Women's Health Issues 24-2 (2014) e231–e236
www.whijournal.com
Original article
Cervical Cancer Prevention: Asian-American Women’s Knowledge and Participation in Screening Practices Katina Robison, MD a,*, Lindsay Clark, MD a, Whitney Eng, MD a, Lily Wu, MD a, Christina Raker a, Melissa Clark, PhD a, Trevor Tejada-Berges, MD a, Don S. Dizon, MD b a b
Women & Infants’ Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Providence, Rhode Island Massachusetts General Hospital Cancer Center, Boston, Massachusetts
Article history: Received 20 May 2013; Received in revised form 20 November 2013; Accepted 12 December 2013
a b s t r a c t Objective: The purpose of this study was to compare cervical cancer knowledge and prevention strategy participation among Chinese-American women compared with Southeast–Asian-American women. Methods: We performed a cross-sectional survey of Chinese and Southeast Asian women in Rhode Island. Anonymous surveys were administered following informed consent. The survey included demographics and questions related to health care practices, cervical cancer, and the human papilloma virus (HPV). Categorical variables were compared by Fisher’s exact test. Mean scores of correct answers on the knowledge questions were compared by Student’s t-test and analysis of variance. Results: Ninety-six Chinese women and 132 Southeast Asian women were included in the analysis. Sixty-seven percent of Chinese women had at least a college education compared with 37% of Southeast Asian women (p < .0001). Nineteen percent of Chinese women reported annual household incomes of greater than $100,000 compared with 3% of Southeast Asian women (p ¼ .0003). Twenty percent of Southeast Asian women did not have health insurance compared with 10% of Chinese women (p ¼ .06). Among both groups, 25% of participants either never had a pap test or did not know if they ever had a pap test. There was a greater lack of knowledge about the relationship between HPV and cervical cancer among Chinese (mean 2.9 out of 8 questions) compared with Southeast Asian (mean 3.6 out of 8 questions; p ¼ .02). Conclusions: Regardless of ethnic subgroup, education, or income, all participants had a poor knowledge of cervical cancer and HPV. This study supports the need for improvement in cervical cancer prevention education among all Asian women. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
In the United States, the implementation of the Papanicolaou test in the 1940s brought about a remarkable decrease in the incidence of and mortality from cervical cancer. With the development and implementation of the human papilloma virus (HPV)
The project described was supported by Award Number K12HD050108 from the Office of the Director, National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The content is solely the responsibility of the author and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Children Health & Human Development of the National Institutes of Health. * Correspondence to: Katina Robison, MD, Program in Women’s Oncology, Women & Infants’ Hospital, 101 Dudley Street, Providence, RI 02905. Phone: þ1 401-453-7520; fax: þ1 401-453-7529. E-mail address: [email protected] (K. Robison).
vaccine in 2009, the incidence of cervical cancer will likely continue to decline both in the United States and worldwide. Unfortunately, despite these advances, racial disparities in cervical cancer incidence and mortality remain in the United States. Although the gap between incidences of cervical cancer in black women and non-Hispanic White women is narrowing, the percentage of Asian or Pacific Islanders diagnosed with cervical cancer is growing (Ward et al., 2012). Asian Americans are often reported to have low cervical cancer screening rates and high cancer mortality rates (Gor, Chilton, Camingue, & Hajek, 2011). However, this is a heterogenous group, which is frequently evaluated together even though there may be specific differences between the ethnic subgroups. In the U.S. National Cancer Institute’s Surveillance, Epidemiology,
1049-3867/$ - see front matter Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.12.005
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K. Robison et al. / Women's Health Issues 24-2 (2014) e231–e236
and End Results program, the Asian or Pacific Islander category comprises at least 12 different ethnic categories, each with different patterns of cancer incidence and mortality. Whereas Chinese women have a cervical cancer incidence less than nonHispanic White women, Vietnamese women have a more than two-fold greater incidence of cervical cancer compared with non-Hispanic White women (Wang, Carreon, Gomez, & Devesa, 2010). Similarly, Vietnamese women had double the incidence of cervical cancer compared with White women in California (McCracken et al., 2007). Additionally, Vietnamese women were more than twice as likely to die of cervical cancer compared with White women and three times as likely compared with ChineseAmerican women (Ho & Dinh, 2011; McCracken et al., 2007). Furthermore, compared with non-Hispanic White women, Southeast Asian women have a cervical cancer incidence rate three times higher and are half as likely to undergo regular cervical cancer screening (Constantine & Jerman, 2007; Dang, Lee, & Tran, 2010). Asian Americans seem to be a heterogeneous group with regard to cervical cancer incidence and evaluating this group in aggregate may mask variations influenced by cultural or socioeconomic factors (Wang et al., 2010). There is a paucity of literature comparing the Asian-American subgroups’ knowledge on cervical cancer and HPV. Southeast Asian women have the highest rates of cervical cancer and often the lowest markers of socioeconomic status among Asian Americans, whereas Chinese women often have lower rates of cervical cancer and higher markers of socioeconomic status (Dang et al., 2010; McCracken et al., 2007). More information on the differences in Asian-American subgroups in relation to participation in cervical cancer screening and HPV vaccination is needed. This information can help to direct targeted interventions specific to Asian subgroups to improve knowledge and participation in cervical cancer screening and vaccination. The goal of this crosssectional study was to compare the knowledge of cervical cancer prevention strategies between Southeast–Asian-American women and Chinese-American women. Methods A 33-question, anonymous survey was developed and institutional review board approval was obtained to conduct the study from June 2009 to June of 2010. The survey included questions regarding demographics, health care practices, cervical cancer, and HPV. The survey was designed with the assistance of members of the Providence Southeast Asian Community Center, Chinese American Brown University medical students, and a Laotian community member. The content validity was assessed through a review by six experts. Each expert was given the survey and asked to review the questions to ensure they were assessing basic knowledge of cervical cancer and HPV. In addition, face validity was evaluated by the experts and determined the survey would measure cervical cancer knowledge among both Chinese and Southeast Asian women. A knowledge scale was developed that included eight questions evaluating the general knowledge of cervical cancer and HPV (Figure 1). There were six questions that evaluated the beliefs about HPV vaccination for women and their daughters. The survey was administered to Southeast Asian women and Chinese women in Rhode Island over an 18-month period. Women were recruited at various community sites, including churches, grocery stores, health fairs, and community centers. Recruiters went out in the community one to three times per month to recruit. Chinese women and Southeast Asian women
were both recruited from the same health fairs, grocery stores and community centers. However, the groups were recruited from Chinese– or Southeast Asian–specific churches. All women were approached by the recruiters and asked verbally if they were Southeast Asian or Chinese. The same recruiters were used at all of the sites. Women who self-identified as either Southeast Asian or Chinese were asked to participate. They were offered the survey in English, Lao, Vietnamese, Hmong, Khmer, Thai, or Chinese after informed consent was obtained. The surveys were self-administered in the language chosen by the participant. Surveys were analyzed using SAS version 9.2 (SAS Institute, Cary, NC). Categorical variables were compared by Fisher’s exact test. Knowledge scores were calculated as the sum of correct answers (range, 0–8). Mean scores were compared between Chinese and Southeast Asian women by the Student t-test and were adjusted for age, education, and income by analysis of variance. Knowledge scores were calculated for those answering at least half (4 or more) of the knowledge questions. Those not answering at least four questions were excluded from the analyses. All p-values presented were two-sided with p < .05 considered significant. Findings We recruited 229 women. One woman was excluded because the majority of the survey was incomplete. Ninety-six Chinese women and 132 Southeast Asian women were included in the analysis. The majority of Southeast Asian women were Cambodian and Laotian. Two Hmong women were considered Southeast Asian in the analysis, even though their country of origin was China because they self-identified as Southeast Asian. Chinese and Southeast Asian women differed on demographic characteristics (Table 1). Chinese women were older and more likely to be married than Southeast Asian women. Chinese women were more educated than Southeast Asian women and had higher household incomes. Twenty percent of Southeast Asian women did not have health insurance compared with 10% of Chinese women. Both Chinese and Southeast Asian women identified themselves as religious. Among both groups, the majority of women reported having a physician and saw a physician annually (Table 2). However, nearly 25% of all participants either never had a pap test or did not know if they ever had a pap test. Of women who did report undergoing a pap test, most women in both groups reported having the test within the last 3 years and were aware of test results. Nearly half of all women reported receiving health information from the Asian community, family, or friends. The majority of Chinese and Southeast Asian women reported receiving health information from their physician. Only one women in the Chinese group and 14 women in the Southeast Asian group answered fewer than half of the questions (Table 3). Based on testing, there was a lack of knowledge about the relationship between cervical cancer and HPV among both Chinese (mean, 2.9) and southeast Asian women (mean, 3.6). The mean knowledge score for Chinese women was lower (mean, 2.7) compared with southeast Asian women (mean, 3.7; p ¼ .05) when adjusting for age, education, and income (Table 4). Among women in the recommended vaccination age range (18–24 years), only 33% of Chinese and 37% of southeast Asian women reported receiving the HPV vaccine. Among women of vaccination age, the majority reported a desire to receive the vaccination (66% southeast Asian vs. 57% Chinese; p ¼ .6). Among women with children, 19.3% of southeast Asian versus 15.4% of
K. Robison et al. / Women's Health Issues 24-2 (2014) e231–e236
e233
Figure 1. Survey questions evaluating knowledge of cervical cancer prevention.
Chinese reported their daughters had received the vaccination (p ¼ .6). Of these women, 48.2% of southeast Asian and 50.9% of Chinese desired their daughters to be vaccinated. Discussion Cervical cancer remains a significant problem globally and racial disparities still exist in the United States. Asian Americans are a unique and heterogeneous group that have been underrepresented in vaccine trials and typically evaluated as a homogeneous group in analyses, even though the group is composed of at least 12 different ethnic categories that differ culturally, behaviorally, and socioeconomically (Garland et al., 2007; Paavonen et al., 2007; Schiller, Castellsague, & Garland, 2012; Wang et al., 2010). These differences may influence cervical cancer screening and HPV vaccination rates. In our study, although Chinese and Southeast Asian women differed demographically, nearly one third of women in both groups had not undergone cervical cancer screening in the last 3 years and women in both groups had inadequate knowledge regarding HPV, the HPV vaccine, and cervical cancer. Similar to prior studies, we found low self-reported cervical cancer screening rates among all Asian-American females (Licht
et al., 2010). Although rates are universally low, there is a cancer screening disparity among Asian-American subgroups even after controlling for relevant factors (Lee, Ju, Vang, & Lundquist, 2010). It has been speculated that the low rate of cervical cancer screening among Asian Americans is associated with lower socioeconomic status and a lack of health insurance (Lee et al., 2010). However, socioeconomic factors vary greatly between subgroups. In our study, we found that although Chinese women had higher levels of education and higher income, their cervical cancer screening rates were the same as southeast Asian women. Consistent with our findings, the U.S. Census Bureau reported nearly 50% of Chinese Americans had a bachelor’s degree compared with fewer than 10% of all Southeast Asians. Additionally, the median income among Chinese Americans was double that of Southeast Asian Americans (McCracken et al., 2007). In our study, we found that the majority of women in both groups had health insurance. This suggests that socioeconomic factors and lack of health insurance may not be the only factors influencing participation in cervical cancer screening among Asian women. There are likely additional cultural factors that may also play a role and differ among the various Asian subgroups. HPV vaccination rates are also known to be low among Asian women, specifically in the Southeast Asian group. A National
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Table 1 Demographic Variables
Table 2 Chinese Versus Southeast Asian Participation in Health Care Services
Variable
Total (n ¼ 228)
Chinese (n ¼ 96)
Southeast Asian (n ¼ 132)
Age (y) 18–24 24–30 30–44 44–59 60 Number of children None 1–3 4–5 >5 Married Yes No Born in the United States Yes No Cambodia Laos Vietnam Thailand Education Up to 8th grade Some high school High school Some college College Graduate school Income (U.S.$) 20,000 20,000–40,000 40,000–60,000 60,000–100,000 100,000 Health insurance Yes No Religious Yes No
n ¼ 225 38 (16.9) 35 (15.6) 73 (32.4) 65 (28.9) 14 (6.2) n ¼ 224
n ¼ 95 10 (10.5) 5 (5.3) 39 (41.1) 34 (35.8) 7 (7.4) n ¼ 95
n ¼ 130 28 (21.5) 30 (23.1) 34 (26.2) 31 (23.9) 7 (5.4) n ¼ 129
58 (25.9) 128 (57.1) 22 (9.8) 16 (7.1) n ¼ 225 147 (65.3) 78 (34.7) n ¼ 223
21 (22.1) 70 (73.7) 2 (2.1) 2 (2.1) n ¼ 95 77 (81.1) 18 (18.9) n ¼ 94
37 (28.7) 58 (45.0) 20 (15.5) 14 (10.9) n ¼ 130 70 (53.9) 60 (46.2) n ¼ 129
43 (19.3) 180 (80.7)
4 (4.3) 90 (95.7)
39 (30.2) 90 (69.8) 46 39 2 3 n ¼ 112 16 (14.3) 7 (6.3) 22 (19.6) 26 (23.2) 29 (25.9) 12 (10.7) n ¼ 102 47 (46.1) 26 (25.5) 14 (13.8) 12 (11.8) 3 (2.9) n ¼ 122 98 (80.3) 24 (19.7) n ¼ 125 117 (93.6) 8 (6.4)
n ¼ 166 16 (9.6) 8 (4.8) 26 (15.7) 39 (23.5) 42 (25.3) 35 (21.1) n ¼ 166 60 (36.1) 42 (25.3) 23 (13.9) 26 (15.7) 15 (9.0) n ¼ 216 183 (84.7) 33 (15.3) n ¼ 220 199 (90.5) 21 (9.6)
n ¼ 54 0 1 (1.9) 4 (7.4) 13 (24.1) 13 (24.1) 23 (42.6) n ¼ 64 13 (20.3) 16 (25.0) 9 (14.1) 14 (21.9) 12 (18.8) n ¼ 94 85 (90.4) 9 (9.6) n ¼ 95 82 (86.3) 13 (13.7)
p Value
Variable
Total (n ¼ 228)
Chinese (n ¼ 96)
Southeast Asian (n ¼ 132)
Do you have a doctor Yes No Frequency of doctor visits Do not have a doctor >Every 5 y Every 2–5 y Annually >Annually Have you had a Pap test Yes No Don’t know/not sure If yes, when was your last Pap? Within last year Within last 3 y >3 y Don’t know/not sure If yes, have you ever had an abnormal Pap? Yes No Don’t know/not sure HPV vaccination status Vaccinated Not vaccinated Do you know of any free health services Yes No Where do you receive your Friends Family The community Television/radio My doctor
n ¼ 215 172 (80.0) 43 (20.0) n ¼ 219 14 (6.4) 11 (5.0) 20 (9.1) 101 (46.1) 73 (33.3) n ¼ 220 166 (75.5) 38 (17.3) 16 (7.3) n ¼ 164
n ¼ 90 77 (85.6) 13 (14.4) n ¼ 95 4 (4.2) 3 (3.2) 6 (6.3) 54 (56.8) 28 (29.5) n ¼ 95 72 (75.8) 15 (15.8) 8 (8.4) n ¼ 72
n ¼ 125 95 (76.0) 30 (24.0) n ¼ 124 10 (8.1) 8 (6.5) 14 (11.3) 47 (37.9) 45 (36.3) n ¼ 125 94 (75.2) 23 (18.4) 8 (6.4) n ¼ 92
.5
124 (75.6) 25 (15.2) 12 (7.3) 3 (1.8) n ¼ 161
56 (77.8) 10 (13.9) 6 (8.3) 0 n ¼ 72
68 (73.9) 15 (16.3) 6 (6.5) 3 (3.3) n ¼ 89
.05
22 (13.7) 130 (80.8) 9 (5.6) n ¼ 205 51 (24.9) 154 (75.1) n ¼ 215
5 (6.9) 64 (88.9) 3 (4.2) n ¼ 93 8 (8.6) 85 (91.4) n ¼ 94
17 (19.1) 66 (74.2) 6 (6.7) n ¼ 112 43 (38.4) 69 (61.6) n ¼ 121
85 (39.5) 40 (42.6) 130 (60.5) 54 (57.5) health information? 64 (28.1) 28 (29.2) 49 (21.5) 21 (21.9) 67 (29.4) 25 (26.0) 48 (21.1) 25 (26.0) 147 (64.5) 66 (68.8)
45 (37.2) 76 (62.8)
.0001
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Original article
Cervical Cancer Prevention: Asian-American Women’s Knowledge and Participation in Screening Practices Katina Robison, MD a,*, Lindsay Clark, MD a, Whitney Eng, MD a, Lily Wu, MD a, Christina Raker a, Melissa Clark, PhD a, Trevor Tejada-Berges, MD a, Don S. Dizon, MD b a b
Women & Infants’ Hospital of Rhode Island, The Warren Alpert Medical School of Brown University, Providence, Rhode Island Massachusetts General Hospital Cancer Center, Boston, Massachusetts
Article history: Received 20 May 2013; Received in revised form 20 November 2013; Accepted 12 December 2013
a b s t r a c t Objective: The purpose of this study was to compare cervical cancer knowledge and prevention strategy participation among Chinese-American women compared with Southeast–Asian-American women. Methods: We performed a cross-sectional survey of Chinese and Southeast Asian women in Rhode Island. Anonymous surveys were administered following informed consent. The survey included demographics and questions related to health care practices, cervical cancer, and the human papilloma virus (HPV). Categorical variables were compared by Fisher’s exact test. Mean scores of correct answers on the knowledge questions were compared by Student’s t-test and analysis of variance. Results: Ninety-six Chinese women and 132 Southeast Asian women were included in the analysis. Sixty-seven percent of Chinese women had at least a college education compared with 37% of Southeast Asian women (p < .0001). Nineteen percent of Chinese women reported annual household incomes of greater than $100,000 compared with 3% of Southeast Asian women (p ¼ .0003). Twenty percent of Southeast Asian women did not have health insurance compared with 10% of Chinese women (p ¼ .06). Among both groups, 25% of participants either never had a pap test or did not know if they ever had a pap test. There was a greater lack of knowledge about the relationship between HPV and cervical cancer among Chinese (mean 2.9 out of 8 questions) compared with Southeast Asian (mean 3.6 out of 8 questions; p ¼ .02). Conclusions: Regardless of ethnic subgroup, education, or income, all participants had a poor knowledge of cervical cancer and HPV. This study supports the need for improvement in cervical cancer prevention education among all Asian women. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
In the United States, the implementation of the Papanicolaou test in the 1940s brought about a remarkable decrease in the incidence of and mortality from cervical cancer. With the development and implementation of the human papilloma virus (HPV)
The project described was supported by Award Number K12HD050108 from the Office of the Director, National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health & Human Development. The content is solely the responsibility of the author and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Children Health & Human Development of the National Institutes of Health. * Correspondence to: Katina Robison, MD, Program in Women’s Oncology, Women & Infants’ Hospital, 101 Dudley Street, Providence, RI 02905. Phone: þ1 401-453-7520; fax: þ1 401-453-7529. E-mail address: [email protected] (K. Robison).
vaccine in 2009, the incidence of cervical cancer will likely continue to decline both in the United States and worldwide. Unfortunately, despite these advances, racial disparities in cervical cancer incidence and mortality remain in the United States. Although the gap between incidences of cervical cancer in black women and non-Hispanic White women is narrowing, the percentage of Asian or Pacific Islanders diagnosed with cervical cancer is growing (Ward et al., 2012). Asian Americans are often reported to have low cervical cancer screening rates and high cancer mortality rates (Gor, Chilton, Camingue, & Hajek, 2011). However, this is a heterogenous group, which is frequently evaluated together even though there may be specific differences between the ethnic subgroups. In the U.S. National Cancer Institute’s Surveillance, Epidemiology,
1049-3867/$ - see front matter Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2013.12.005
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K. Robison et al. / Women's Health Issues 24-2 (2014) e231–e236
and End Results program, the Asian or Pacific Islander category comprises at least 12 different ethnic categories, each with different patterns of cancer incidence and mortality. Whereas Chinese women have a cervical cancer incidence less than nonHispanic White women, Vietnamese women have a more than two-fold greater incidence of cervical cancer compared with non-Hispanic White women (Wang, Carreon, Gomez, & Devesa, 2010). Similarly, Vietnamese women had double the incidence of cervical cancer compared with White women in California (McCracken et al., 2007). Additionally, Vietnamese women were more than twice as likely to die of cervical cancer compared with White women and three times as likely compared with ChineseAmerican women (Ho & Dinh, 2011; McCracken et al., 2007). Furthermore, compared with non-Hispanic White women, Southeast Asian women have a cervical cancer incidence rate three times higher and are half as likely to undergo regular cervical cancer screening (Constantine & Jerman, 2007; Dang, Lee, & Tran, 2010). Asian Americans seem to be a heterogeneous group with regard to cervical cancer incidence and evaluating this group in aggregate may mask variations influenced by cultural or socioeconomic factors (Wang et al., 2010). There is a paucity of literature comparing the Asian-American subgroups’ knowledge on cervical cancer and HPV. Southeast Asian women have the highest rates of cervical cancer and often the lowest markers of socioeconomic status among Asian Americans, whereas Chinese women often have lower rates of cervical cancer and higher markers of socioeconomic status (Dang et al., 2010; McCracken et al., 2007). More information on the differences in Asian-American subgroups in relation to participation in cervical cancer screening and HPV vaccination is needed. This information can help to direct targeted interventions specific to Asian subgroups to improve knowledge and participation in cervical cancer screening and vaccination. The goal of this crosssectional study was to compare the knowledge of cervical cancer prevention strategies between Southeast–Asian-American women and Chinese-American women. Methods A 33-question, anonymous survey was developed and institutional review board approval was obtained to conduct the study from June 2009 to June of 2010. The survey included questions regarding demographics, health care practices, cervical cancer, and HPV. The survey was designed with the assistance of members of the Providence Southeast Asian Community Center, Chinese American Brown University medical students, and a Laotian community member. The content validity was assessed through a review by six experts. Each expert was given the survey and asked to review the questions to ensure they were assessing basic knowledge of cervical cancer and HPV. In addition, face validity was evaluated by the experts and determined the survey would measure cervical cancer knowledge among both Chinese and Southeast Asian women. A knowledge scale was developed that included eight questions evaluating the general knowledge of cervical cancer and HPV (Figure 1). There were six questions that evaluated the beliefs about HPV vaccination for women and their daughters. The survey was administered to Southeast Asian women and Chinese women in Rhode Island over an 18-month period. Women were recruited at various community sites, including churches, grocery stores, health fairs, and community centers. Recruiters went out in the community one to three times per month to recruit. Chinese women and Southeast Asian women
were both recruited from the same health fairs, grocery stores and community centers. However, the groups were recruited from Chinese– or Southeast Asian–specific churches. All women were approached by the recruiters and asked verbally if they were Southeast Asian or Chinese. The same recruiters were used at all of the sites. Women who self-identified as either Southeast Asian or Chinese were asked to participate. They were offered the survey in English, Lao, Vietnamese, Hmong, Khmer, Thai, or Chinese after informed consent was obtained. The surveys were self-administered in the language chosen by the participant. Surveys were analyzed using SAS version 9.2 (SAS Institute, Cary, NC). Categorical variables were compared by Fisher’s exact test. Knowledge scores were calculated as the sum of correct answers (range, 0–8). Mean scores were compared between Chinese and Southeast Asian women by the Student t-test and were adjusted for age, education, and income by analysis of variance. Knowledge scores were calculated for those answering at least half (4 or more) of the knowledge questions. Those not answering at least four questions were excluded from the analyses. All p-values presented were two-sided with p < .05 considered significant. Findings We recruited 229 women. One woman was excluded because the majority of the survey was incomplete. Ninety-six Chinese women and 132 Southeast Asian women were included in the analysis. The majority of Southeast Asian women were Cambodian and Laotian. Two Hmong women were considered Southeast Asian in the analysis, even though their country of origin was China because they self-identified as Southeast Asian. Chinese and Southeast Asian women differed on demographic characteristics (Table 1). Chinese women were older and more likely to be married than Southeast Asian women. Chinese women were more educated than Southeast Asian women and had higher household incomes. Twenty percent of Southeast Asian women did not have health insurance compared with 10% of Chinese women. Both Chinese and Southeast Asian women identified themselves as religious. Among both groups, the majority of women reported having a physician and saw a physician annually (Table 2). However, nearly 25% of all participants either never had a pap test or did not know if they ever had a pap test. Of women who did report undergoing a pap test, most women in both groups reported having the test within the last 3 years and were aware of test results. Nearly half of all women reported receiving health information from the Asian community, family, or friends. The majority of Chinese and Southeast Asian women reported receiving health information from their physician. Only one women in the Chinese group and 14 women in the Southeast Asian group answered fewer than half of the questions (Table 3). Based on testing, there was a lack of knowledge about the relationship between cervical cancer and HPV among both Chinese (mean, 2.9) and southeast Asian women (mean, 3.6). The mean knowledge score for Chinese women was lower (mean, 2.7) compared with southeast Asian women (mean, 3.7; p ¼ .05) when adjusting for age, education, and income (Table 4). Among women in the recommended vaccination age range (18–24 years), only 33% of Chinese and 37% of southeast Asian women reported receiving the HPV vaccine. Among women of vaccination age, the majority reported a desire to receive the vaccination (66% southeast Asian vs. 57% Chinese; p ¼ .6). Among women with children, 19.3% of southeast Asian versus 15.4% of
K. Robison et al. / Women's Health Issues 24-2 (2014) e231–e236
e233
Figure 1. Survey questions evaluating knowledge of cervical cancer prevention.
Chinese reported their daughters had received the vaccination (p ¼ .6). Of these women, 48.2% of southeast Asian and 50.9% of Chinese desired their daughters to be vaccinated. Discussion Cervical cancer remains a significant problem globally and racial disparities still exist in the United States. Asian Americans are a unique and heterogeneous group that have been underrepresented in vaccine trials and typically evaluated as a homogeneous group in analyses, even though the group is composed of at least 12 different ethnic categories that differ culturally, behaviorally, and socioeconomically (Garland et al., 2007; Paavonen et al., 2007; Schiller, Castellsague, & Garland, 2012; Wang et al., 2010). These differences may influence cervical cancer screening and HPV vaccination rates. In our study, although Chinese and Southeast Asian women differed demographically, nearly one third of women in both groups had not undergone cervical cancer screening in the last 3 years and women in both groups had inadequate knowledge regarding HPV, the HPV vaccine, and cervical cancer. Similar to prior studies, we found low self-reported cervical cancer screening rates among all Asian-American females (Licht
et al., 2010). Although rates are universally low, there is a cancer screening disparity among Asian-American subgroups even after controlling for relevant factors (Lee, Ju, Vang, & Lundquist, 2010). It has been speculated that the low rate of cervical cancer screening among Asian Americans is associated with lower socioeconomic status and a lack of health insurance (Lee et al., 2010). However, socioeconomic factors vary greatly between subgroups. In our study, we found that although Chinese women had higher levels of education and higher income, their cervical cancer screening rates were the same as southeast Asian women. Consistent with our findings, the U.S. Census Bureau reported nearly 50% of Chinese Americans had a bachelor’s degree compared with fewer than 10% of all Southeast Asians. Additionally, the median income among Chinese Americans was double that of Southeast Asian Americans (McCracken et al., 2007). In our study, we found that the majority of women in both groups had health insurance. This suggests that socioeconomic factors and lack of health insurance may not be the only factors influencing participation in cervical cancer screening among Asian women. There are likely additional cultural factors that may also play a role and differ among the various Asian subgroups. HPV vaccination rates are also known to be low among Asian women, specifically in the Southeast Asian group. A National
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K. Robison et al. / Women's Health Issues 24-2 (2014) e231–e236
Table 1 Demographic Variables
Table 2 Chinese Versus Southeast Asian Participation in Health Care Services
Variable
Total (n ¼ 228)
Chinese (n ¼ 96)
Southeast Asian (n ¼ 132)
Age (y) 18–24 24–30 30–44 44–59 60 Number of children None 1–3 4–5 >5 Married Yes No Born in the United States Yes No Cambodia Laos Vietnam Thailand Education Up to 8th grade Some high school High school Some college College Graduate school Income (U.S.$) 20,000 20,000–40,000 40,000–60,000 60,000–100,000 100,000 Health insurance Yes No Religious Yes No
n ¼ 225 38 (16.9) 35 (15.6) 73 (32.4) 65 (28.9) 14 (6.2) n ¼ 224
n ¼ 95 10 (10.5) 5 (5.3) 39 (41.1) 34 (35.8) 7 (7.4) n ¼ 95
n ¼ 130 28 (21.5) 30 (23.1) 34 (26.2) 31 (23.9) 7 (5.4) n ¼ 129
58 (25.9) 128 (57.1) 22 (9.8) 16 (7.1) n ¼ 225 147 (65.3) 78 (34.7) n ¼ 223
21 (22.1) 70 (73.7) 2 (2.1) 2 (2.1) n ¼ 95 77 (81.1) 18 (18.9) n ¼ 94
37 (28.7) 58 (45.0) 20 (15.5) 14 (10.9) n ¼ 130 70 (53.9) 60 (46.2) n ¼ 129
43 (19.3) 180 (80.7)
4 (4.3) 90 (95.7)
39 (30.2) 90 (69.8) 46 39 2 3 n ¼ 112 16 (14.3) 7 (6.3) 22 (19.6) 26 (23.2) 29 (25.9) 12 (10.7) n ¼ 102 47 (46.1) 26 (25.5) 14 (13.8) 12 (11.8) 3 (2.9) n ¼ 122 98 (80.3) 24 (19.7) n ¼ 125 117 (93.6) 8 (6.4)
n ¼ 166 16 (9.6) 8 (4.8) 26 (15.7) 39 (23.5) 42 (25.3) 35 (21.1) n ¼ 166 60 (36.1) 42 (25.3) 23 (13.9) 26 (15.7) 15 (9.0) n ¼ 216 183 (84.7) 33 (15.3) n ¼ 220 199 (90.5) 21 (9.6)
n ¼ 54 0 1 (1.9) 4 (7.4) 13 (24.1) 13 (24.1) 23 (42.6) n ¼ 64 13 (20.3) 16 (25.0) 9 (14.1) 14 (21.9) 12 (18.8) n ¼ 94 85 (90.4) 9 (9.6) n ¼ 95 82 (86.3) 13 (13.7)
p Value
Variable
Total (n ¼ 228)
Chinese (n ¼ 96)
Southeast Asian (n ¼ 132)
Do you have a doctor Yes No Frequency of doctor visits Do not have a doctor >Every 5 y Every 2–5 y Annually >Annually Have you had a Pap test Yes No Don’t know/not sure If yes, when was your last Pap? Within last year Within last 3 y >3 y Don’t know/not sure If yes, have you ever had an abnormal Pap? Yes No Don’t know/not sure HPV vaccination status Vaccinated Not vaccinated Do you know of any free health services Yes No Where do you receive your Friends Family The community Television/radio My doctor
n ¼ 215 172 (80.0) 43 (20.0) n ¼ 219 14 (6.4) 11 (5.0) 20 (9.1) 101 (46.1) 73 (33.3) n ¼ 220 166 (75.5) 38 (17.3) 16 (7.3) n ¼ 164
n ¼ 90 77 (85.6) 13 (14.4) n ¼ 95 4 (4.2) 3 (3.2) 6 (6.3) 54 (56.8) 28 (29.5) n ¼ 95 72 (75.8) 15 (15.8) 8 (8.4) n ¼ 72
n ¼ 125 95 (76.0) 30 (24.0) n ¼ 124 10 (8.1) 8 (6.5) 14 (11.3) 47 (37.9) 45 (36.3) n ¼ 125 94 (75.2) 23 (18.4) 8 (6.4) n ¼ 92
.5
124 (75.6) 25 (15.2) 12 (7.3) 3 (1.8) n ¼ 161
56 (77.8) 10 (13.9) 6 (8.3) 0 n ¼ 72
68 (73.9) 15 (16.3) 6 (6.5) 3 (3.3) n ¼ 89
.05
22 (13.7) 130 (80.8) 9 (5.6) n ¼ 205 51 (24.9) 154 (75.1) n ¼ 215
5 (6.9) 64 (88.9) 3 (4.2) n ¼ 93 8 (8.6) 85 (91.4) n ¼ 94
17 (19.1) 66 (74.2) 6 (6.7) n ¼ 112 43 (38.4) 69 (61.6) n ¼ 121
85 (39.5) 40 (42.6) 130 (60.5) 54 (57.5) health information? 64 (28.1) 28 (29.2) 49 (21.5) 21 (21.9) 67 (29.4) 25 (26.0) 48 (21.1) 25 (26.0) 147 (64.5) 66 (68.8)
45 (37.2) 76 (62.8)
.0001
