J Community Health DOI 10.1007/s10900-014-9887-x
ORIGINAL PAPER
Socioecological Perspectives on Cervical Cancer and Cervical Cancer Screening Among Asian American Women Jongwon Lee • Mauricio Carvallo
Springer Science+Business Media New York 2014
Abstract Although cervical cancer is one of the most commonly diagnosed cancers among Vietnamese American women (VAW) and Korean American women (KAW), both groups consistently report much lower rates of cervical cancer screening compared with other Asian ethnic subgroups and non-Hispanic Whites. This study aimed to explore multilevel factors that may underlie low screening rates among VAW and KAW living in a city where their ethnic communities are relatively small. The socioecological model was used as a conceptual framework. Thirty participants were conveniently recruited from ethnic beauty salons run by VA and KA cosmetologists in Albuquerque, New Mexico. The participants’ average age was 44.6 years (SD = .50; range = 21–60). Most participants were married (80 %) and employed (73.3 %), and had health insurance (83.3 %). A qualitative interview was conducted in Vietnamese or Korean and transcribed verbatim. A thematic content analysis was used to identify major codes, categories, and patterns across the transcripts. The study identified several factors at the individual (e.g., pregnancy, poverty, personality), interpersonal (e.g., family responsibility, mother as influential referent), and community (e.g., lack of availability, community size) levels. The study sheds light on four major areas that must be taken into consideration in the development of culturally appropriate, community-based interventions aimed to reduce disparities in cervical cancer screening among J. Lee (&) College of Nursing, University of New Mexico, MSC 09 5350, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA e-mail: [email protected] M. Carvallo Department of Psychology, University of Oklahoma, Norman, OK, USA
ethnic minority women in the United States: (1) ethnic community size and geographic location; (2) cross-cultural similarities and dissimilarities; (3) targeting of not only unmarried young women, but also close referents; and (4) utilization of trusted resources within social networks. Keywords Cervical cancer Screening Asian American Socioecological model Qualitative
Introduction Over the last decade, cervical cancer incidence and mortality rates have steadily declined in the United States due to early detection and prevention programs [1]. Despite this trend, however, significant disparities among ethnic minority women belonging to certain Asian subgroup populations exist. Although Asian American women, as a whole, report the lowest cervical cancer incidence and mortality rates of any other ethnic group in the United States [2], Vietnamese American women (VAW) and Korean American women (KAW) fare significantly worse. These two groups not only report disproportionally higher incidence and mortality rates of cervical cancer, but also lower screening rates compared with other ethnic groups, including non-Hispanic Whites [3, 4]. The incidence rates of invasive cervical cancer for VAW (18.9/100,000) and KAW (11.9/100,000) are much higher than those for non-Hispanic Whites (7.1/100,000) and other major Asian American subgroups (9.1/100,000) [4]. Cervical cancer is one of the major causes of death for VAW and KAW, and their mortality rates (3.0–4.8/100,000) are also higher than those for non-Hispanic Whites (2.0/ 100,000) and Asian Americans as a whole (2.7/100,000) [5]. These high incidence and mortality rates are similar to
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recent trends reported for Vietnamese and Korean women living in their countries of origin [6–8]. Despite these high incidence and mortality rates, VAW and KAW consistently report much lower rates of cervical cancer screening than do other Asian ethnic subgroups and non-Hispanic Whites. A study exploring racial/ethnic differences in cancer screening in California showed that, compared with other Asian subgroups (80–89 %) and nonHispanic Whites (88 %), both VAW and KAW reported the third lowest (81 %) and lowest (79 %) rates, respectively, of cervical cancer screening [9]. More recent studies revealed even lower rates of screening (i.e., 54–75 %) for both these groups [10–12]. These rates are far below the Healthy People 2020 goal of having 93 % of women reporting a Pap smear within the past 3 years [13]. VAW and KAW’s low cervical cancer screening rates are concerning, especially because Asian Americans are the second fastest-growing racial and ethnic group in the country, at 17.3 million, or 5.6 % of the total US population [14]. Vietnamese and Korean Americans represent the fourth and fifth largest Asian subgroups, respectively, totaling 1.7 million and 1.6 million [14]. Vietnamese and Korean Americans are among the fastest growing populations in this country, more than doubling in size since 1990 [14, 15]. Although the population of Asian Americans is still large in California and New York, it recently has increased in other states, such as New Mexico (NM). Although Asian Americans currently comprise only 2 % of the population in NM, the percentage of growth has more than doubled since 1990, which is larger than any other major ethnic group in the state [14, 15]. Despite the rapid influx of Asian Americans to NM, little is known about the health status or factors influencing the health-related behaviors of Asian Americans. To our knowledge, no data on cervical cancer and cervical cancer screening of VAW and KAW living in NM exist. Special attention should be paid to both of these groups because cervical cancer is one of the most commonly diagnosed cancers in VAW and KAW. In addition, as the population of VAW and KAW in NM continues to grow and starts to approximate the general US population, higher cervical cancer incidence and mortality rates and lower cervical cancer screening rates are expected. Previous studies have identified various factors underlying low rates of cervical cancer screening among VAW and KAW, such as socioeconomic status (SES), beliefs and myths, and lack of knowledge [10, 16–18]. However, these studies were conducted in regions where both Vietnamese and Korean Americans were densely populated. To the best of our knowledge, no studies have targeted VAW and KAW living in areas where Asian populations are sparse and where minorities represent the majority of the population, such as NM. There are geographic differences in
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Table 1 Sample characteristics (N = 30) Characteristics
n
%
Ethnicity (n = 30) Vietnamese
15
50.0
Korean
15
50.0
Marital status (n = 30) Single Married
6
20.0
24
80.0
Education (n = 29) Middle school or lower High school College graduate or higher Partial college Religion (n = 30) Catholic Other christian
4
13.8
11
37.9
8
27.6
6
20.7
4
13.3
16
53.3
Buddhism
7
23.3
Other
3
10.0
None
5
16.7
One
4
13.3
Two
17
56.7
4
13.3
Yes
25
83.3
No
5
16.7
Number of children (n = 30)
Three or more Health insurance (n = 30)
Age on entering the US, years (n = 30) B20 21–30 31–40 C41
8
26.7
12 8
40.0 26.7
2
6.7
Length of residency in the US, years (n = 30) B10
8
26.7
11–20
10
33.3
21–30
9
30.0
C31
3
10.0
cancer incidence rates, screening, and adherence behaviors [19–21], suggesting that factors underlying cancer screening and adherence may also differ geographically. The current study aimed to explore factors influencing cervical cancer screening, especially unique challenges VAW and KAW encountered while living in NM, where their ethnic community is relatively small.
Framework The conceptualization of this study is based on the socioecological model (SEM) [22]. The SEM posits that
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behavior affects and is affected by multiple levels of influence, including intrapersonal, interpersonal, and community levels, and that behavior shapes and is shaped by influences at multiple levels. This model emphasizes the interaction between and interdependence of various factors within and across all levels of health-related problems and behaviors [23]. The SEM has often been used as a conceptual framework for studying cancer-related behaviors, especially in exploring individual, social, and environmental factors influencing cancer screening prior to developing interventions [24–26]. From a SEM standpoint, this study explored VAW and KAW’s personal characteristics, beliefs, knowledge, and behavior related to cervical cancer and screening (intrapersonal), support exchanged via social networks (interpersonal), and ecological structures that constrain or promote screening (community).
Methods A qualitative research approach was used in this study. The study was approved by the Human Research Review Committee at the University of New Mexico.
determined their eligibility and interest in participating in the study. If they were eligible and agreed to participate, they were guided to a private room in the salon, and the PI and coordinators described the purpose of the study, the incentive ($20 gift card), and their rights as participants. A convenient date, time, and place were set up outside regular working hours for any cosmetologists who expressed interest but could not participate because of her busy schedule. Semistructured interviews were conducted from February 2012 through October 2012. The research coordinators interviewed participants of their same ethnicity, along with the PI’s assistance. To maintain the integrity of the data collection, the coordinators were trained by the PI using the study protocol. Interviews were conducted in the participant’s primary language (Vietnamese or Korean), lasted about 40–60 min, and were tape-recorded. Audiotaped interviews were transcribed verbatim in Vietnamese or Korean by transcriptionists who were fluent in Vietnamese or Korean, respectively. Transcriptions were back-translated into English by translators fluent in Vietnamese or Korean for analysis. Data Analysis
Sample and Settings Thirty VAW (n = 15) and KAW (n = 15) were conveniently sampled from ethnic beauty salons located in Albuquerque, NM. The salons were run by VA and KA cosmetologists and were frequented for hair, nail, and other services. Women were included in the study if they were 18 years of age or older and self-identified as Vietnamese or Korean. Table 1 shows the demographic characteristics of the participants. Data Collection Procedures Two bilingual research coordinators (one Korean and one Vietnamese) and the principal investigator (PI) identified a list of ethnic beauty salons run by VA and KA cosmetologists via social networks and the classified sections of ethnic community newsletters. Under the PI’s guidance, each coordinator made an initial contact by telephone to set up an appointment to meet with each salon owner of her same ethnicity. On the day of the appointment, the PI and the coordinator met with the owner, explained the study purpose, and asked for permission to use the salon as a place for recruiting potential participants. Salon owners were also asked whether they were interested in participating in the study. Of the 15 owners contacted, 12 granted permission (i.e., 5 Korean cosmetologists and 7 Vietnamese cosmetologists). The PI and the coordinators approached the cosmetologists and customers in the salons and
The interview data were entered into ATLAS-ti (version 6.2) [27] qualitative data analysis program and coded using a thematic content analysis technique to identify similar words, phrases, and patterns across the transcripts [28, 29]. Prior to analysis, the investigators met to develop an initial coding scheme based on the SEM and discuss coding labels and definitions. To ensure the consistency of coding across the analysis team and enhance the scientific rigor of the findings, a codebook was developed, including the code, a brief definition, and example quotes. A detailed audit trail was also developed and used throughout the analyses that included memos and the investigators’ reflexivity. The PI first conducted an initial analysis of the transcripts and coded the interview contents based on the SEM levels: individual, interpersonal, and community. The contents were further coded into categories and subcategories by grouping codes with similar meanings and concepts. The other investigator then analyzed the data independently. The codes and categories that emerged from the analyses were compared, and any discrepancies were resolved by the analysis team. The underlying meanings of the different categories were analyzed for their patterns, and broad themes were identified.
Results Data analysis revealed several levels of factors related to cervical cancer and cervical cancer screening, which were
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U.S health services & systems: Lack of availability Lack of accessibility Lack of affordability Community size & location: Regional differences in barriers Ethnic provider preference Homeland health services: Health inequity Expedited services Family networks: Peer networks:
Provider-patient networks:
Extrinsic personal attributes:
Intrinsic personal attributes:
Responsibility & roles Mother as influential referent Support Interpersonal distrust Credibility of information Provider attributes Quality of communication Demographic tripartite Pregnancy history Illness experiences Poverty in homeland Personality Misbeliefs: Virginity Sexual promiscuity Words become seeds Absence of symptom Religious faith Lack of Knowledge
Fig. 1 Socioecological factors on cervical cancer and cervical cancer screening
organized into three domains, based on the socioecological framework: individual, interpersonal, and community (Fig. 1). Individual Level of Influence Extrinsic Personal Attributes Demographic Tripartite Age, marital status, and parental status emerged from VAW and KAW as the major factors influencing, separately or in combination, participants’ perceptions of cervical cancer and screening, and other health-related behaviors. Women who were younger, single, and had no children tended not to perceive the importance of screening practices. They did not consider health as an imperative issue, nor were they inclined to talk about it. Some of these women perceived that they were in a ‘‘safety zone’’ free of illnesses, including cancer. They automatically related their ‘‘young age’’ to a lack of health problems, ultimately decreasing their intention to seek screening and actual screening. In contrast, older women, especially those over age 40, were more likely to perceive that they were at increased risk for illness due to their age and considered their health a major priority. In particular, married women who had children indicated that they became less sensitive about and more open to discussing issues pertaining to their private reproductive organs. They held the perception that there
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was ‘‘nothing to hide’’ with respect to their reproductive organs, as they had gone through marriage and childbirth. Thus, they were not concerned about having a check-up and exposing their private reproductive parts to physicians, including male physicians. One elder woman noted, ‘‘As people get older, there is a risk of getting things, especially cancer. I felt more compelled to pay more attention to it [health] now because of my age.’’ Pregnancy History Pregnancy was a critical turning point for women to enter the US health care system, regardless of whether they had medical issues in the past. Women said that the first time they heard of or received a Pap smear was as part of their initial check-up for pregnancy. One participant stated, ‘‘When I was pregnant, the obstetrics/ gynecology (OB/GYN) doctor told me I had to make sure that I got these things [Pap smears] checked out each year. So, since then, I started to get the checkups.’’ This suggests that OB/GYN doctors and nurses are in an important position to initiate conversations on topics related to cervical cancer for VAW and KAW and educate them about the importance of regular screening. Illness Experiences The experience of illness or family members’ medical problems affected the degree to which women perceived the importance of routine health checkups, including cervical cancer screening. Women tended to perceive that they were at risk for certain diseases if their
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family members had been ill, especially, if they had a family member who had been diagnosed with cancer. This propelled them to start thinking about their own health and become more aware of cancer screening and prevention, leading them to seek regular checkups and undergo screening. In contrast, if there was no family history of disease, they tended to believe that they would not encounter any health problems. Poverty in the Country of Origin Perceptions of health and prevention, including cervical cancer screening, varied and depended on participants’ SES in their country of origin. For women who were born in Vietnam and immigrated to the United States, the concept of prevention and health was not previously considered because in Vietnam, they were poor and could not afford to take time off from work or seek health care. A Vietnamese woman said, ‘‘Money comes first, then health,’’ meaning that their health status was secondary to work and earning money. Intrinsic Personal Attributes Personality Personality can be a barrier or a motivator to engage in prevention practices. Some VAW and KAW felt that stubbornness, introversion, or conservatism negatively influenced their level of openness, which, in turn, impacted their ability to ask their care providers questions and their willingness to talk about health-related topics with others. This limited their opportunities for learning about the importance of prevention, negatively affecting their healthseeking behaviors, including getting Pap smears. One participant noted, ‘‘We’re old-fashioned and thus, it’s hard to open up.’’ Misbeliefs A woman’s virginity status affected how she felt about getting screened. A common misbelief shared by both VAW and KAW was that young, virgin women are not at risk for cervical cancer because they are not sexually active. Sexuality, before and after marriage, also influenced their perceptions of whether they should get screened. Most women said that not having sexual relationships before marriage shielded them from the risk of cervical cancer. Ultimately, this belief deterred them from seeking regular screening. Some women still held the view that they did not need to get screened, even after getting married and becoming sexually active, because they had had only one sexual partner. They tended to believe that they were not at risk for contracting cervical cancer because they were not sexually promiscuous and that only those who have multiple sexual partners were. There is the common misbelief in both Vietnamese and Korean cultures that ‘‘words become seeds.’’ This belief prevents VAW and KAW from openly talking about
cancer-related topics. Women tend to believe that if they talk about cancer or any disease, they will ultimately get it or become sick. One woman noted, ‘‘In general, people don’t really talk about cancer or being sick. They just want to avoid the topic. I don’t want to talk about it. It’s just a taboo. If you do it, it will happen to you.’’ Moreover, most women lack the concept of health prevention and tend to equate the absence of symptoms with being ‘‘healthy.’’ This, in turn, leads them to perceive that there is no need for regular screening or check-ups in the absence of symptoms. Religious Faith Some women indicated that religious faith influenced how they viewed life events such as illnesses, including cancer, and their religious beliefs affected their acceptance of and willingness to overcome such events. Religious faith also influenced women’s perceptions of or readiness for death. One participant stated, ‘‘At first, I was really scared, but as I prayed, God showed me what a blessed person I was, then I was like…what’s the big deal about cancer…if God says it’s time to go, then I die.’’ Although some women stated that religious faith had little to do with the experience of illnesses, including cancer, and could not heal or cure physical ailments, they were likely to perceive faith in a positive way and acknowledge that it may provide a coping mechanism to deal with illnesses. Lack of Knowledge Some women were aware of the fact that cervical cancer is curable and preventable, and were able to identify some of the risk factors, such as human papillomavirus and smoking. However, the majority stated that they had never heard about cervical cancer and did not know about the cause, risk factors, treatments, and recommended screening guidelines. They also were significantly misinformed. For example, some indicated that the acidity of their body, dust, or mud could cause cancer of the cervix. One participant stated, ‘‘When you work on the farm, you are really in close contact with mud and dust and it [mud and dust] gets to you from the bottom up. So, that’s how you get it [cancer].’’ In addition, some women believed that if they did not keep their perineal areas clean or have a healthy diet, then they would get cancer. Interpersonal Level of Influence Family Networks Responsibility and Roles Women’s perceived levels of responsibility and their roles as mothers or wives positively influenced their prevention and screening practices. Women who had family members, especially children, felt they had to remain healthy to take care of them. These
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women also indicated that they tried to remain healthy because they did not want to be a burden to their families if they got sick. This ultimately drove them to obtain regular health check-ups, including cervical cancer screening. One woman stated, ‘‘I’m a mom worrying about my kids. If I’m not here, how will they live? So, I am more diligent and try to keep healthy.’’ Mothers as Influential Referents For young women, the concept of health and prevention seemed to be mainly influenced by family members they perceived as most significant in their lives. What their mothers thought they should (or should not) do regarding their health determined the degree to which they followed treatments and were aware of the importance of regular health check-ups for early detection and prevention. A young, single, woman said that she refused to take birth control pills to regulate her menstrual pain because her mother did not allow her to take them (despite her doctor’s recommendation), but took painkillers on a monthly basis to control it. Another young woman stated that she had received a Pap smear yearly because her mother asked her to do so. Peer Networks Support Friends, peers, or coworkers acted as major sources of health-related information and served as motivators driving women to ultimately undergo screening. One woman said, ‘‘My friend told me to get it [Pap smear]. So I went to the doctor…3 months ago.’’
Provider–Patient Networks Provider’s Attributes Health care providers’ characteristics, such as gender, appearance, or expected roles, affected women’s provider preferences and perceptions of the credibility of the health information received. This, in turn, affected the level of trust women had in a provider and the degree to which they were willing to adhere to regimens directed by the provider. For example, one woman said that male doctors were more skillful than female doctors and preferred to seek services from a male doctor. Another woman said that the provider’s appearance affected the credibility of the information she received (e.g., a provider who eats doughnuts and provides information about healthy diets is not trustworthy). Communication The amount and quality of health information women received from their health care providers affected their initiation of, adherence to, and awareness of cervical cancer screening. Of women who had ever received or been compliant with cervical cancer screening, most indicated that their provider recommended that they be screened. Yet, some women who went for routine check-ups commented that they were not even aware that a Pap smear was being done during their visit or why. This was due, in part, to their provider’s lack of a thorough explanation of the examination procedure or their own language barriers. Both these factors were cited as barriers, causing stress when seeking services. Community Level of Influence
Distrust Although most women commented that they were willing to be open and share their health-related information and problems with friends, peers, or coworkers whom they trusted, some women said they were reluctant to share such information because they were afraid of being a victim of gossip or back-stabbing. One participant stated, ‘‘The person I’m close to me tells me all kinds of thing about people I don’t even know. I feel that this person will also talk about me like that to others. So, I’m careful.’’ Such a relational distrust is present in both Vietnamese and Korean cultures, sometimes preventing the women from seeking support or health-related information from their peers. Credibility Women also commented that health-related information from their peers was not entirely accurate. One participant noted, ‘‘Well, I don’t trust 100 %. I must be careful and need to ask a doctor to make sure of this [information].’’ The degree to which they judged the information as reliable was mainly based on the type of job or credentials peers held or whether the illness their peers had experienced was similar.
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US Health Services and Systems Lack of Availability The unavailability of care providers and receiving services in a timely fashion constituted a major factor that limited health-seeking behaviors, including screening practices. The majority of women, especially KAW, complained that it was extremely hard to schedule an appointment, they had to wait too long to be seen by a doctor, and their health problems already disappeared by the time of their appointment. Some of them said that they had given up on making appointments to see their primary doctor and ultimately ended up seeking urgent care or emergency services or relied on alternative medicine to treat their health problems. Lack of Accessibility The difficulty of locating or accessing clinics was the biggest factor limiting their screening practices. Many women said that US health clinics were spread out all over town, and it was not easy to reach them when needed. Most women also stated that fragmentation of services was a big issue. They were
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concerned that they could not get all the services required in one place, in one visit, if they had more than one health problem. They had to go to one clinic for one problem and another clinic for a different problem. Lack of Affordability Many VAW and KAW said that the US health insurance policies were inefficient and costly. They expressed concern that although they were covered by insurance, the copayments and monthly premiums were too expensive, and they could not afford to seek services when needed. Thus, some of them regularly sought health services abroad: ‘‘I have insurance here, but it’s too expensive… When I go to Korea on vacation, I get my entire health check-ups there. I don’t have insurance there, but it’s still cheaper there.’’ Community Size and Location The size and geographic location of ethnic communities also present barriers to cervical cancer screening. Many woman indicated that the language barrier, which is a wellknown factor limiting health-seeking behaviors, had never been an issue when living in a place where a large ethnic community existed (e.g., Los Angeles (LA), California). In LA, a large number of ethnic providers and clinics are available; therefore, not being fluent in English did not prevent them from seeking services. However, it was a problem if they lived in a place with a small ethnic enclave (e.g., Albuquerque, NM), with limited culturally appropriate resources. Community size also affected women’s preference of ethnic providers. Women who had previously lived in a large community where their ethnic group was densely populated (e.g., LA) and had moved to a place with a smaller ethnic community (e.g., Albuquerque) preferred not to choose providers of their same ethnicity, favoring American providers instead, even if they were males, because they were concerned that their health information would become known to the entire community. One Korean woman said, ‘‘As the community is small, these doctors could spread out my health information to their friends, then their friends to other friends.’’ Homeland Health Services The degree to which women appreciate the US health care system varied, depending on where they came from and what levels of services they experienced in their country of origin. For example, Vietnamese women who had little access to quality services in their homeland due to poverty expressed appreciation for US health care services. They felt that the US health care system is set up so that people’s health comes first and payment for services is secondary;
they have an opportunity to get regular checkups, regardless of whether they can pay for it all up front at the time of their visit. One Vietnamese woman compared US health services with those she received in Vietnam: ‘‘My payment (in the United States) was never an issue. Doctors treated me first and billed me later. Their main concern is my health, not my ability to pay. But in Vietnam you have to pay first before they even think of treating you.’’ In contrast, most Korean women who had experienced the health system in their homeland expressed dissatisfaction with US health services, mainly due to the systemic, structural barriers noted previously.
Discussion The purpose of this study was to explore multiple levels of interactive factors that influence VAW and KAW’s cervical cancer screening through a socioecological lens. The study provides insight into the unique barriers to cervical cancer screening among VAW and KAW, and contributes to an understanding of the reasons cervical cancer screening rates are so low in these groups. In particular, the findings reveal that the size of the ethnic community in which a woman lives can constitute a barrier that limits her access to cervical cancer screening. For example, for those living in a place where their ethnic community is relatively small, the language barrier is a particular issue. Despite this barrier, however, women may not seek health services from their own ethnic providers who are fluent in their primary language, even if the provider is female, in part, because of concerns that their private health information may be revealed to the entire community. Although the existing literature suggests that the use of same ethnic providers, preferably females, constitutes a culturally sensitive intervention strategy that enhances preventive health practices, including cervical cancer screening in ethnic minority women [30–33], this is not as evident among VAW and KAW living in cities with a small ethnic community. This finding suggests that concealment of health information is a higher priority than is gender-specific, language-concordant ethnic providers in these populations. It indicates that culturally sensitive interventions must be developed by taking into account the size or geographic location of the ethnic enclave and tailoring the interventions to the unique needs of these populations. The majority of multilevel influencing factors identified in this study are similar between VAW and KAW, implying that there are cultural similarities in perceptions of cervical cancer and the underlying reasons for not seeking (or seeking) cervical cancer screening. However, the study also reveals that there are unique differences
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between these two groups. For example, the degree to which both VAW and KAW perceive barriers to access to cervical cancer screening depends on their country of origin and their SES and experiences with health services in their homelands. Most VAW, who had a low SES and limited access to health care in their homelands, appreciated the access to health services in the United States, regardless of their current SES. In contrast, the majority of KAW who experienced expedited quality services in their homeland tended to perceive the US health services as difficult to navigate, complex, fragmented, and unavailable when needed. This ultimately leads them to give up on seeking services if they are not urgently needed or to use costly emergency services. This finding suggests that to portray a complete picture underlying low cervical cancer screening rates in VAW and KAW, especially immigrants, social determinants of health (e.g., economic status, health care inequity) rooted in their country of origin must be taken into account. Multifaceted interventions that are cross-culturally applicable but that also take into account cultural dissimilarities and uniqueness in these populations must be developed. This study also revealed that both VAW and KAW’s perceived susceptibility to health and illness, including cervical cancer, varies depending on personal attributes (e.g., age, marital status, illness experiences, misbeliefs) that may or may not be amenable to intervention. For example, the majority of VAW and KAW, particularly young, single women who have no children or family history of illness, tend to have the misperception that virginity or the absence of symptoms indicates a ‘‘healthy status,’’ This view leads to the false belief that they are not susceptible to getting cervical cancer and there is no need for screening. Along with these misbeliefs, a lack of knowledge about cervical cancer and screening is typical in both groups, regardless of education level. Even highly educated women (young women in particular) barely know the cause and risk factors of cervical cancer and the benefits of screening. Young women’s perceptions of health, prevention, and health-seeking behaviors are mainly determined by family referents (e.g., mothers) who are the most influential in their lives. These findings suggest that interventions tailored to personal unique attributes, weighted on reframing incorrect beliefs and targeted not only to unmarried young women but also their mothers, must be developed. Furthermore, these interventions must be implemented at an early age. The younger women are, the more receptive they are to changing misbeliefs and acquiring correct knowledge through logical reasoning and learning mechanisms [34], ultimately leading them to adopt new healthy behaviors with little resistance. Lastly, the study reveals that health care professionals play a critical role in distributing cervical cancer-related
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knowledge to VAW and KAW. These referents are likely to motivate them to initiate and adhere to screening practices. Obstetrician/gynecologists, in particular, have the potential to provide an orientation to the US health care system and to initiate an open dialogue related to cervical cancer with women who enter the US health care system for the first time due to pregnancy. Indeed, most VAW and KAW in the study recognized that health professionals serve as an important source of health-related information and resources. Even so, they did not entirely trust nor exclusively rely on such information and used the information selectively. Friends are also influential in the dissemination of knowledge about cervical cancer. Thus, interventions to enhance cervical cancer screening in these populations should take full advantage of trusted sources within societal networks (e.g., well-recognized ethnic members, cervical cancer survivors, etc.). A limitation of this study is that the results are not generalizable to other racial and ethnic groups or VAW and KAW living in different regions of the United States.
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ORIGINAL PAPER
Socioecological Perspectives on Cervical Cancer and Cervical Cancer Screening Among Asian American Women Jongwon Lee • Mauricio Carvallo
Springer Science+Business Media New York 2014
Abstract Although cervical cancer is one of the most commonly diagnosed cancers among Vietnamese American women (VAW) and Korean American women (KAW), both groups consistently report much lower rates of cervical cancer screening compared with other Asian ethnic subgroups and non-Hispanic Whites. This study aimed to explore multilevel factors that may underlie low screening rates among VAW and KAW living in a city where their ethnic communities are relatively small. The socioecological model was used as a conceptual framework. Thirty participants were conveniently recruited from ethnic beauty salons run by VA and KA cosmetologists in Albuquerque, New Mexico. The participants’ average age was 44.6 years (SD = .50; range = 21–60). Most participants were married (80 %) and employed (73.3 %), and had health insurance (83.3 %). A qualitative interview was conducted in Vietnamese or Korean and transcribed verbatim. A thematic content analysis was used to identify major codes, categories, and patterns across the transcripts. The study identified several factors at the individual (e.g., pregnancy, poverty, personality), interpersonal (e.g., family responsibility, mother as influential referent), and community (e.g., lack of availability, community size) levels. The study sheds light on four major areas that must be taken into consideration in the development of culturally appropriate, community-based interventions aimed to reduce disparities in cervical cancer screening among J. Lee (&) College of Nursing, University of New Mexico, MSC 09 5350, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA e-mail: [email protected] M. Carvallo Department of Psychology, University of Oklahoma, Norman, OK, USA
ethnic minority women in the United States: (1) ethnic community size and geographic location; (2) cross-cultural similarities and dissimilarities; (3) targeting of not only unmarried young women, but also close referents; and (4) utilization of trusted resources within social networks. Keywords Cervical cancer Screening Asian American Socioecological model Qualitative
Introduction Over the last decade, cervical cancer incidence and mortality rates have steadily declined in the United States due to early detection and prevention programs [1]. Despite this trend, however, significant disparities among ethnic minority women belonging to certain Asian subgroup populations exist. Although Asian American women, as a whole, report the lowest cervical cancer incidence and mortality rates of any other ethnic group in the United States [2], Vietnamese American women (VAW) and Korean American women (KAW) fare significantly worse. These two groups not only report disproportionally higher incidence and mortality rates of cervical cancer, but also lower screening rates compared with other ethnic groups, including non-Hispanic Whites [3, 4]. The incidence rates of invasive cervical cancer for VAW (18.9/100,000) and KAW (11.9/100,000) are much higher than those for non-Hispanic Whites (7.1/100,000) and other major Asian American subgroups (9.1/100,000) [4]. Cervical cancer is one of the major causes of death for VAW and KAW, and their mortality rates (3.0–4.8/100,000) are also higher than those for non-Hispanic Whites (2.0/ 100,000) and Asian Americans as a whole (2.7/100,000) [5]. These high incidence and mortality rates are similar to
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recent trends reported for Vietnamese and Korean women living in their countries of origin [6–8]. Despite these high incidence and mortality rates, VAW and KAW consistently report much lower rates of cervical cancer screening than do other Asian ethnic subgroups and non-Hispanic Whites. A study exploring racial/ethnic differences in cancer screening in California showed that, compared with other Asian subgroups (80–89 %) and nonHispanic Whites (88 %), both VAW and KAW reported the third lowest (81 %) and lowest (79 %) rates, respectively, of cervical cancer screening [9]. More recent studies revealed even lower rates of screening (i.e., 54–75 %) for both these groups [10–12]. These rates are far below the Healthy People 2020 goal of having 93 % of women reporting a Pap smear within the past 3 years [13]. VAW and KAW’s low cervical cancer screening rates are concerning, especially because Asian Americans are the second fastest-growing racial and ethnic group in the country, at 17.3 million, or 5.6 % of the total US population [14]. Vietnamese and Korean Americans represent the fourth and fifth largest Asian subgroups, respectively, totaling 1.7 million and 1.6 million [14]. Vietnamese and Korean Americans are among the fastest growing populations in this country, more than doubling in size since 1990 [14, 15]. Although the population of Asian Americans is still large in California and New York, it recently has increased in other states, such as New Mexico (NM). Although Asian Americans currently comprise only 2 % of the population in NM, the percentage of growth has more than doubled since 1990, which is larger than any other major ethnic group in the state [14, 15]. Despite the rapid influx of Asian Americans to NM, little is known about the health status or factors influencing the health-related behaviors of Asian Americans. To our knowledge, no data on cervical cancer and cervical cancer screening of VAW and KAW living in NM exist. Special attention should be paid to both of these groups because cervical cancer is one of the most commonly diagnosed cancers in VAW and KAW. In addition, as the population of VAW and KAW in NM continues to grow and starts to approximate the general US population, higher cervical cancer incidence and mortality rates and lower cervical cancer screening rates are expected. Previous studies have identified various factors underlying low rates of cervical cancer screening among VAW and KAW, such as socioeconomic status (SES), beliefs and myths, and lack of knowledge [10, 16–18]. However, these studies were conducted in regions where both Vietnamese and Korean Americans were densely populated. To the best of our knowledge, no studies have targeted VAW and KAW living in areas where Asian populations are sparse and where minorities represent the majority of the population, such as NM. There are geographic differences in
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Table 1 Sample characteristics (N = 30) Characteristics
n
%
Ethnicity (n = 30) Vietnamese
15
50.0
Korean
15
50.0
Marital status (n = 30) Single Married
6
20.0
24
80.0
Education (n = 29) Middle school or lower High school College graduate or higher Partial college Religion (n = 30) Catholic Other christian
4
13.8
11
37.9
8
27.6
6
20.7
4
13.3
16
53.3
Buddhism
7
23.3
Other
3
10.0
None
5
16.7
One
4
13.3
Two
17
56.7
4
13.3
Yes
25
83.3
No
5
16.7
Number of children (n = 30)
Three or more Health insurance (n = 30)
Age on entering the US, years (n = 30) B20 21–30 31–40 C41
8
26.7
12 8
40.0 26.7
2
6.7
Length of residency in the US, years (n = 30) B10
8
26.7
11–20
10
33.3
21–30
9
30.0
C31
3
10.0
cancer incidence rates, screening, and adherence behaviors [19–21], suggesting that factors underlying cancer screening and adherence may also differ geographically. The current study aimed to explore factors influencing cervical cancer screening, especially unique challenges VAW and KAW encountered while living in NM, where their ethnic community is relatively small.
Framework The conceptualization of this study is based on the socioecological model (SEM) [22]. The SEM posits that
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behavior affects and is affected by multiple levels of influence, including intrapersonal, interpersonal, and community levels, and that behavior shapes and is shaped by influences at multiple levels. This model emphasizes the interaction between and interdependence of various factors within and across all levels of health-related problems and behaviors [23]. The SEM has often been used as a conceptual framework for studying cancer-related behaviors, especially in exploring individual, social, and environmental factors influencing cancer screening prior to developing interventions [24–26]. From a SEM standpoint, this study explored VAW and KAW’s personal characteristics, beliefs, knowledge, and behavior related to cervical cancer and screening (intrapersonal), support exchanged via social networks (interpersonal), and ecological structures that constrain or promote screening (community).
Methods A qualitative research approach was used in this study. The study was approved by the Human Research Review Committee at the University of New Mexico.
determined their eligibility and interest in participating in the study. If they were eligible and agreed to participate, they were guided to a private room in the salon, and the PI and coordinators described the purpose of the study, the incentive ($20 gift card), and their rights as participants. A convenient date, time, and place were set up outside regular working hours for any cosmetologists who expressed interest but could not participate because of her busy schedule. Semistructured interviews were conducted from February 2012 through October 2012. The research coordinators interviewed participants of their same ethnicity, along with the PI’s assistance. To maintain the integrity of the data collection, the coordinators were trained by the PI using the study protocol. Interviews were conducted in the participant’s primary language (Vietnamese or Korean), lasted about 40–60 min, and were tape-recorded. Audiotaped interviews were transcribed verbatim in Vietnamese or Korean by transcriptionists who were fluent in Vietnamese or Korean, respectively. Transcriptions were back-translated into English by translators fluent in Vietnamese or Korean for analysis. Data Analysis
Sample and Settings Thirty VAW (n = 15) and KAW (n = 15) were conveniently sampled from ethnic beauty salons located in Albuquerque, NM. The salons were run by VA and KA cosmetologists and were frequented for hair, nail, and other services. Women were included in the study if they were 18 years of age or older and self-identified as Vietnamese or Korean. Table 1 shows the demographic characteristics of the participants. Data Collection Procedures Two bilingual research coordinators (one Korean and one Vietnamese) and the principal investigator (PI) identified a list of ethnic beauty salons run by VA and KA cosmetologists via social networks and the classified sections of ethnic community newsletters. Under the PI’s guidance, each coordinator made an initial contact by telephone to set up an appointment to meet with each salon owner of her same ethnicity. On the day of the appointment, the PI and the coordinator met with the owner, explained the study purpose, and asked for permission to use the salon as a place for recruiting potential participants. Salon owners were also asked whether they were interested in participating in the study. Of the 15 owners contacted, 12 granted permission (i.e., 5 Korean cosmetologists and 7 Vietnamese cosmetologists). The PI and the coordinators approached the cosmetologists and customers in the salons and
The interview data were entered into ATLAS-ti (version 6.2) [27] qualitative data analysis program and coded using a thematic content analysis technique to identify similar words, phrases, and patterns across the transcripts [28, 29]. Prior to analysis, the investigators met to develop an initial coding scheme based on the SEM and discuss coding labels and definitions. To ensure the consistency of coding across the analysis team and enhance the scientific rigor of the findings, a codebook was developed, including the code, a brief definition, and example quotes. A detailed audit trail was also developed and used throughout the analyses that included memos and the investigators’ reflexivity. The PI first conducted an initial analysis of the transcripts and coded the interview contents based on the SEM levels: individual, interpersonal, and community. The contents were further coded into categories and subcategories by grouping codes with similar meanings and concepts. The other investigator then analyzed the data independently. The codes and categories that emerged from the analyses were compared, and any discrepancies were resolved by the analysis team. The underlying meanings of the different categories were analyzed for their patterns, and broad themes were identified.
Results Data analysis revealed several levels of factors related to cervical cancer and cervical cancer screening, which were
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U.S health services & systems: Lack of availability Lack of accessibility Lack of affordability Community size & location: Regional differences in barriers Ethnic provider preference Homeland health services: Health inequity Expedited services Family networks: Peer networks:
Provider-patient networks:
Extrinsic personal attributes:
Intrinsic personal attributes:
Responsibility & roles Mother as influential referent Support Interpersonal distrust Credibility of information Provider attributes Quality of communication Demographic tripartite Pregnancy history Illness experiences Poverty in homeland Personality Misbeliefs: Virginity Sexual promiscuity Words become seeds Absence of symptom Religious faith Lack of Knowledge
Fig. 1 Socioecological factors on cervical cancer and cervical cancer screening
organized into three domains, based on the socioecological framework: individual, interpersonal, and community (Fig. 1). Individual Level of Influence Extrinsic Personal Attributes Demographic Tripartite Age, marital status, and parental status emerged from VAW and KAW as the major factors influencing, separately or in combination, participants’ perceptions of cervical cancer and screening, and other health-related behaviors. Women who were younger, single, and had no children tended not to perceive the importance of screening practices. They did not consider health as an imperative issue, nor were they inclined to talk about it. Some of these women perceived that they were in a ‘‘safety zone’’ free of illnesses, including cancer. They automatically related their ‘‘young age’’ to a lack of health problems, ultimately decreasing their intention to seek screening and actual screening. In contrast, older women, especially those over age 40, were more likely to perceive that they were at increased risk for illness due to their age and considered their health a major priority. In particular, married women who had children indicated that they became less sensitive about and more open to discussing issues pertaining to their private reproductive organs. They held the perception that there
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was ‘‘nothing to hide’’ with respect to their reproductive organs, as they had gone through marriage and childbirth. Thus, they were not concerned about having a check-up and exposing their private reproductive parts to physicians, including male physicians. One elder woman noted, ‘‘As people get older, there is a risk of getting things, especially cancer. I felt more compelled to pay more attention to it [health] now because of my age.’’ Pregnancy History Pregnancy was a critical turning point for women to enter the US health care system, regardless of whether they had medical issues in the past. Women said that the first time they heard of or received a Pap smear was as part of their initial check-up for pregnancy. One participant stated, ‘‘When I was pregnant, the obstetrics/ gynecology (OB/GYN) doctor told me I had to make sure that I got these things [Pap smears] checked out each year. So, since then, I started to get the checkups.’’ This suggests that OB/GYN doctors and nurses are in an important position to initiate conversations on topics related to cervical cancer for VAW and KAW and educate them about the importance of regular screening. Illness Experiences The experience of illness or family members’ medical problems affected the degree to which women perceived the importance of routine health checkups, including cervical cancer screening. Women tended to perceive that they were at risk for certain diseases if their
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family members had been ill, especially, if they had a family member who had been diagnosed with cancer. This propelled them to start thinking about their own health and become more aware of cancer screening and prevention, leading them to seek regular checkups and undergo screening. In contrast, if there was no family history of disease, they tended to believe that they would not encounter any health problems. Poverty in the Country of Origin Perceptions of health and prevention, including cervical cancer screening, varied and depended on participants’ SES in their country of origin. For women who were born in Vietnam and immigrated to the United States, the concept of prevention and health was not previously considered because in Vietnam, they were poor and could not afford to take time off from work or seek health care. A Vietnamese woman said, ‘‘Money comes first, then health,’’ meaning that their health status was secondary to work and earning money. Intrinsic Personal Attributes Personality Personality can be a barrier or a motivator to engage in prevention practices. Some VAW and KAW felt that stubbornness, introversion, or conservatism negatively influenced their level of openness, which, in turn, impacted their ability to ask their care providers questions and their willingness to talk about health-related topics with others. This limited their opportunities for learning about the importance of prevention, negatively affecting their healthseeking behaviors, including getting Pap smears. One participant noted, ‘‘We’re old-fashioned and thus, it’s hard to open up.’’ Misbeliefs A woman’s virginity status affected how she felt about getting screened. A common misbelief shared by both VAW and KAW was that young, virgin women are not at risk for cervical cancer because they are not sexually active. Sexuality, before and after marriage, also influenced their perceptions of whether they should get screened. Most women said that not having sexual relationships before marriage shielded them from the risk of cervical cancer. Ultimately, this belief deterred them from seeking regular screening. Some women still held the view that they did not need to get screened, even after getting married and becoming sexually active, because they had had only one sexual partner. They tended to believe that they were not at risk for contracting cervical cancer because they were not sexually promiscuous and that only those who have multiple sexual partners were. There is the common misbelief in both Vietnamese and Korean cultures that ‘‘words become seeds.’’ This belief prevents VAW and KAW from openly talking about
cancer-related topics. Women tend to believe that if they talk about cancer or any disease, they will ultimately get it or become sick. One woman noted, ‘‘In general, people don’t really talk about cancer or being sick. They just want to avoid the topic. I don’t want to talk about it. It’s just a taboo. If you do it, it will happen to you.’’ Moreover, most women lack the concept of health prevention and tend to equate the absence of symptoms with being ‘‘healthy.’’ This, in turn, leads them to perceive that there is no need for regular screening or check-ups in the absence of symptoms. Religious Faith Some women indicated that religious faith influenced how they viewed life events such as illnesses, including cancer, and their religious beliefs affected their acceptance of and willingness to overcome such events. Religious faith also influenced women’s perceptions of or readiness for death. One participant stated, ‘‘At first, I was really scared, but as I prayed, God showed me what a blessed person I was, then I was like…what’s the big deal about cancer…if God says it’s time to go, then I die.’’ Although some women stated that religious faith had little to do with the experience of illnesses, including cancer, and could not heal or cure physical ailments, they were likely to perceive faith in a positive way and acknowledge that it may provide a coping mechanism to deal with illnesses. Lack of Knowledge Some women were aware of the fact that cervical cancer is curable and preventable, and were able to identify some of the risk factors, such as human papillomavirus and smoking. However, the majority stated that they had never heard about cervical cancer and did not know about the cause, risk factors, treatments, and recommended screening guidelines. They also were significantly misinformed. For example, some indicated that the acidity of their body, dust, or mud could cause cancer of the cervix. One participant stated, ‘‘When you work on the farm, you are really in close contact with mud and dust and it [mud and dust] gets to you from the bottom up. So, that’s how you get it [cancer].’’ In addition, some women believed that if they did not keep their perineal areas clean or have a healthy diet, then they would get cancer. Interpersonal Level of Influence Family Networks Responsibility and Roles Women’s perceived levels of responsibility and their roles as mothers or wives positively influenced their prevention and screening practices. Women who had family members, especially children, felt they had to remain healthy to take care of them. These
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women also indicated that they tried to remain healthy because they did not want to be a burden to their families if they got sick. This ultimately drove them to obtain regular health check-ups, including cervical cancer screening. One woman stated, ‘‘I’m a mom worrying about my kids. If I’m not here, how will they live? So, I am more diligent and try to keep healthy.’’ Mothers as Influential Referents For young women, the concept of health and prevention seemed to be mainly influenced by family members they perceived as most significant in their lives. What their mothers thought they should (or should not) do regarding their health determined the degree to which they followed treatments and were aware of the importance of regular health check-ups for early detection and prevention. A young, single, woman said that she refused to take birth control pills to regulate her menstrual pain because her mother did not allow her to take them (despite her doctor’s recommendation), but took painkillers on a monthly basis to control it. Another young woman stated that she had received a Pap smear yearly because her mother asked her to do so. Peer Networks Support Friends, peers, or coworkers acted as major sources of health-related information and served as motivators driving women to ultimately undergo screening. One woman said, ‘‘My friend told me to get it [Pap smear]. So I went to the doctor…3 months ago.’’
Provider–Patient Networks Provider’s Attributes Health care providers’ characteristics, such as gender, appearance, or expected roles, affected women’s provider preferences and perceptions of the credibility of the health information received. This, in turn, affected the level of trust women had in a provider and the degree to which they were willing to adhere to regimens directed by the provider. For example, one woman said that male doctors were more skillful than female doctors and preferred to seek services from a male doctor. Another woman said that the provider’s appearance affected the credibility of the information she received (e.g., a provider who eats doughnuts and provides information about healthy diets is not trustworthy). Communication The amount and quality of health information women received from their health care providers affected their initiation of, adherence to, and awareness of cervical cancer screening. Of women who had ever received or been compliant with cervical cancer screening, most indicated that their provider recommended that they be screened. Yet, some women who went for routine check-ups commented that they were not even aware that a Pap smear was being done during their visit or why. This was due, in part, to their provider’s lack of a thorough explanation of the examination procedure or their own language barriers. Both these factors were cited as barriers, causing stress when seeking services. Community Level of Influence
Distrust Although most women commented that they were willing to be open and share their health-related information and problems with friends, peers, or coworkers whom they trusted, some women said they were reluctant to share such information because they were afraid of being a victim of gossip or back-stabbing. One participant stated, ‘‘The person I’m close to me tells me all kinds of thing about people I don’t even know. I feel that this person will also talk about me like that to others. So, I’m careful.’’ Such a relational distrust is present in both Vietnamese and Korean cultures, sometimes preventing the women from seeking support or health-related information from their peers. Credibility Women also commented that health-related information from their peers was not entirely accurate. One participant noted, ‘‘Well, I don’t trust 100 %. I must be careful and need to ask a doctor to make sure of this [information].’’ The degree to which they judged the information as reliable was mainly based on the type of job or credentials peers held or whether the illness their peers had experienced was similar.
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US Health Services and Systems Lack of Availability The unavailability of care providers and receiving services in a timely fashion constituted a major factor that limited health-seeking behaviors, including screening practices. The majority of women, especially KAW, complained that it was extremely hard to schedule an appointment, they had to wait too long to be seen by a doctor, and their health problems already disappeared by the time of their appointment. Some of them said that they had given up on making appointments to see their primary doctor and ultimately ended up seeking urgent care or emergency services or relied on alternative medicine to treat their health problems. Lack of Accessibility The difficulty of locating or accessing clinics was the biggest factor limiting their screening practices. Many women said that US health clinics were spread out all over town, and it was not easy to reach them when needed. Most women also stated that fragmentation of services was a big issue. They were
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concerned that they could not get all the services required in one place, in one visit, if they had more than one health problem. They had to go to one clinic for one problem and another clinic for a different problem. Lack of Affordability Many VAW and KAW said that the US health insurance policies were inefficient and costly. They expressed concern that although they were covered by insurance, the copayments and monthly premiums were too expensive, and they could not afford to seek services when needed. Thus, some of them regularly sought health services abroad: ‘‘I have insurance here, but it’s too expensive… When I go to Korea on vacation, I get my entire health check-ups there. I don’t have insurance there, but it’s still cheaper there.’’ Community Size and Location The size and geographic location of ethnic communities also present barriers to cervical cancer screening. Many woman indicated that the language barrier, which is a wellknown factor limiting health-seeking behaviors, had never been an issue when living in a place where a large ethnic community existed (e.g., Los Angeles (LA), California). In LA, a large number of ethnic providers and clinics are available; therefore, not being fluent in English did not prevent them from seeking services. However, it was a problem if they lived in a place with a small ethnic enclave (e.g., Albuquerque, NM), with limited culturally appropriate resources. Community size also affected women’s preference of ethnic providers. Women who had previously lived in a large community where their ethnic group was densely populated (e.g., LA) and had moved to a place with a smaller ethnic community (e.g., Albuquerque) preferred not to choose providers of their same ethnicity, favoring American providers instead, even if they were males, because they were concerned that their health information would become known to the entire community. One Korean woman said, ‘‘As the community is small, these doctors could spread out my health information to their friends, then their friends to other friends.’’ Homeland Health Services The degree to which women appreciate the US health care system varied, depending on where they came from and what levels of services they experienced in their country of origin. For example, Vietnamese women who had little access to quality services in their homeland due to poverty expressed appreciation for US health care services. They felt that the US health care system is set up so that people’s health comes first and payment for services is secondary;
they have an opportunity to get regular checkups, regardless of whether they can pay for it all up front at the time of their visit. One Vietnamese woman compared US health services with those she received in Vietnam: ‘‘My payment (in the United States) was never an issue. Doctors treated me first and billed me later. Their main concern is my health, not my ability to pay. But in Vietnam you have to pay first before they even think of treating you.’’ In contrast, most Korean women who had experienced the health system in their homeland expressed dissatisfaction with US health services, mainly due to the systemic, structural barriers noted previously.
Discussion The purpose of this study was to explore multiple levels of interactive factors that influence VAW and KAW’s cervical cancer screening through a socioecological lens. The study provides insight into the unique barriers to cervical cancer screening among VAW and KAW, and contributes to an understanding of the reasons cervical cancer screening rates are so low in these groups. In particular, the findings reveal that the size of the ethnic community in which a woman lives can constitute a barrier that limits her access to cervical cancer screening. For example, for those living in a place where their ethnic community is relatively small, the language barrier is a particular issue. Despite this barrier, however, women may not seek health services from their own ethnic providers who are fluent in their primary language, even if the provider is female, in part, because of concerns that their private health information may be revealed to the entire community. Although the existing literature suggests that the use of same ethnic providers, preferably females, constitutes a culturally sensitive intervention strategy that enhances preventive health practices, including cervical cancer screening in ethnic minority women [30–33], this is not as evident among VAW and KAW living in cities with a small ethnic community. This finding suggests that concealment of health information is a higher priority than is gender-specific, language-concordant ethnic providers in these populations. It indicates that culturally sensitive interventions must be developed by taking into account the size or geographic location of the ethnic enclave and tailoring the interventions to the unique needs of these populations. The majority of multilevel influencing factors identified in this study are similar between VAW and KAW, implying that there are cultural similarities in perceptions of cervical cancer and the underlying reasons for not seeking (or seeking) cervical cancer screening. However, the study also reveals that there are unique differences
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between these two groups. For example, the degree to which both VAW and KAW perceive barriers to access to cervical cancer screening depends on their country of origin and their SES and experiences with health services in their homelands. Most VAW, who had a low SES and limited access to health care in their homelands, appreciated the access to health services in the United States, regardless of their current SES. In contrast, the majority of KAW who experienced expedited quality services in their homeland tended to perceive the US health services as difficult to navigate, complex, fragmented, and unavailable when needed. This ultimately leads them to give up on seeking services if they are not urgently needed or to use costly emergency services. This finding suggests that to portray a complete picture underlying low cervical cancer screening rates in VAW and KAW, especially immigrants, social determinants of health (e.g., economic status, health care inequity) rooted in their country of origin must be taken into account. Multifaceted interventions that are cross-culturally applicable but that also take into account cultural dissimilarities and uniqueness in these populations must be developed. This study also revealed that both VAW and KAW’s perceived susceptibility to health and illness, including cervical cancer, varies depending on personal attributes (e.g., age, marital status, illness experiences, misbeliefs) that may or may not be amenable to intervention. For example, the majority of VAW and KAW, particularly young, single women who have no children or family history of illness, tend to have the misperception that virginity or the absence of symptoms indicates a ‘‘healthy status,’’ This view leads to the false belief that they are not susceptible to getting cervical cancer and there is no need for screening. Along with these misbeliefs, a lack of knowledge about cervical cancer and screening is typical in both groups, regardless of education level. Even highly educated women (young women in particular) barely know the cause and risk factors of cervical cancer and the benefits of screening. Young women’s perceptions of health, prevention, and health-seeking behaviors are mainly determined by family referents (e.g., mothers) who are the most influential in their lives. These findings suggest that interventions tailored to personal unique attributes, weighted on reframing incorrect beliefs and targeted not only to unmarried young women but also their mothers, must be developed. Furthermore, these interventions must be implemented at an early age. The younger women are, the more receptive they are to changing misbeliefs and acquiring correct knowledge through logical reasoning and learning mechanisms [34], ultimately leading them to adopt new healthy behaviors with little resistance. Lastly, the study reveals that health care professionals play a critical role in distributing cervical cancer-related
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knowledge to VAW and KAW. These referents are likely to motivate them to initiate and adhere to screening practices. Obstetrician/gynecologists, in particular, have the potential to provide an orientation to the US health care system and to initiate an open dialogue related to cervical cancer with women who enter the US health care system for the first time due to pregnancy. Indeed, most VAW and KAW in the study recognized that health professionals serve as an important source of health-related information and resources. Even so, they did not entirely trust nor exclusively rely on such information and used the information selectively. Friends are also influential in the dissemination of knowledge about cervical cancer. Thus, interventions to enhance cervical cancer screening in these populations should take full advantage of trusted sources within societal networks (e.g., well-recognized ethnic members, cervical cancer survivors, etc.). A limitation of this study is that the results are not generalizable to other racial and ethnic groups or VAW and KAW living in different regions of the United States.
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