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Adaptation and Testing of Instruments to Measure Cervical Cancer Screening Factors Among Vietnamese Immigrant Women Connie K. Y. Nguyen-Truong, Michael C. Leo, Frances Lee-Lin, Vivian Gedaly-Duff, Lillian M. Nail, Jessica Gregg, Tuong Vy Le and Tuyen Tran J Transcult Nurs published online 1 April 2014 DOI: 10.1177/1043659614524245 The online version of this article can be found at: http://tcn.sagepub.com/content/early/2014/03/31/1043659614524245
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TCNXXX10.1177/1043659614524245Journal of Transcultural NursingNguyen-Truong et al.
Research Department
Adaptation and Testing of Instruments to Measure Cervical Cancer Screening Factors Among Vietnamese Immigrant Women
Journal of Transcultural Nursing 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524245 tcn.sagepub.com
Connie K. Y. Nguyen-Truong, PhD, RN, PCCN1, Michael C. Leo, PhD2, Frances Lee-Lin, PhD, RN, OCN, CNS1, Vivian Gedaly-Duff, DNSc, RN1, Lillian M. Nail, PhD, RN, FAAN1, Jessica Gregg, PhD, MD1, Tuong Vy Le, MS3, and Tuyen Tran, MPA-HA4
Abstract Purpose: Vietnamese American women diagnosed with cervical cancer are more likely to have advanced cancer than nonHispanic White women. We sought to (a) develop a culturally sensitive Vietnamese translation of the Revised Susceptibility, Benefits, and Barriers Scale; Cultural Barriers to Screening Inventory; Confidentiality Issues Scale; and Quality of Care from the Health Care System Scale and (b) examine the psychometric properties. Design: Cross-sectional study with 201 Vietnamese immigrant women from the Portland, Oregon, metropolitan area. Method: We used a community-based participatory research approach and the U.S. Census Bureau’s team approach to translation. Results: Cronbach’s alpha ranged from .57 to .91. The incremental fit index ranged from .83 to .88. Discussion and Conclusions: The instruments demonstrated moderate to strong subscale internal consistency. Further research to assess structural validity is needed. Implications for Practice: Our approaches to translation and psychometric examination support use of the instruments in Vietnamese immigrant women. Keywords Vietnamese immigrant women, instruments, translation, cervical cancer, Pap testing, community-based participatory research approach Vietnamese American women (both immigrants and U.S.born) diagnosed with cervical cancer are more likely than non-Hispanic White, Korean, and Japanese Asian American women to have advanced cancer that has spread regionally (36%, 28%, 34%, and 32%, respectively) (Miller, Chu, Hankey, & Ries, 2008). This disparity results in part from Papanicolaou (Pap) testing rates among Vietnamese American women, which are lower than the national objectives of the Centers for Disease Control and Prevention report Healthy People 2010 (Gomez, Tan, Keegan, & Clarke, 2007; Ho et al., 2005; Tung, Nguyen, & Tran, 2008) and to the proposed objectives of Healthy People 2020 (Healthy People.gov, n.d.-a, n.d.-b). Currently, there are 577,600 Vietnamese immigrant women (VIW, foreign-born) residing in the United States (U.S. Census Bureau, 2009-2011). However, the low Pap testing rates among VIW are not well understood, but a number of cultural factors have been explored. VIW believe that a woman’s cervix should not be seen or touched by anyone besides her husband, and they may feel embarrassed and hesitant to have a Pap test regardless of the doctor’s gender
(Donnelly, 2006b). VIW may also believe that cervical cancer can be caused by vaginal uncleanliness (Burke et al., 2004; Donnelly, 2006b), and they may feel that a doctor’s visit is necessary only when symptoms are present (Nguyen, Barg, Armstrong, Holmes, & Hornik, 2007). Furthermore, some VIW perceive cancer as a fatal diagnosis, which may decrease motivation to be screened (Burke et al., 2004; Donnelly, 2006b). While VIW rely on the guidance of medical doctors with respect to tests and treatments, they perceive doctors as lacking enough time to talk (Donnelly, 2006b; Nguyen et al., 1
Oregon Health & Science University, Portland, OR, USA Kaiser Permanente–Center for Health Research, Portland, OR, USA 3 Vietnamese Community Member, Portland, OR, USA 4 Providence Cancer Center of Providence Health & Services, Portland, OR, USA 2
Corresponding Author: Connie K. Y. Nguyen-Truong, School of Nursing, Oregon Health & Science University, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA. Email: [email protected]
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2007). Moreover, VIW may be reluctant to ask doctors for information, lest they be seen as questioning the doctors’ authority (Donnelly, 2006b). Finally, VIW tend to rely on the guidance of family elders in making medical decisions (Davis, 2000). The obligation to care for one’s family is seen as a major motivator for attending to one’s health among VIW (Davis, 2000; Donnelly, 2006b). Vietnamese American women who believe strongly in the protective effects of their personal preventive regimens were found to be less concerned with receiving medical care, including Pap tests, particularly when access to medical care is difficult (Gregg, Nguyen-Truong, Wang, & Kobus, 2011). This population also emphasized healthy diets and exercise (Donnelly, 2006b; Gregg et al., 2011). VIW believe that good health is achieved by balancing forces such as am (cold) and duong (hot) (Donnelly, 2006b; Purnell, 2008). Eastern medicine is viewed as a cold force and Western medicine as a hot force (Purnell, 2008), and VIW choose between them based on the perceived appropriateness of each type for particular diseases (Donnelly, 2006a). The number of instruments that measure Pap testing health beliefs (Champion, 1999), cultural barriers to cancer screening (Tang, Solomon, & McCracken, 2000), and patients’ views about the quality of care being delivered in the United States (Nguyen et al., 2006) are limited. Furthermore, the effectiveness of these instruments may depend on a thorough translation process that accounts for culturally specific beliefs and customs. Therefore, in order to accurately measure the factors affecting cervical cancer screening decisions among VIW, it is essential to examine the psychometric properties of Vietnamese-translated instruments. The aims of this study were to adapt and develop a culturally sensitive Vietnamese translation of the Revised Susceptibility, Benefits, and Barriers Scale (RSBBS-V); Cultural Barriers to Screening Inventory (CBSI-V); Confidentiality Issues Scale (CIS-V); and Quality of Care from the Health Care System Scale (QoC-V); and also to examine the internal consistency and structural validity of these instruments. This study was a part of the primary survey study (Nguyen-Truong et al., 2012) that explored the relationships among factors that might influence Pap test receipt and adherence to screening recommendations among VIW.
Theoretical Framework We used the ecological model of health behavior as a theoretical framework to explain that there are multiple influencing factors in obtaining a cervical Pap test (Sallis, Owen, & Fisher, 2008). The RSBBS-V measures Pap testing health beliefs and the CBSI-V measures perceived cultural barriers to Pap testing, which are intrapersonal influences. Confidentiality issues in obtaining a Pap test are also intrapersonal influences and are measured by the CIS-V. The QoC-V measures the perception of the quality of care from
the health care system, which focuses on organizational influences. Nguyen-Truong et al. (2012) provide a detailed description of survey items used to examine other influencing variables in Pap testing at the intrapersonal, interpersonal, organizational, community, and health insurance mandate levels.
Method Approach The primary author (a Vietnamese bilingual, bicultural investigator) adapted a prolonged engagement approach (Knobf et al., 2007), which included active participation in Vietnamese community outreach activities (e.g., health fairs) in the Portland, Oregon, metropolitan area from February 2007 to January 2010. A partnership was developed between the Asian Family Center, a program of Oregon’s Immigrant & Refugee Community Organization (IRCO), and Oregon Health & Science University. Based on the adapted principles of community-based participatory research as described by Minkler and Wallerstein (2003), we strived to equitably and actively involve investigators, organizational representatives, and community members in all aspects of the research process.
Design We developed and evaluated our survey instruments through a process that included modifications, community review, pretesting, and psychometric testing. This process is discussed in detail in later sections. The study protocol and materials were approved by our institution’s review board for protection of human participants.
Sample and Setting In the primary survey study, participants had to be at least 21 years old, be self-identified as a VIW, never have been diagnosed with cervical cancer, and be able to read and speak Vietnamese or English. We used purposeful sampling to maximize sampling feasibility, and we recruited from 12 Vietnamese and Asian-based community organizations and faith-based organizations. Of the 250 VIW we recruited, 5 refused to participate and 39 did not return a completed selfadministered questionnaire. We excluded 10 VIW who responded to the English questionnaire. A sample of 201 VIW responded to the Vietnamese version of the questionnaire for a response rate of 80%. The final sample size was based on the power analysis for the primary survey study (Nguyen-Truong et al., 2012). There are no well-established power analysis approaches for confirmatory factor analysis (CFA); however, common rules of thumb are for an N > 200 or a ratio of at least 10 cases per parameter, which this sample size achieves (Jackson, 2003).
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Measures Pap Testing Health Beliefs. We adapted the RSBBS to measure Pap testing health beliefs because the RSBBS had been validated in other racial and ethnic groups, including nonHispanic White (Champion, 1984, 1993, 1999), African American (Champion, 1999), Chinese American immigrant women (Lee-Lin et al., 2008), VIW (Ho et al., 2005), Korean (Lee, Kim, & Song, 2002), and Jordanian (Mikhail & PetroNustas, 2001). The RSBBS originally consisted of 19 items rated on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree) and formed three subscales: perceived susceptibility (3 items), perceived benefits (5 items), and perceived barriers (11 items). Content validity was supported by both expert opinion and focus groups of women (Champion, 1999). Evidence to support structural validity was demonstrated by both an exploratory factor analysis, in which the three extracted factors accounted for 54% of the variance, and a CFA with a goodness-of-fit index of .87 (Champion, 1999). Cronbach’s alpha values demonstrated acceptable internal consistency (.87, .75, and .88, respectively) (Champion, 1999). Six-week test–retest correlations demonstrated moderate reliability (r = .62, .61, and .71, respectively) for the three subscales (Champion, 1999). Scores were summed, with higher scores indicating higher levels of perceived susceptibility, benefits, and barriers. Perceived Cultural Barriers to Pap Testing. We adapted the CBSI because it has been validated in Chinese American (Tang et al., 2000), Chinese American immigrant (Lee-Lin et al., 2008), and Asian American women (Tang, Solomon, Yeh, & Worden, 1999) to measure cultural barriers to breast, colorectal, and cervical cancer screening. The CBSI originally consisted of 17 items rated on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree) and consisted of four domains: utilization of Eastern/ Asian medicine for illness (3 items), modesty about one’s body (6 items), crisis orientation regarding Pap testing (orientation surrounding early detection of cervical cancer; 4 items), and lack of family support (4 items) (Tang et al.). Some evidence to support structural validity was demonstrated with an exploratory factor analysis, in which the four factors accounted for 54% of the variance (Tang et al.). The inventory also demonstrated moderate poor to acceptable internal consistency for the four subscales (Cronbach’s α = .72, .72, .61, and .54, respectively) (Tang et al.). Scores were reverse coded for crisis orientation and lack of family support, and scores were summed, with higher scores indicating higher levels of the perceived cultural barrier domain. Quality of Care From the Health Care System. The Health is Gold Survey (HGS) is a study-specific instrument that was based on the pathways model (Nguyen et al., 2006). Nguyen et al. (2006) reported that the HGS was guided by focus
groups and key informants and was developed in collaboration with the Vietnamese Reach for Health Initiative, a community coalition. The HGS has not been formally examined for its psychometric properties. We modified one section of this survey, about attitudes toward health care systems, to create the Quality of Care from the Health Care System Scale (QoC; 5 items). To our knowledge, this was the only available measure for Vietnamese women’s views about the quality of care being delivered in the United States. Scores were reverse coded and summed, with higher scores indicating a higher opinion about the quality of care from the health care system. Modification and Translation of Instruments. We first modified the instruments to improve their applicability to the target population. For the RSBBS, we removed one item from the perceived barriers subscale, “Having a mammogram exposes me to unnecessary radiation,” because Pap tests involve no radiation. We used the term perceived common barriers instead of perceived barriers to differentiate from perceived cultural barriers. For the CBSI, we changed “health care provider” to “doctor and nurse practitioner” to improve clarity. We removed one item from the modesty subscale, “I would feel embarrassed examining my own breasts for lumps,” because self-examination is not part of the Pap testing guidelines (U.S. Preventive Services Task Force, 2012). We also added one item to the lack of family support subscale, “My spouse or partner has recommended that I get checked for cancer,” because there was an item referring to adult children but not to a spouse or partner. We conceptually defined “family” as blood kin to differentiate family support from social support; therefore, the term friends was removed from three items. In the primary survey study, Nguyen-Truong et al. (2012) measured friends’ influence on Pap testing (social support) with a single item. Of the five HGS items, we removed one question pertaining to trust in doctors and other health care providers to do what is best for patients, as it was not relevant to our conceptual definition. We modified one item to read, “When going to a doctor or nurse practitioner for health care services, Vietnamese receive the same quality of health care as Caucasian/non-Hispanic Whites.” We used a 5-point Likerttype scale (1 = strongly disagree to 5 = strongly agree) to rate item responses. Community review. Two PhD-prepared community experts (one is a medical doctor and an anthropologist; the other has a background in adult education and community health) had suggested, based on their work with the community-based Vietnamese Women’s Health Project in Portland, Oregon, that we include items pertaining to confidentiality issues in obtaining a Pap test (Gregg, Nguyen-Truong, Wang, & Kobus, 2010). We therefore developed the Confidentiality Issues Scale (CIS), which consisted of two items: “One reason for not getting a Pap test would be because I am worried that my
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doctor or nurse practitioner will let other people know” and “One reason for not getting a Pap test would be because I am worried that the Vietnamese interpreter will let other people know.” Translation procedures. Through discussions with selected Vietnamese community members about cultural perspectives on informal and formal communication styles, we were able to create culturally sensitive questions that were face valid. In this context, face validity requires that the translated items convey the same intended meaning as the original items, rather than reestablish that each item was relevant to each of the domains (i.e., content validity). For example, when translating items that included the word you, we used the thirdperson construction qúy vị, a more respectful and formal way to address participants. When translating items that included the word I, we opted for the first-person word tôi, an acceptable form of informal self-address. In accordance with the U.S. Census Bureau’s approach (2004) to translation, we formed a translation team comprising a committee and a reviewer. Our committee included the primary author, a female Vietnamese immigrant community consultant (bilingual, bicultural, Vietnamese language teacher, community health education background), and a female Vietnamese Chinese immigrant community advisor (multilingual, multicultural, nurse). We chose a modified committee approach (Schoua-Glusberg, 2004) in which each member translated a portion of the items independently and documented translation decisions and questions in a log format. Lee-Lin et al. (2007) previously found this approach to produce accurate text translation. After a combined 24 hours of independent translation time, our committee met as a group for 8 hours to conduct an item-by-item review and reach consensus on all the translated items. Translation issues focused primarily on minor grammar edits, logical flow, and clarity. For example, there was no commonly understood translated term for “nurse practitioner.” The translation committee arrived at chuyên viên y tá [quyền chẩn đoán bệnh và được viết toa thuốc], or “nursing health care professional [diagnosing and prescribing privileges].” Following the translation committee’s work, our translation reviewer (Vietnamese immigrant woman, bilingual, bicultural, public health administration background) conducted an independent review requiring a total of 12 hours. She used a log format to document her translation decisions and questions, which focused primarily on minor grammatical edits, logical flow, and clarity. These reviewed items were then given to the committee, which took 3 hours to reach consensus on approving the reviewer’s suggestions. The whole translation process took about 47 hours across 12 days to complete. Pre-testing. We pre-tested with 10 VIW who resembled the participants in the primary survey study. The Vietnamese version had seven participants, and the English version had
three. We pre-tested both versions simultaneously to get back advice and opinions that could help guide culturally and linguistically appropriate modifications. The consenting process mirrored that of the primary survey study. Participants took an average of 23 minutes to complete the self-administered questionnaire (range = 13-35 minutes) following an interview that lasted about 1 hour. Participants received one $20 grocery gift card. Most participant suggestions focused on logical flow (e.g., consistent instructions for all instrument sections) and clarity. Because some participants did not understand what “Neutral” meant on the 5-point Likert-type response scale, that option was changed to Neither Disagree or Agree. None of the participants stated that the items irritated them or made them uncomfortable.
Data Collection Procedures We advertised the study in a community newsletter and asked either the primary author or leaders/members of 12 Vietnamese- and Asian-based community organizations and faith-based organizations to make an announcement about the study during or after a service activity. The primary author, who attended 21 community meetings and services for Vietnamese American women and men, explained the purpose of the voluntary study and described the one-time, self-administered pen-and-paper questionnaire that would take about 30 minutes to complete. Eligible participants received an information sheet as a waiver of signed consent. The primary author was present at the data collection sites and available for questions. We provided light refreshments at the data collection sites as suggested by the community consultant, and gave each participant a $10 grocery gift card at the completion of the self-administered questionnaire. We provided a Vietnamese-English bilingual Cervical Cancer and Pap Testing informational brochure and a Pap test referral to participants who had never had a Pap test or on request.
Data Analysis Strategy We used SPSS (Version 17.0.2, SPSS, Chicago, IL) and Amos (Version 17.0 Chicago, IL) to conduct the data analyses. Descriptive statistics were used to describe the sample characteristics, and Cronbach’s alpha was used to evaluate the internal consistency of the scales/subscales. Because we are in the early stages of construct validation, Nunnally and Bernstein (1994) suggest that a minimum Cronbach’s alpha of .70 is acceptable. Given that the modifications we made may have changed the factor structure, we conducted exploratory factor analyses to compare factors found in the original studies. We used principal axis factoring extraction for the RSBBS-Vietnamese version (V) and CBSI-V to compare our results with previous studies that examined the dimensionality of these instruments
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Table 1. Comparison of Principal Axis Factoring With Varimax Rotated Factor Loadings for the Original RSBBS and RSBBS-V (n = 201).
Items of the RSBBS-V
Original RSBBS
RSBBS-V
Factor loading
Factor loading
.91 .89 .87
.82 .82 .76
.71 .75 .55 .73 .75
.47b .57 .49 .67 .70
.64 .72 .68 .79 .75 .64 .66 .48 .67 .70
.61 .73 .45 .78 .80 .61 .54 .33 .52 .55
Perceived Susceptibility Subscale It is likely will get CCaa Chances of getting CCa in the next few years are greata Will get CCa sometime during lifea Perceived Benefits Subscale Having a Pap test will help find abnormal cells earlya Having a Pap test is the best way to find abnormal cellsa If get a Pap test, nothing is found, do not worry as much about CCaa If find abnormal cells through a Pap test, treatment for CCa may not be as bada Having a Pap test will decrease chances of dying from CCaa Perceived Common Barriers Subscale Afraid to have a Pap test because might find out something is wronga Afraid to have a Pap test because don’t understand what will be donea Don’t know how to go about getting a Pap testa Having a Pap test is too embarrassinga Having a Pap test takes too much timea Having a Pap test is too painfula People doing Pap tests are rude to womena Cannot remember to schedule a Pap testa Have other problems more important than getting a Pap testa Too old to need a routine Pap testa
Note. RSBBS = Revised Susceptibility, Benefits, and Barriers Scale; RSBBS-V = RSBBS–Vietnamese Version; CCa = cervical cancer; Pap = Papanicolaou test. a. The items have been modified to reflect Pap testing health beliefs. The items were paraphrased from the actual items of the RSBBS-V. b. An item, “Having a Pap test will help find abnormal cells early,” also cross-loaded onto the perceived susceptibility subscale (.31).
(Champion, 1999; Tang et al., 2000). We used different rotational methods depending on what the original studies used to maximize comparability. We also performed this analysis to explore the factor structure of the QoC. We formally evaluated the structural validity with CFA for the translated instruments because there were hypothesized (a priori) factor structures based on theory and previous research. That is, we were no longer in a completely exploratory phase, even though we made some modifications to the original instruments. We performed a CFA to evaluate the fit of the hypothesized three-factor structure of the RSBBS-V and of the four-factor structure of the CBSI-V. Hu and Bentler (1999) recommended a two-index presentation strategy to evaluate the goodness of fit. We chose (a) the incremental fit index (IFI), which measures the proportionate improvement in fit by comparing a chisquare of the hypothesized model with a null model with no common factors (Hu & Bentler, 1998) and (b) the root mean square error of approximation (RMSEA), which measures the lack of fit due to approximation (SchermellehEngel, Mossbrugger, & Muller, 2003). An IFI ≥ .95 and RMSEA ≤ .06 were used as criteria for good model fit (Hu & Bentler, 1999). Items with standardized regression weights less than .50 might indicate that an item was not related to a particular factor (Moss, 2008).
Results Sample Characteristics Participants with mean age 50 years (SD = 13.96), were an average of 35 years old when they immigrated to the United States (SD = 14.63), and had lived an average of 15 years in the United States (SD = 9.15). About 40% spoke English poorly or not at all, about 66% were currently married or living with a partner, 39% had less than high school education, 48% were employed full-time, and 94% identified with a religion. Of the 79% that responded to the income item, 33% had less than $15,000 total annual household income before taxes. A detailed description of the sample characteristics for the primary survey study has been reported elsewhere (Nguyen-Truong et al., 2012).
Structural Validity and Internal Consistency of the RSBBS-V Table 1 compares factor loadings for the original RSBBS and RSBBS-V. We forced a three-factor solution with a varimax rotation, as used by Champion (1999). These factors accounted for 44% of the item variance. Cronbach’s alpha values for perceived susceptibility, benefits, and common barriers of the RSBBS-V were .86, .69, and .86, respectively.
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Table 2. Sensitivity Testing for Items of the RSBBS-V and the CBSI-V with Standardized Regression Weights (Factor Loadings)
Adaptation and Testing of Instruments to Measure Cervical Cancer Screening Factors Among Vietnamese Immigrant Women Connie K. Y. Nguyen-Truong, Michael C. Leo, Frances Lee-Lin, Vivian Gedaly-Duff, Lillian M. Nail, Jessica Gregg, Tuong Vy Le and Tuyen Tran J Transcult Nurs published online 1 April 2014 DOI: 10.1177/1043659614524245 The online version of this article can be found at: http://tcn.sagepub.com/content/early/2014/03/31/1043659614524245
Published by: http://www.sagepublications.com
On behalf of:
Transcultural Nursing Society
Additional services and information for Journal of Transcultural Nursing can be found at: Email Alerts: http://tcn.sagepub.com/cgi/alerts Subscriptions: http://tcn.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Apr 1, 2014 What is This?
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524245
research-article2014
TCNXXX10.1177/1043659614524245Journal of Transcultural NursingNguyen-Truong et al.
Research Department
Adaptation and Testing of Instruments to Measure Cervical Cancer Screening Factors Among Vietnamese Immigrant Women
Journal of Transcultural Nursing 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524245 tcn.sagepub.com
Connie K. Y. Nguyen-Truong, PhD, RN, PCCN1, Michael C. Leo, PhD2, Frances Lee-Lin, PhD, RN, OCN, CNS1, Vivian Gedaly-Duff, DNSc, RN1, Lillian M. Nail, PhD, RN, FAAN1, Jessica Gregg, PhD, MD1, Tuong Vy Le, MS3, and Tuyen Tran, MPA-HA4
Abstract Purpose: Vietnamese American women diagnosed with cervical cancer are more likely to have advanced cancer than nonHispanic White women. We sought to (a) develop a culturally sensitive Vietnamese translation of the Revised Susceptibility, Benefits, and Barriers Scale; Cultural Barriers to Screening Inventory; Confidentiality Issues Scale; and Quality of Care from the Health Care System Scale and (b) examine the psychometric properties. Design: Cross-sectional study with 201 Vietnamese immigrant women from the Portland, Oregon, metropolitan area. Method: We used a community-based participatory research approach and the U.S. Census Bureau’s team approach to translation. Results: Cronbach’s alpha ranged from .57 to .91. The incremental fit index ranged from .83 to .88. Discussion and Conclusions: The instruments demonstrated moderate to strong subscale internal consistency. Further research to assess structural validity is needed. Implications for Practice: Our approaches to translation and psychometric examination support use of the instruments in Vietnamese immigrant women. Keywords Vietnamese immigrant women, instruments, translation, cervical cancer, Pap testing, community-based participatory research approach Vietnamese American women (both immigrants and U.S.born) diagnosed with cervical cancer are more likely than non-Hispanic White, Korean, and Japanese Asian American women to have advanced cancer that has spread regionally (36%, 28%, 34%, and 32%, respectively) (Miller, Chu, Hankey, & Ries, 2008). This disparity results in part from Papanicolaou (Pap) testing rates among Vietnamese American women, which are lower than the national objectives of the Centers for Disease Control and Prevention report Healthy People 2010 (Gomez, Tan, Keegan, & Clarke, 2007; Ho et al., 2005; Tung, Nguyen, & Tran, 2008) and to the proposed objectives of Healthy People 2020 (Healthy People.gov, n.d.-a, n.d.-b). Currently, there are 577,600 Vietnamese immigrant women (VIW, foreign-born) residing in the United States (U.S. Census Bureau, 2009-2011). However, the low Pap testing rates among VIW are not well understood, but a number of cultural factors have been explored. VIW believe that a woman’s cervix should not be seen or touched by anyone besides her husband, and they may feel embarrassed and hesitant to have a Pap test regardless of the doctor’s gender
(Donnelly, 2006b). VIW may also believe that cervical cancer can be caused by vaginal uncleanliness (Burke et al., 2004; Donnelly, 2006b), and they may feel that a doctor’s visit is necessary only when symptoms are present (Nguyen, Barg, Armstrong, Holmes, & Hornik, 2007). Furthermore, some VIW perceive cancer as a fatal diagnosis, which may decrease motivation to be screened (Burke et al., 2004; Donnelly, 2006b). While VIW rely on the guidance of medical doctors with respect to tests and treatments, they perceive doctors as lacking enough time to talk (Donnelly, 2006b; Nguyen et al., 1
Oregon Health & Science University, Portland, OR, USA Kaiser Permanente–Center for Health Research, Portland, OR, USA 3 Vietnamese Community Member, Portland, OR, USA 4 Providence Cancer Center of Providence Health & Services, Portland, OR, USA 2
Corresponding Author: Connie K. Y. Nguyen-Truong, School of Nursing, Oregon Health & Science University, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239-2941, USA. Email: [email protected]
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2007). Moreover, VIW may be reluctant to ask doctors for information, lest they be seen as questioning the doctors’ authority (Donnelly, 2006b). Finally, VIW tend to rely on the guidance of family elders in making medical decisions (Davis, 2000). The obligation to care for one’s family is seen as a major motivator for attending to one’s health among VIW (Davis, 2000; Donnelly, 2006b). Vietnamese American women who believe strongly in the protective effects of their personal preventive regimens were found to be less concerned with receiving medical care, including Pap tests, particularly when access to medical care is difficult (Gregg, Nguyen-Truong, Wang, & Kobus, 2011). This population also emphasized healthy diets and exercise (Donnelly, 2006b; Gregg et al., 2011). VIW believe that good health is achieved by balancing forces such as am (cold) and duong (hot) (Donnelly, 2006b; Purnell, 2008). Eastern medicine is viewed as a cold force and Western medicine as a hot force (Purnell, 2008), and VIW choose between them based on the perceived appropriateness of each type for particular diseases (Donnelly, 2006a). The number of instruments that measure Pap testing health beliefs (Champion, 1999), cultural barriers to cancer screening (Tang, Solomon, & McCracken, 2000), and patients’ views about the quality of care being delivered in the United States (Nguyen et al., 2006) are limited. Furthermore, the effectiveness of these instruments may depend on a thorough translation process that accounts for culturally specific beliefs and customs. Therefore, in order to accurately measure the factors affecting cervical cancer screening decisions among VIW, it is essential to examine the psychometric properties of Vietnamese-translated instruments. The aims of this study were to adapt and develop a culturally sensitive Vietnamese translation of the Revised Susceptibility, Benefits, and Barriers Scale (RSBBS-V); Cultural Barriers to Screening Inventory (CBSI-V); Confidentiality Issues Scale (CIS-V); and Quality of Care from the Health Care System Scale (QoC-V); and also to examine the internal consistency and structural validity of these instruments. This study was a part of the primary survey study (Nguyen-Truong et al., 2012) that explored the relationships among factors that might influence Pap test receipt and adherence to screening recommendations among VIW.
Theoretical Framework We used the ecological model of health behavior as a theoretical framework to explain that there are multiple influencing factors in obtaining a cervical Pap test (Sallis, Owen, & Fisher, 2008). The RSBBS-V measures Pap testing health beliefs and the CBSI-V measures perceived cultural barriers to Pap testing, which are intrapersonal influences. Confidentiality issues in obtaining a Pap test are also intrapersonal influences and are measured by the CIS-V. The QoC-V measures the perception of the quality of care from
the health care system, which focuses on organizational influences. Nguyen-Truong et al. (2012) provide a detailed description of survey items used to examine other influencing variables in Pap testing at the intrapersonal, interpersonal, organizational, community, and health insurance mandate levels.
Method Approach The primary author (a Vietnamese bilingual, bicultural investigator) adapted a prolonged engagement approach (Knobf et al., 2007), which included active participation in Vietnamese community outreach activities (e.g., health fairs) in the Portland, Oregon, metropolitan area from February 2007 to January 2010. A partnership was developed between the Asian Family Center, a program of Oregon’s Immigrant & Refugee Community Organization (IRCO), and Oregon Health & Science University. Based on the adapted principles of community-based participatory research as described by Minkler and Wallerstein (2003), we strived to equitably and actively involve investigators, organizational representatives, and community members in all aspects of the research process.
Design We developed and evaluated our survey instruments through a process that included modifications, community review, pretesting, and psychometric testing. This process is discussed in detail in later sections. The study protocol and materials were approved by our institution’s review board for protection of human participants.
Sample and Setting In the primary survey study, participants had to be at least 21 years old, be self-identified as a VIW, never have been diagnosed with cervical cancer, and be able to read and speak Vietnamese or English. We used purposeful sampling to maximize sampling feasibility, and we recruited from 12 Vietnamese and Asian-based community organizations and faith-based organizations. Of the 250 VIW we recruited, 5 refused to participate and 39 did not return a completed selfadministered questionnaire. We excluded 10 VIW who responded to the English questionnaire. A sample of 201 VIW responded to the Vietnamese version of the questionnaire for a response rate of 80%. The final sample size was based on the power analysis for the primary survey study (Nguyen-Truong et al., 2012). There are no well-established power analysis approaches for confirmatory factor analysis (CFA); however, common rules of thumb are for an N > 200 or a ratio of at least 10 cases per parameter, which this sample size achieves (Jackson, 2003).
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Measures Pap Testing Health Beliefs. We adapted the RSBBS to measure Pap testing health beliefs because the RSBBS had been validated in other racial and ethnic groups, including nonHispanic White (Champion, 1984, 1993, 1999), African American (Champion, 1999), Chinese American immigrant women (Lee-Lin et al., 2008), VIW (Ho et al., 2005), Korean (Lee, Kim, & Song, 2002), and Jordanian (Mikhail & PetroNustas, 2001). The RSBBS originally consisted of 19 items rated on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree) and formed three subscales: perceived susceptibility (3 items), perceived benefits (5 items), and perceived barriers (11 items). Content validity was supported by both expert opinion and focus groups of women (Champion, 1999). Evidence to support structural validity was demonstrated by both an exploratory factor analysis, in which the three extracted factors accounted for 54% of the variance, and a CFA with a goodness-of-fit index of .87 (Champion, 1999). Cronbach’s alpha values demonstrated acceptable internal consistency (.87, .75, and .88, respectively) (Champion, 1999). Six-week test–retest correlations demonstrated moderate reliability (r = .62, .61, and .71, respectively) for the three subscales (Champion, 1999). Scores were summed, with higher scores indicating higher levels of perceived susceptibility, benefits, and barriers. Perceived Cultural Barriers to Pap Testing. We adapted the CBSI because it has been validated in Chinese American (Tang et al., 2000), Chinese American immigrant (Lee-Lin et al., 2008), and Asian American women (Tang, Solomon, Yeh, & Worden, 1999) to measure cultural barriers to breast, colorectal, and cervical cancer screening. The CBSI originally consisted of 17 items rated on a 5-point Likert-type scale (1 = strongly disagree; 5 = strongly agree) and consisted of four domains: utilization of Eastern/ Asian medicine for illness (3 items), modesty about one’s body (6 items), crisis orientation regarding Pap testing (orientation surrounding early detection of cervical cancer; 4 items), and lack of family support (4 items) (Tang et al.). Some evidence to support structural validity was demonstrated with an exploratory factor analysis, in which the four factors accounted for 54% of the variance (Tang et al.). The inventory also demonstrated moderate poor to acceptable internal consistency for the four subscales (Cronbach’s α = .72, .72, .61, and .54, respectively) (Tang et al.). Scores were reverse coded for crisis orientation and lack of family support, and scores were summed, with higher scores indicating higher levels of the perceived cultural barrier domain. Quality of Care From the Health Care System. The Health is Gold Survey (HGS) is a study-specific instrument that was based on the pathways model (Nguyen et al., 2006). Nguyen et al. (2006) reported that the HGS was guided by focus
groups and key informants and was developed in collaboration with the Vietnamese Reach for Health Initiative, a community coalition. The HGS has not been formally examined for its psychometric properties. We modified one section of this survey, about attitudes toward health care systems, to create the Quality of Care from the Health Care System Scale (QoC; 5 items). To our knowledge, this was the only available measure for Vietnamese women’s views about the quality of care being delivered in the United States. Scores were reverse coded and summed, with higher scores indicating a higher opinion about the quality of care from the health care system. Modification and Translation of Instruments. We first modified the instruments to improve their applicability to the target population. For the RSBBS, we removed one item from the perceived barriers subscale, “Having a mammogram exposes me to unnecessary radiation,” because Pap tests involve no radiation. We used the term perceived common barriers instead of perceived barriers to differentiate from perceived cultural barriers. For the CBSI, we changed “health care provider” to “doctor and nurse practitioner” to improve clarity. We removed one item from the modesty subscale, “I would feel embarrassed examining my own breasts for lumps,” because self-examination is not part of the Pap testing guidelines (U.S. Preventive Services Task Force, 2012). We also added one item to the lack of family support subscale, “My spouse or partner has recommended that I get checked for cancer,” because there was an item referring to adult children but not to a spouse or partner. We conceptually defined “family” as blood kin to differentiate family support from social support; therefore, the term friends was removed from three items. In the primary survey study, Nguyen-Truong et al. (2012) measured friends’ influence on Pap testing (social support) with a single item. Of the five HGS items, we removed one question pertaining to trust in doctors and other health care providers to do what is best for patients, as it was not relevant to our conceptual definition. We modified one item to read, “When going to a doctor or nurse practitioner for health care services, Vietnamese receive the same quality of health care as Caucasian/non-Hispanic Whites.” We used a 5-point Likerttype scale (1 = strongly disagree to 5 = strongly agree) to rate item responses. Community review. Two PhD-prepared community experts (one is a medical doctor and an anthropologist; the other has a background in adult education and community health) had suggested, based on their work with the community-based Vietnamese Women’s Health Project in Portland, Oregon, that we include items pertaining to confidentiality issues in obtaining a Pap test (Gregg, Nguyen-Truong, Wang, & Kobus, 2010). We therefore developed the Confidentiality Issues Scale (CIS), which consisted of two items: “One reason for not getting a Pap test would be because I am worried that my
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doctor or nurse practitioner will let other people know” and “One reason for not getting a Pap test would be because I am worried that the Vietnamese interpreter will let other people know.” Translation procedures. Through discussions with selected Vietnamese community members about cultural perspectives on informal and formal communication styles, we were able to create culturally sensitive questions that were face valid. In this context, face validity requires that the translated items convey the same intended meaning as the original items, rather than reestablish that each item was relevant to each of the domains (i.e., content validity). For example, when translating items that included the word you, we used the thirdperson construction qúy vị, a more respectful and formal way to address participants. When translating items that included the word I, we opted for the first-person word tôi, an acceptable form of informal self-address. In accordance with the U.S. Census Bureau’s approach (2004) to translation, we formed a translation team comprising a committee and a reviewer. Our committee included the primary author, a female Vietnamese immigrant community consultant (bilingual, bicultural, Vietnamese language teacher, community health education background), and a female Vietnamese Chinese immigrant community advisor (multilingual, multicultural, nurse). We chose a modified committee approach (Schoua-Glusberg, 2004) in which each member translated a portion of the items independently and documented translation decisions and questions in a log format. Lee-Lin et al. (2007) previously found this approach to produce accurate text translation. After a combined 24 hours of independent translation time, our committee met as a group for 8 hours to conduct an item-by-item review and reach consensus on all the translated items. Translation issues focused primarily on minor grammar edits, logical flow, and clarity. For example, there was no commonly understood translated term for “nurse practitioner.” The translation committee arrived at chuyên viên y tá [quyền chẩn đoán bệnh và được viết toa thuốc], or “nursing health care professional [diagnosing and prescribing privileges].” Following the translation committee’s work, our translation reviewer (Vietnamese immigrant woman, bilingual, bicultural, public health administration background) conducted an independent review requiring a total of 12 hours. She used a log format to document her translation decisions and questions, which focused primarily on minor grammatical edits, logical flow, and clarity. These reviewed items were then given to the committee, which took 3 hours to reach consensus on approving the reviewer’s suggestions. The whole translation process took about 47 hours across 12 days to complete. Pre-testing. We pre-tested with 10 VIW who resembled the participants in the primary survey study. The Vietnamese version had seven participants, and the English version had
three. We pre-tested both versions simultaneously to get back advice and opinions that could help guide culturally and linguistically appropriate modifications. The consenting process mirrored that of the primary survey study. Participants took an average of 23 minutes to complete the self-administered questionnaire (range = 13-35 minutes) following an interview that lasted about 1 hour. Participants received one $20 grocery gift card. Most participant suggestions focused on logical flow (e.g., consistent instructions for all instrument sections) and clarity. Because some participants did not understand what “Neutral” meant on the 5-point Likert-type response scale, that option was changed to Neither Disagree or Agree. None of the participants stated that the items irritated them or made them uncomfortable.
Data Collection Procedures We advertised the study in a community newsletter and asked either the primary author or leaders/members of 12 Vietnamese- and Asian-based community organizations and faith-based organizations to make an announcement about the study during or after a service activity. The primary author, who attended 21 community meetings and services for Vietnamese American women and men, explained the purpose of the voluntary study and described the one-time, self-administered pen-and-paper questionnaire that would take about 30 minutes to complete. Eligible participants received an information sheet as a waiver of signed consent. The primary author was present at the data collection sites and available for questions. We provided light refreshments at the data collection sites as suggested by the community consultant, and gave each participant a $10 grocery gift card at the completion of the self-administered questionnaire. We provided a Vietnamese-English bilingual Cervical Cancer and Pap Testing informational brochure and a Pap test referral to participants who had never had a Pap test or on request.
Data Analysis Strategy We used SPSS (Version 17.0.2, SPSS, Chicago, IL) and Amos (Version 17.0 Chicago, IL) to conduct the data analyses. Descriptive statistics were used to describe the sample characteristics, and Cronbach’s alpha was used to evaluate the internal consistency of the scales/subscales. Because we are in the early stages of construct validation, Nunnally and Bernstein (1994) suggest that a minimum Cronbach’s alpha of .70 is acceptable. Given that the modifications we made may have changed the factor structure, we conducted exploratory factor analyses to compare factors found in the original studies. We used principal axis factoring extraction for the RSBBS-Vietnamese version (V) and CBSI-V to compare our results with previous studies that examined the dimensionality of these instruments
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Table 1. Comparison of Principal Axis Factoring With Varimax Rotated Factor Loadings for the Original RSBBS and RSBBS-V (n = 201).
Items of the RSBBS-V
Original RSBBS
RSBBS-V
Factor loading
Factor loading
.91 .89 .87
.82 .82 .76
.71 .75 .55 .73 .75
.47b .57 .49 .67 .70
.64 .72 .68 .79 .75 .64 .66 .48 .67 .70
.61 .73 .45 .78 .80 .61 .54 .33 .52 .55
Perceived Susceptibility Subscale It is likely will get CCaa Chances of getting CCa in the next few years are greata Will get CCa sometime during lifea Perceived Benefits Subscale Having a Pap test will help find abnormal cells earlya Having a Pap test is the best way to find abnormal cellsa If get a Pap test, nothing is found, do not worry as much about CCaa If find abnormal cells through a Pap test, treatment for CCa may not be as bada Having a Pap test will decrease chances of dying from CCaa Perceived Common Barriers Subscale Afraid to have a Pap test because might find out something is wronga Afraid to have a Pap test because don’t understand what will be donea Don’t know how to go about getting a Pap testa Having a Pap test is too embarrassinga Having a Pap test takes too much timea Having a Pap test is too painfula People doing Pap tests are rude to womena Cannot remember to schedule a Pap testa Have other problems more important than getting a Pap testa Too old to need a routine Pap testa
Note. RSBBS = Revised Susceptibility, Benefits, and Barriers Scale; RSBBS-V = RSBBS–Vietnamese Version; CCa = cervical cancer; Pap = Papanicolaou test. a. The items have been modified to reflect Pap testing health beliefs. The items were paraphrased from the actual items of the RSBBS-V. b. An item, “Having a Pap test will help find abnormal cells early,” also cross-loaded onto the perceived susceptibility subscale (.31).
(Champion, 1999; Tang et al., 2000). We used different rotational methods depending on what the original studies used to maximize comparability. We also performed this analysis to explore the factor structure of the QoC. We formally evaluated the structural validity with CFA for the translated instruments because there were hypothesized (a priori) factor structures based on theory and previous research. That is, we were no longer in a completely exploratory phase, even though we made some modifications to the original instruments. We performed a CFA to evaluate the fit of the hypothesized three-factor structure of the RSBBS-V and of the four-factor structure of the CBSI-V. Hu and Bentler (1999) recommended a two-index presentation strategy to evaluate the goodness of fit. We chose (a) the incremental fit index (IFI), which measures the proportionate improvement in fit by comparing a chisquare of the hypothesized model with a null model with no common factors (Hu & Bentler, 1998) and (b) the root mean square error of approximation (RMSEA), which measures the lack of fit due to approximation (SchermellehEngel, Mossbrugger, & Muller, 2003). An IFI ≥ .95 and RMSEA ≤ .06 were used as criteria for good model fit (Hu & Bentler, 1999). Items with standardized regression weights less than .50 might indicate that an item was not related to a particular factor (Moss, 2008).
Results Sample Characteristics Participants with mean age 50 years (SD = 13.96), were an average of 35 years old when they immigrated to the United States (SD = 14.63), and had lived an average of 15 years in the United States (SD = 9.15). About 40% spoke English poorly or not at all, about 66% were currently married or living with a partner, 39% had less than high school education, 48% were employed full-time, and 94% identified with a religion. Of the 79% that responded to the income item, 33% had less than $15,000 total annual household income before taxes. A detailed description of the sample characteristics for the primary survey study has been reported elsewhere (Nguyen-Truong et al., 2012).
Structural Validity and Internal Consistency of the RSBBS-V Table 1 compares factor loadings for the original RSBBS and RSBBS-V. We forced a three-factor solution with a varimax rotation, as used by Champion (1999). These factors accounted for 44% of the item variance. Cronbach’s alpha values for perceived susceptibility, benefits, and common barriers of the RSBBS-V were .86, .69, and .86, respectively.
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Table 2. Sensitivity Testing for Items of the RSBBS-V and the CBSI-V with Standardized Regression Weights (Factor Loadings)
