Vietnamese-American Women And Cervical Cancer Screening: A Missed Opportunity?

This article is a meta-analysis of literature that discusses receipt of immunizations by Vietnamese-American children, and receipt of cancer screening services by Vietnamese-American women. The results of the seven articles identified for inclusion in the meta-analysis were collated to determine what factors contribute to the discrepancies between Vietnamese-American children’s relatively high rates of immunizations, and Vietnamese-American women’s significantly low rates of Pap smear receipt. The article concludes that the difference in immunization rates for Vietnamese-American children, and cervical cancer screening rates for Vietnamese-American women, may be due to federally mandated vaccination requirements for all children entering school, and cultural barriers that dissuade women from receiving pap tests. The article suggests that providing outreach, education, and even cervical cancer screenings to Vietnamese-American women at pediatric and public health clinics that they frequent with their children, would provide an opportunity to increase cervical cancer screening rates for Vietnamese-American women.

More than 800,000 Vietnamese refugees and immigrants from Southeast Asia have resettled in the United States since the end of the Vietnam War in 1975(Ngo-Metzger, Tran, Sugrue-McElearney, Levy, Williams, Phillips, 2001. The second largest concentration of Vietnamese outside of Vietnam is in the San Francisco Bay Area (Lin, Phan, Lin, 2002). Because they are federally designated refugee populations, Southeast Asians from Vietnam, Cambodia, and Laos are provided access to health services that immigrants normally do not receive. Unlike most immigrant populations, the Southeast Asian population is entitled to Medi-Cal and programs such as Refugee Preventive Health Services. Consequently, government programs provide free or low-cost treatment for infectious diseases including hepatitis B and tuberculosis. Because the government provides health care services for immigrants from Vietnam, Vietnamese-Americans do not experience the same barriers to receipt of adequate health care that many immigrant groups face, especially prohibitive costs and lack of accessible facilities (Ito, 1999).
Despite government supported health care programs, Vietnamese-American women have the lowest rate of Pap test receipt among the various ethnic and racial groups in the United States. Vietnamese-American women also have the highest rate of cervical cancer (Houston, 2002). The incidence of cervical cancer among Vietnamese-American women is 43.0/100,000, which is five times that of Caucasian women, whose cervical cancer incidence is 8.7/100,000 (Nguyen, McPhee, Nguyen, Lam, Mock, 2002).
However, for Vietnamese-American children, unlike Vietnamese-American women, rates of receipt of preventative health care services are high.
Federally sponsored, mandatory inoculation programs are in effect for all schoolage children, including Vietnamese-American children (Jenkins, McPhee, Wong, Nguyen, Euler, 2000). Perhaps because immunizations against childhood diseases are mandated by the federal government, and because these vaccinations are provided free of cost, Vietnamese-American children have parity with all ethnic and racial groups of children in the United States as to their rates of vaccination receipt.
The purpose of this paper is to analyze the current literature to examine the medical, social, and demographic barriers to receipt of cervical cancer screenings by Vietnamese-American women. Through examination of barriers and prior interventions, an innovative program to provide education, outreach, and Pap tests to Vietnamese-American women is proposed.

Methods
A meta-analysis of the literature that discusses receipt of screening services by Vietnamese-American women was conducted. The results of the nine articles identified for inclusion were collated to determine what factors contribute to the low rates of receipt of preventative screenings by these women. A comparison between the low screening rates for Vietnamese-American women and the relatively high receipt of preventative vaccinations by Vietnamese-American children was also conducted to understand the discrepancies between the utilization of health care services between the two groups. The articles for review were chosen based upon the timeliness and relevance of the research to the topic.

Immunization Rates For Vietnamese-American Children
The immunization rates for Vietnamese-American children improved dramatically in the United States during the 1990s. By age two, 80-90% of Asian-American children were up-todate with childhood immunizations . A measure of preventative health screening rates for Vietnamese-American children may be attained by examining the rates of receipt of hepatitis B vaccinations by this group. Ngo-Metzger et al. (2001)

Cancer
Screening Rates For Vietnamese-American Women All studies of cervical cancer screening rates among Vietnamese-American women report low receipt of Pap tests. Nguyen et al. (2002) conducted a telephone survey of Vietnamese-American women over 18 years of age to determine their knowledge and receipt of Pap tests for cervical cancer in Santa Clara County, California, and in Harris County, Texas. No significant differences in awareness of, or receipt of, Pap tests were reported between the two sites. The rate of awareness of Pap tests varied from 73% in Harris County and 76% in Santa Clara County, while reported receipt of Pap tests was 74% in Harris County and 78% in Santa Clara County (2002). Women older than 65 had the lowest rates for both awareness and receipt of Pap tests. For all women surveyed, being married, having a higher level of education, having a female doctor, and doctor recommendation for the test, were associated with receipt of Pap tests.
Educational interventions pertaining to cervical cancer screenings greatly improve Pap test knowledge and slightly improve Pap test receipt. McPhee (1998) researched the effects of a mass media educational campaign targeting cervical cancer awareness among Vietnamese-American women. The study had a pre-test and post-test group design of telephone surveys, conducted in the Vietnamese language, to determine knowledge and receipt of Pap tests for cervical cancer before and after the mass media educational campaign. The intervention groups surveyed were Vietnamese-American women over 18 years of age living in Santa Clara and Alameda Counties, California. The control group surveyed consisted of Vietnamese-American women in Orange County, California who did not receive a mass media educational campaign. Women in the intervention group were significantly more likely to receive a Pap test than the control group.
There is a strong cultural taboo in Vietnamese-American communities against an unmarried woman receiving a Pap test. In 1998 a study of college-aged Vietnamese-American women at the University of Houston, Texas was conducted by Yi to determine who among the population had received Pap tests for cervical cancer. Mail and telephone surveys to determine the prevalence of receipt of Pap tests by Vietnamese-American college-aged women were administered. The study examined the role of acculturation in explaining cervical cancer screening behavior. The low numbers of the women participating in the study who had received a Pap test, 36.8%, reflects lack of knowledge about cervical cancer screening and about the importance of having a Pap test (1998).

Barriers To Receipt Of Pap Tests By Vietnamese-American Women
Several cultural barriers prevent receipt of Pap tests by Vietnamese-American women. Among these barriers are intrinsic conflicts between Western and Eastern medical practices, dissimilar orientations to time between the two cultures, and a fervent expectation that the Vietnamese-American family unit will participate in each member's health care. Further, Vietnamese-Americans tend to seek Western medical care during a crisis situation, rather than under preventative circumstances. The barriers may be summarized into three main categories as medical practice barriers, sociocultural barriers and demographic barriers.

Medical practice barriers. A belief held by
Vietnamese-Americans that Western medicine is too harsh on the body contributes to cultural disparity between Vietnamese and American medical practices (Houston, 2002). Vietnamese-Americans may utilize traditional Eastern medicine to treat symptoms of "female problems;" there is no comparative procedure in Vietnamese traditional medicine to the Pap test (Tang, Solomon, Yeh, Worden, 1999). Vietnamese in America often are compelled to conceal their use of time-honored Vietnamese health practices because of fear of American doctors' unsupportive and/or condescending attitudes towards traditional Vietnamese medicine.

Crisis versus prevention.
Preventative health care for Vietnamese-Americans often involves diet and herbal remedies rather than screenings and tests. Tang, Solomon, Yeh, and Worden (1999) studied cultural factors affecting the receipt of Pap tests by Vietnamese-American women. Their research found that Vietnamese-Americans tend to focus on "crisis vs. prevention" (1999). If a Vietnamese-American woman has no symptoms of illness, for example, she is highly unlikely to seek medical attention from a doctor. Preventative strategies for Asians, including Vietnamese, routinely consist of a good diet, good spiritual balance, and herbal remedies. Additional research on college-aged Vietnamese women in the United States concludes that Vietnamese-American women most often seek medical attention only after they experience physical symptoms. Vietnamese-Americans tend to focus on curative, rather than preventative health care (1999).

Social-cultural barriers, time orientation.
Another barrier contributing to the low rate of Pap tests by Vietnamese-American women is the fact that Vietnamese traditionally follow "P," or polychronic time, a time orientation that involves people and the completion of tasks, and is quite unlike Western time schedules, which are based on "M," or monochronic, highly structured time. Therefore, miscommunication between health care providers and Vietnamese-American clients regarding time frames may result in missed or skipped medical appointments (Houston, 2002).
Social-cultural barriers, importance of family. Vietnamese tend to be "high context" and identify more comfortably as group members, rather than as separate individuals. Consequently, there is an expectation among Vietnamese-Americans in health care settings that their family will provide emotional support, monitor their treatment, and provide special resources such as ethnic food and/or medicine (Houston, 2002). Vietnamese family members' anticipation of involvement in their relative's health care may create conflict in health care settings as cultural expectations between Vietnamese patients and American health care providers may clash. It is relatively uncommon for Western health care providers to include their patients' extended families in medical consultations between the provider and the patient.

Social-cultural barriers, lack of communication regarding sexual topics.
Other cultural factors that contribute to lack of receipt of Pap tests are a Vietnamese woman's sense of modesty, the fact that young women model their mothers' behavior and do not readily receive Pap tests, as well as a general lack of communication about, and an unwillingness to discuss, sexuality among Vietnamese-American women of all ages (Tang et al., 1999).
Comfort with self-examination. The receipt of breast examinations by Vietnamese-American women contrasts dramatically with the receipt of Pap tests by this group. Tang's (1999) research compared the receipt of breast self-examinations and Pap tests among Vietnamese-American women. Vietnamese-American women have a fairly high rate of breast self-examination. They also are more likely to administer the test because breast self-examinations are "selfadministered." A Pap test, on the other hand, is initiated by the health care provider (Tang et al., 1999).

Social-cultural barriers, fatalism.
While not understanding the risks of cervical cancer may act as a barrier to receipt of Pap tests by Vietnamese-American women, Nguyen et al. (2002) found that awareness of the high rate of cervical cancer among Vietnamese-American women might also act as a deterrent to receipt of Pap tests. Vietnamese-American women may avoid Pap tests as a means of protection from the discovery of cervical cancer (2002).

Demographic barriers.
Research on awareness of Pap tests, intention to obtain a Pap test, and receipt of a Pap test in Vietnamese-American women demonstrated that the oldest women in the study were least likely to have received a Pap test. Additionally, unmarried women were perceived as not needing a Pap test due to cultural taboos against premarital sex. The more educated a woman was, the more likely she was to have received a Pap test. Research studies have indicated that access to culturally appropriate care by a female doctor who has suggested receiving a Pap test and in a setting where the woman is comfortable asking for a pap test contribute to the increased likelihood of receiving a Pap test .

Some Successful Interventions
Community-based health care. Studies of Vietnamese-Americans' behavior in various Western health care settings suggest possible solutions to receipt of Pap tests among women in this group. While unrelated to Vietnamese-American woman and cervical cancer screening, Ito's (1999) research on methods to overcome barriers to compliance by Vietnamese-Americans with an INH regimen offers possible solutions to cultural barriers to receipt of Pap tests by Vietnamese-American woman. Many Vietnamese immigrants test positive for inactive tuberculosis (TB) when they enter the United States. Because the treatment for TB is extremely unpleasant, with side effects of irritability, dehydration, and general malaise, treatment compliance is difficult to attain (1999).
Representatives from various Vietnamese community organizations in Ito's (1999) study cited the need for health education that was not sponsored by county or other government agencies. The representatives stated that the county lacked cultural understanding, did not work with Vietnamese community contacts, and hence lacked credibility to deliver effective health education messages. Ito's (1999) research concluded that Vietnamese-Americans' health culture is transmitted and reinforced through surrounding social networks. When health care centers are community-based, rather than clinicbased, the cultural needs of the Vietnamese-American clients are more adequately assessed, thus improving the rate of compliance with INH treatment (1999).

Lay health workers.
Training lay health workers to provide education has proven to be an effective tool for increasing both knowledge and receipt of Pap tests among Vietnamese-American women. McPhee (1998) oversaw an intervention with Vietnamese-American women in San Francisco's Vietnamese community that utilized lay health workers to inform Vietnamese-American women about cervical cancer risks, early detection, and prevention. The results of McPhee's (1998) study demonstrate that the lay health worker intervention not only increased awareness of cervical cancer screening, it also increased receipt of Pap tests. The study concludes that personal contact from a knowledgeable peer is a highly effective technique for encouraging cervical cancer screenings (1998).

Missed Opportunity
Data indicate that Vietnamese-American children have a high rate of receipt of immunizations against childhood illnesses. Therefore, it is safe to presume that the families of Vietnamese-American children are utilizing Western medical health care centers for their children's inoculations. Because Vietnamese-Americans are accessing these health care centers for their children, and because mothers are most often present when their children receive treatment, pediatric clinics could serve as potential sites for health education, outreach and even cervical cancer screening if appropriate resources are available.

Education Materials
In addition to providing on-site Peer Educators who are knowledgeable about cervical cancer screenings, culturally sensitive, Vietnameselanguage educational materials on the subject of Pap tests should be readily available in pediatric clinics. While outreach by Peer Educators could be provided spontaneously as women check their children in for vaccinations, discussion groups on the benefits of cervical cancer screening could also be available at predetermined scheduled times.

Pap Tests
Vietnamese-American women could be offered Pap tests on a drop-in, and/or pre-scheduled basis at the pediatric clinic. Because a physician does not need to administer a Pap test, ideally a female nurse, with a Peer Educator acting as "stand-by," could perform the test. Once a Vietnamese-American woman actually receives a Pap test, hopefully she will be less reluctant to receive future screenings.

Conclusion
Vietnamese-American women have the highest rates of cervical cancer among all ethnic and racial groups in the United States, and the rate of receipt of cervical cancer screenings for this group of women is decidedly low, culturally appropriate and easily accessible interventions to encourage Pap test receipt are of prime importance. Contrasting sharply with the low rate of receipt of Pap tests by Vietnamese-American women, is the fact that Vietnamese-American children receive vaccinations for childhood illness by the school entry age on par with all other racial and ethnic groups in the United States. The high inoculation compliance for Vietnamese-American children indicates that Vietnamese-American parents are consistently accessing clinics that provide their children with vaccinations. Pediatric Vietnamese-American community clinics offer a promising setting to provide not only educational interventions, but also Pap tests for Vietnamese-American women.
Utilizing the resources available within the Vietnamese-American community to provide preventative cervical cancer screenings in community pediatric clinics, and striving to create a culturally amenable environment for Vietnamese-American women to receive Pap tests, is an opportunity that should not be missed. By approaching these families receiving immunizations at the pediatric clinics in an interdisciplinary way by pediatricians and gynecologists can help in making major strides in improving the levels of cervical cancer screening for Vietnamese-American women.