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Pushing Pap across cultural lines

PHS, Harborview team identifies barriers to cervical-cancer screening among Vietnamese-American women
pap test
Understanding barriers to Pap testing aids in the development of culturally appropriate intervention strategies aimed at reducing rates of cervical cancer. Photo by Todd McNaught

A new Seattle-area study offers insight into why many Vietnamese-American women fail to receive an effective cervical-cancer-screening test, which many experts believe accounts for the high rates of the disease in this population.

Researchers found that Vietnamese-American women were more likely to undergo regular Pap screening if they were married, knew that the test was necessary when they have no symptoms, had doctors who had recommended testing or had asked their doctors for testing. Based on these findings, the investigators are developing culturally appropriate informational pamphlets and videos to encourage regular screening. Such an intervention could help to reduce incidence of invasive cervical cancer among Vietnamese-Americans, which is five times higher than that of non-Latina whites.

Dr. Vicky Taylor, investigator in the Public Health Sciences Division, led the study, along with colleagues at the University of Washington, Harborview Medical Center and the University of California, San Francisco. The work was part of a larger study, Cancer Control in a Vietnamese-American Population, which is overseen by Dr. J. Carey Jackson, director of the International Medicine Clinic at Harborview. The clinic, which is staffed by bilingual providers, offers primary care for adult refugees and immigrants.

The researchers have targeted their efforts toward cervical-cancer prevention because many studies have shown that regular screening with the Papincolaou (Pap) test, in which a sample of cervical tissue is microscopically analyzed for precancerous cells, is associated with dramatic reductions in cervical-cancer deaths. The American Cancer Society recommends yearly Pap screening for women aged 21 to 30, and screening every two to three years for women over age 30 who have had three consecutive normal tests.

Another compelling reason for conducting this research, Taylor said, is that the high cervical-cancer incidence among Vietnamese-American women is exactly the type of health disparity that the National Institutes of Health is working to eliminate through their Healthy People 2010 initiative.

"The incidence of invasive cervical cancer in this population is a very glaring health disparity," she said.

To assess the barriers to Pap screening, the researchers analyzed responses to in-person, at-home interviews with 352 Vietnamese-American women aged 18 to 64 in south Seattle, an area of the city in which the Vietnamese community is concentrated. The questionnaire for the study was developed in English, translated into Vietnamese and modified to ensure its equivalence in both languages. Virtually all of the women completed the survey in Vietnamese. Bilingual Vietnamese-Americans conducted the interviews, a factor that Taylor said was critical to the high percent response rate.

"Studies like these cannot be conducted without staff, who are members of the community," she said.

Variables for screening

Researchers found that 71 percent of respondents had received a Pap test on at least one occasion, and 68 percent of respondents had been screened for cervical cancer in the preceding three years. The numbers fall far below the objectives of NIH's Healthy People 2010 initiative, which aims to achieve respective Pap screening rates of 97 percent and 90 percent.

Among the variables that researchers identified to have a significant impact on whether women were likely to have been recently screened for cervical cancer:

  • Married women were more than two-and-a-half times as likely to have undergone recent Pap screening than unmarried or previously married women.
  • Women who knew that Pap testing is necessary even when no symptoms are present were three-and-a-half times more likely to have been recently screened than those who did not.
  • Women whose doctors had recommended Pap testing were nearly seven times more likely to have been recently screened compared to those whose doctors had not.
  • Women who had asked their doctor for Pap testing were eight times more likely to have been recently screened than those who had not.

Unique barriers

Previous studies of low-income African Americans and Hispanics have identified modesty as a barrier to Pap testing, a variable not found to be significant in this study.

"A lot of barriers are cultural in nature and very specific to particular populations," Taylor said. "In order to develop effective intervention strategies, it's important to identify those unique barriers."

The study appears in the April issue of Cancer Epidemiology, Biomarkers and Prevention. In addition to Jackson, coauthors included Dr. Yutaka Yasui, Elizabeth Acorda and Pingping Qu of PHS; Drs. Nancy Burke ant Tung Nguyen, UCSF; and Dr. Hue Thai, Harborview Medical Center.

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