Original articleCultural Views, English Proficiency and Regular Cervical Cancer Screening Among Older Chinese American Women
Introduction
Cervical cancer incidence and mortality have declined considerably over the past three decades in the United States owing to the adoption of the Pap smear test. Despite these trends, cervical cancer still remains a serious health threat to certain groups, including Asian American women, recent immigrants, and women without health insurance, because of their underutilization of the Pap smear test and lack of maintenance of regular screening (American Cancer Society [ACS], 2009). Chinese Americans, the largest subgroup of Asian Americans and Pacific Islanders, are among the fastest growing immigrant populations in the United States (Terrazas & Devani, 2008). Although emerging research has begun to examine screening behaviors and associated barriers to screening within Chinese American populations (Gao et al., 2008, Lee et al., 1996, Taylor et al., 2002b, Tu et al., 2003), relatively little information is available on this group compared with other groups, such as African and Hispanic Americans.
One early study completed in 1990 showed that 45% of adult Chinese women reported never having had a Pap smear test (Centers for Disease Control and Prevention, 1992). More recent reports document use of Pap smear tests by Chinese women, with lifetime screening rates ranging from 67% to 84% and recent screening rates ranging from 37% to 68% (Do et al., 2001, Kagawa-Singer and Pourat, 2000, Lee et al., 1996, Lee-Lin et al., 2007, Taylor et al., 2002b). Despite recent improvements in rates of screening, the overall screening rate of Chinese American women is still below the national average and far below the objective of Healthy People 2010 (specifically, 97% of American women report having received a Pap test in their lifetime and 90% report having received a Pap test within the past 3 years). Studies in countries such as Canada and New Zealand also demonstrate the lower cervical cancer screening rate among women from Asian backgrounds (Gao et al., 2008, McDonald and Kennedy, 2007, Wong et al., 2009).
Barriers to cervical cancer screening among Chinese immigrants and other ethnic minorities have been documented, including logistic barriers such as language barriers, lack of health insurance, and ideological and psychological barriers, such as fatalistic attitudes and fear of the Pap smear test (Johnson et al., 2008, Lee-Lin et al., 2007, Liang et al., 2004, Ross et al., 2008) . According to data from the 2000 Census (U.S. Census Bureau, 2000), 79% of Chinese Americans speak a language other than English at home and 70% were born in a foreign country. As such, Chinese Americans may face unique cultural and language barriers to utilizing health services, including cancer screening (Ma, 1999). For example, prior qualitative research has suggested that traditional Chinese values like fatalism and the balance of Yin (cold) and Yang (hot) kept Chinese individuals from seeking Western medical care and created misconceptions of illness and cancer (Hoeman et al., 1996, Ma, 1999, Tu et al., 2003, Yamashiro and Matsuoka, 1997). In addition, Chinese American women who hold more traditional cultural views were less likely to receive cancer screenings (Liang et al., 2009, Yamashiro and Matsuoka, 1997) compared with Chinese American women who report holding fewer traditionally Chinese values.
Limited English proficiency is a potentially important contributor to disparities in cervical cancer screening among minorities. Studies in the Hispanic population have shown that acculturation, as measured by English proficiency, is significantly related to the receipt of Pap tests (Suarez & Pulley, 1995). A few studies also indicate that English proficiency is strongly associated with Chinese American women's adherence to cervical cancer screening (Hiatt et al., 2001, Lee et al., 1996, Yu et al., 2003). For example, Hiatt et al. (2001) examined cancer screening rates among several underserved groups and found that Chinese American women who could not speak English were less likely to ever have had a Pap test and a recent Pap test compared with those who did speak English (Hiatt et al., 2001). We are not aware of any studies that have examined the impact of both cultural views and English proficiency while also controlling for multiple potential confounders, including other important screening barriers, in older Chinese American women.
To fill this gap in knowledge, we examined the role of cultural views and English proficiency in predicting Chinese women's regular uptake of Pap tests, controlling for other factors such as demographics, cancer worry, physician recommendation, and health care access barriers. We hypothesized that Chinese women who held strong traditional cultural views and had limited English ability would be less likely to maintain a regular screening history than those who held less traditional cultural views and had a higher level of English proficiency.
Section snippets
Conceptual Framework
The current study was guided by the Predisposing, Reinforcing and Enabling Construct in Educational Evaluation and Diagnosis (PRECEED) framework as this framework was developed for diagnosing and planning educational interventions to change health-related behaviors (Green & Kreuter, 1991). The PRECEED framework outlines a diagnostic planning process to assist in the development of community-based health education programs. For the present study, cultural views and attitudes regarding cancer and
Results
A total of 473 asymptomatic Chinese women age 50 and older were included in study analyses. Demographic characteristic of the sample are provided in Table 1. As Table 1 indicates, 98% of the women were foreign born, and they had a mean age of 64, ranging from 50 to 89 years. Slightly more than half of the sample (55.6%) were 50 to 64 and 44.4% were 65 and above. The majority of participating women had a college degree or higher (69%), were married (73%), and were not employed (63%). About 50.5%
Discussion
This study among the first empirical studies to examine how cultural views and English proficiency affect and predict older Chinese American women's regular receipt of the Pap smear test by using a comprehensive measure of cultural views toward illness and health and controlling for other important predisposing, reinforcing and enabling factors. The present study used the PRECEED framework to examine the association between cultural views, English proficiency, and the cervical cancer screening
Cheng Shuang Ji, PhD, is a Research Instructor in the Department of Oncology at the Georgetown University. Her research includes health disparities, cancer prevention, culture competency and immigrant families.
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Cheng Shuang Ji, PhD, is a Research Instructor in the Department of Oncology at the Georgetown University. Her research includes health disparities, cancer prevention, culture competency and immigrant families.
Mei-Yuh Chen, MS, is a Research Assistant in the Department of Oncology at the Georgetown University. She is also a registered Nurse.
Junfeng Sun, PhD, is an adjunct faculty of Department of Biostatistics, Bioinformatics, and Biomathematics at the Georgetown University.
Wenchi Liang, DDS, PhD, was an Assistant Professor in the Department of Oncology at the Georgetown University at the time of submission. She was the principal investigator of the project and her research focused on cancer health disparities, community-based intervention, behavioral change, and patient-physician communication.
Supported by funding from the National Cancer Institute Career Development Award (K07 CA90352, Liang W).