Facilitators and Barriers to Cervical Cancer Screening Among Chinese Canadian Women T.G. Hislop1,2 M. Deschamps3 C. Teh1,2
C. Jackson4,5 S-P. Tu4,5 Y. Yasui6
S.M. Schwartz6,7 A. Kuniyuki6 V. Taylor6,8
ABSTRACT Background: Chinese Canadian women have higher cervical cancer incidence, and lower Pap testing, rates than the general Canadian population. Predisposing, enabling and reinforcing factors associated with ever having a Pap test, and having a recent Pap test within the last 2 years, were assessed in Chinese women in British Columbia using the PRECEDE-PROCEED model. Method: Chinese women (n=512) between the ages of 20 and 79 years and residing in Greater Vancouver were interviewed about Pap testing, health care, traditional health beliefs, acculturation and sociodemographic characteristics. Two analyses were done, comparing women who had ever and never had a Pap test, and comparing women who had and had not received a recent Pap test. Focus groups and qualitative interviews ensured cultural sensitivity in the survey questionnaire. Results: Seventy-six percent reported ever having a Pap test and 57% reported having a Pap test within the last 2 years. Traditional health beliefs were not associated with ever or recent Pap testing. However, belief that Pap testing prevented cancer and general knowledge about the Pap test were associated with screening. Concern about pain/discomfort with the test, availability of time, culturally sensitive health care services and recommendation for Pap testing by a physician were also associated with screening. Factors differed for ever, and recently, having a Pap test. Interpretation: Pap testing is less common among Chinese Canadian women. Continuing education about Pap testing is recommended for physicians serving underscreened Chinese women. Culturally and linguistically appropriate educational materials are needed for the Chinese community.
La traduction du résumé se trouve à la fin de l’article. 1. Population and Preventive Oncology, BC Cancer Agency, Vancouver, BC 2. Cancer Control Research Program, BC Cancer Agency 3. Direction de la Santé Publique Montréal-Centre, Québec 4. Department of Medicine, University of Washington, Seattle, WA 5. International Medicine Clinic, Harborview Medical Center, Seattle 6. Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle 7. Department of Epidemiology, University of Washington 8. Department of Health Services, University of Washington Correspondence: Dr. T. Gregory Hislop, BC Cancer Agency, 600 West 10th Avenue, Vancouver, BC V5Z 4E6, Tel: 604-877-6000, Fax: 604-872-1868, E-mail:
[email protected] Acknowledgements: This work was supported by the US National Cancer Institute (Grant #74326 and Cooperative Agreement #86322) and the British Columbia Health Research Foundation (Grant #180(96-2)). We thank the women who participated in these interviews; the interviewers: C. Chan, I. Chan, L. Hsu, A. Ko, S. Leung, M. Li, J. Ng, E. Ng, C. Pang, G. Troung; the community advisory coalition: I. Chan and L. Lai (Canadian Cancer Society), Dr. J. Ko (Taiwanese Canadian Cultural Society), G. Mumick (Vancouver-Richmond Health Board), S. Leung (SUCCESS), Dr. L. Sent (Asian Women’s Health Clinic), Dr. C. Wang (Chinese Canadian Medical Society), Dr. M. Yu (Chinese Cultural Centre); other members of the research team: T. Labo and A. Lai; and E. Baptiste for preparing the manuscript. 68
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ecent immigration has contributed to substantial population growth among Chinese in British Columbia (BC), the majority of whom are foreign-born and coming mainly from East and Southeast Asia. In 1996, nearly 300,000 (8%) of the BC population identified themselves as Chinese, 1 the vast majority residing in Vancouver and adjacent Richmond; these municipalities have the highest density of Chinese people in Canada. Cervical cancer is a significant health problem in Chinese women, being the second leading cause of cancer deaths in Mainland China.2 Chinese American women who were Asian-born have higher incidence rates than those who were North American-born, and BC Chinese women (irrespective of their place of birth) have twice the incidence of White women.3 These findings may be explained in part by differences in Pap testing rates.3-6 Over 50 years ago, BC was the first jurisdiction in the world to establish an organized cervical cancer screening program, currently known as the Cervical Cancer Screening Program (CCSP). This program has been very effective in reducing incidence of, and deaths from, invasive cervical cancer by 85% and 78%, respectively.7 However, approximately 25% of the age-eligible women in BC, representing approximately 1.3 million women, have not been screened in a recent 30-month period.8 The CCSP is committed to developing strategies and educational materials to promote Pap testing in underserved communities. We conducted a comprehensive evaluation of Pap testing in Chinese women in BC9 and Washington State.10 Lower Pap testing rates were found among Chinese women as compared to other BC women, and several sociodemographic factors were associated with less Pap testing, including older age, single marital status, having been born in Mainland China, lower education, lower household income and less acculturation.9 This paper presents the results of more in-depth analyses that were performed using the PRECEDE-PROCEED model. 11 Predisposing, enabling and reinforcing factors were examined by comparing women who had ever and never had a previous Pap test, and by comparing women who had and had not received a VOLUME 94, NO. 1
CERVICAL CANCER SCREENING AMONG CHINESE CANADIAN WOMEN
recent Pap test within the last 2 years. Predisposing factors involve individual motivation to participate in the CCSP and include knowledge, attitudes, beliefs, perceived value, perceived need and capacity to take action. Enabling factors involve availability and access to services. Reinforcing factors focus on the feedback and support given by society, peers and health professionals.
TABLE I Sociodemographic Factors Associated with Pap Testing Factor
Category
No.
Age (years)
20-39 40-59 60-69 70-79 Mainland China Hong Kong SE Asia Taiwan North America Other Currently married Previously married Never married 0-7 8-12 13+ < $20K $20K - $29K $30K - $49K $50K+ Owned Rented Subsidized 0-13% 14-26% 27-43% 44%+ Yes No Yes No
147 248 74 43 247 174 21 28 9 33 419 53 40 111 202 196 107 85 105 65 442 47 13 130 128 136 117 190 322 39 473
Place of Birth
Marital Status
METHODS Education (years)
Conceptual framework A cross-sectional study was done using the PRECEDE-PROCEED model to develop the survey questionnaire and for analysis. This model consists of ten steps: the first five analyze the situation and establish priorities and objectives, and the last five deal with implementation, follow-up and evaluation of the program. Within the first five steps, major problems and needs are identified with direct involvement of targeted population (Social Diagnosis); importance of these health problems are documented through survey and epidemiological data (Epidemiological Diagnosis); behavioural and lifestyle factors are identified that relate to the health problems (Behavioural and Environmental Diagnosis); factors are investigated that must be changed to maintain or modify behaviours or lifestyle (Educational and Organizational Diagnosis); and organizational resources are analyzed that influence the implementation of a program (Administrative and Policy Diagnosis). This paper will focus on Educational and Organizational Diagnosis. Community advisory group A Community Advisory Committee was formed to advise the research team throughout the study and to assist in introducing the study to the community. This representative committee included six members from different Chinese organizations serving the Cantonese- and Mandarin-speaking communities and two family physicians serving the Chinese community. The Chinese community was informed about the study through Chinese radio announcements, newspaper articles and newsletters of local Chinese organizations about one month before the start of the survey. JANUARY – FEBRUARY 2003
Household Income
Housing Type Proportion of Life in North America Speaks English Fluently Previous Hysterectomy
% Ever Screened 72.1 85.9 66.2 44.2 69.6 79.3 90.5 78.6 88.9 84.8 82.3 60.4 25.0 64.0 81.7 76.0 69.2 72.9 86.7 87.7 78.3 63.8 30.8 72.3 75.0 71.3 84.6 81.1 72.4 76.9 75.5
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% Recently Screened 58.5 69.8 36.5 18.6 49.4 63.2 76.2 50.0 77.8 75.8 64.9 30.2 15.0 46.0 62.4 59.2 52.3 51.8 62.9 75.4 59.7 48.9 15.4 55.4 51.6 55.9 68.4 62.6 54.3 30.8 59.6
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