>60 years) counterparts. This finding is in contrast to a number of studies [
16,
28–
30], which have been summarized in several recent reviews [
31,
32]. But a recent study of young Asian American women [
33] also reported that younger age was associated with lower likelihood of obtaining screening. With increasing age, there was an increase in odds of ever having had a Pap smear test. Our finding that younger Vietnamese women were less likely to have ever had a Pap test may be due, in part, to cultural norms that promote more conservative views about sexual relations among unmarried individuals [
12]. Specifically, focus groups among young Asian Americans revealed that premarital sexual behavior was generally not widely acceptable, nor was seeking gynecological examinations prior to marriage, as that might adversely reflect sexual promiscuity [
33]. As a result, younger unmarried women may be less likely to seek cervical cancer screening due to the perceived community stigma associated with sexual promiscuity. This would also be consistent with prior findings reporting the common belief that Pap testing is only for women who are married or who have had children [
12]. Indeed, in the present study, we found that women who were not married or who were divorced/separated were less likely to have ever had a Pap smear test. Therefore, these findings highlight the need to focus on younger Vietnamese American women or those who are not married who may not engage in screening behaviors due to cultural barriers and beliefs.
Our findings that higher levels of education, English proficiency, employment, access to a physician, physician recommendation, and having health insurance are associated with significantly higher rates of Pap screening and are corroborated by other studies [
31,
34,
35]. For example, higher educational attainment was associated with greater likelihood of screening, whereas being unemployed was associated with lower likelihood of screening. These associations may be attributed, in part, to differences in knowledge and access to care. Women with higher educational levels may have greater knowledge and understanding regarding the need for cancer screening tests [
36,
37]. In addition, as education level is frequently associated with income, women with higher education or who have employment may have greater financial resources with which to obtain preventive care. Women who could not speak English and who were foreign-born were less likely to have ever had a Pap smear test. This is consistent with prior studies that have reported difficulties with English as a significant obstacle to screening for this population [
38,
39]. Unfortunately, language issues continue to serve as a barrier to screening as multilingual screening services are extremely limited or unavailable for most Vietnamese American women.
Access barriers continue to remain a challenge in this population [
34]. Vietnamese women who do not have a regular healthcare provider were less likely to report ever having had a Pap test, which is consistent with numerous prior studies [
16,
28,
31]. Having a physician that one sees for routine healthcare over time is likely to lead to better quality of care and offers more opportunities for discussing prevention and screening options than if one only visits a healthcare provider when one is ill. Further, receiving a physician recommendation for screening was the strongest factor associated with screening, similar to prior published findings [
30,
31,
35]. These findings highlight the importance of having access to a regular healthcare provider who can recommend the appropriate screening tests and remind women to participate in preventive care. Although programs are available that provide low-cost or free cancer screening services for women without health insurance or a healthcare provider, Vietnamese American women are often unaware of these services, not eligible for these programs, or face considerable barriers to accessing such programs. As a result, intervention programs to reduce cervical cancer disparities need to identify and target the subgroups of women who are not able to access or receive these cancer screening programs.
Our study identified 11 factors in the knowledge, attitudes, and beliefs domain that were associated with Vietnamese women's cervical cancer screening behavior. Specifically, a lack of knowledge was associated with poor participation in cervical cancer screening. Other studies have reported that Vietnamese American women may hold various misconceptions about cervical cancer and cervical cancer screening [
29,
35]; as a result, these beliefs may prevent women from obtaining the necessary screening. However, women who correctly reported that a Pap smear test can detect cervical cancer early were twice as likely to have had a Pap test compared to women who did not hold this belief. Similarly, women who had heard about human papillomavirus (HPV) were more likely to have had a Pap test.
It should be noted that HPV-specific knowledge was relatively low in this population. Indeed, nearly half of the study participants did not know that HPV can cause cervical cancer or that it was sexually transmitted. In addition, many women could not identify risk factors for HPV infection and over half of the women thought that HPV infection is rare. Further, these findings likely overestimate HPV-related knowledge given that between 9%–18% of respondents left these items blank. However, women who did have knowledge about HPV and its risk factors were more likely to have undergone screening.
Potential limitations of the study include the cross-sectional study design and using self-report to categorize prior screening behavior. In addition, our findings may not be generalizable to Vietnamese residents who are not closely engaged with their communities, and nonparticipants may have different patterns of cancer screening behaviors from the study respondents. However, the findings from the present study offer one of the largest assessments of cervical cancer screening among Vietnamese American women residing in the eastern USA and provide insights regarding identified significant factors for promoting cervical cancer screening in this population.
In summary, this study adds to the literature on cancer health disparities among Vietnamese American women and sheds light on the special health needs of this relatively recent immigrant population. Vietnamese women have the highest incidence rates of cervical cancer in the USA, and numerous factors serve as barriers to their participation in Pap test screening programs. These data help us identify the subgroup of Vietnamese American women who may be underutilizing screening services, as well as significant factors that we can address to enhance screening rates. Intervention programs need to address lack of knowledge and misconceptions regarding preventive care, language difficulties and access issues. Culturally tailored and linguistically appropriate educational materials and navigation assistance to overcome access barriers have been found to be effective in increasing screening rates in other studies [
40]. Indeed, although interventions that target women's health beliefs can increase knowledge, the effectiveness of such interventions is likely to be attenuated if access barriers are not adequately addressed. Access barriers, including the cost of screening, lack of insurance, and language difficulties, pose formidable challenges to this population. Community partnerships may be helpful for reducing some access barriers by providing essential infrastructure and resources to facilitate the broad implementation of health promotion programs. In addition, overcoming access barriers may necessitate setting aside additional resources to help underserved communities obtain the recommended healthcare services and/or require changing current healthcare program guidelines, such as expanding the eligibility criteria for state- and/or federally funded programs that provide low-cost cancer screening and prevention services for underserved women.
