Predictors of Cervical Cancer Screening Among Vietnamese American Women

ORIGINAL PAPER

Predictors of Cervical Cancer Screening Among VietnameseAmerican Women

Mai Do

� Springer Science+Business Media New York 2013

Abstract This study examines Pap testing behavior

among 265 Vietnamese American women aged 18 or

above. A community-based survey was conducted with

Vietnamese women in five cities: Houston (TX), Spring-

field (MA), Camden (NJ), Charlotte (NC), and Falls

Church (VA). Seventy-five percent of the study sample

ever received a Pap test, 45 % within the last 12 months.

Women’s perceived risks of cancer, belief that cancer can

be detected early with screening, and disagreement that it is

embarrassing to get tested and that only married women

should get tested are related to Pap testing. Having health

insurance is the most important predictor of Pap testing.

Main reasons for not having tested in the last 12 months

include: feeling well, having no insurance, and high costs.

Interventions should improve financial access to Pap test-

ing among Vietnamese American women. Results also

suggest that future communication programs should

emphasize preventive practices and change traditional

attitudes and misconceptions related to Pap testing.

Keywords Pap testing � Cervical cancer � Health

Belief Model � Vietnamese American � Women

Background

Vietnamese women reportedly have a higher rate of inva-

sive cervical cancer than other ethnic groups in the United

States [1–4]. Cervical cancer incidence among Vietnamese

women is more than twice of that among white women [2,

5, 6], likely due to the low level of Papanicolaou (Pap)

testing among Vietnamese women, compared to other

groups [7–16]. A recent review of the literature revealed

that between 37 and 74 % of Vietnamese American women

ever had a Pap test [9, 10, 17–20].

Much of the previous research on cervical cancer,

however, is either not theory-driven or only focused on

Vietnamese women in California and Texas [10–12, 14,

21–23], which may not represent Vietnamese women in the

United States. In this study, we document cervical cancer

screening behavior and factors associated with it among

Vietnamese women living in five cities: Houston (TX),

Springfield (MA), Falls Church (VA), Camden (NJ), and

Charlotte (NC). The Health Belief Model (HBM) [24] is

employed to guide this study. The study is part of the

Health Awareness and Prevention Project: A Cancer

Focus (HAPP), implemented by BPSOS (Boat People

SOS), a national Vietnamese non-profit organization, and

focused on five types of cancer: lung, liver, breast, cervix,

and prostate. BPSOS employs a number of strategies,

including mass media communication (via radio, newspa-

pers, and other printed materials), group communication

(via health workshops, health fairs, etc.), as well as one-on-

one counseling and education to promote cancer screening

among Vietnamese population.

The Health Belief Model

The HBM is one of the conceptual frameworks commonly

used to explain health behavior. The HBM has five main

components that can influence behavior [24]. The first

component, perceived susceptibility, refers to one’s per-

ception of the risk of getting a health condition. Second,

M. Do (&)

Department of Global Health System and Development, Tulane

University School of Public Health and Tropical Medicine, 1440

Canal Street, New Orleans, LA 70112, USA

e-mail: [email protected]

123

J Immigrant Minority Health

DOI 10.1007/s10903-013-9925-2

perceived severity refers on one’s belief regarding how

serious a health condition and its consequences are. Third,

perceived benefits indicate one’s belief in the effectiveness

of recommended actions to reduce risks of getting the

health condition. Fourth, perceived barriers, which are

tangible and psychological costs associated with the rec-

ommended action, may prevent one from taking the action.

Fifth, cues to action are external factors, such as the

availability of a reminder system, that can motivate one to

take the recommended action.

Only two studies have so far employed the HBM to

examine Pap testing among Vietnamese American women.

One is a study among Vietnamese women in Houston

(TX), in which two-thirds of Vietnamese women reported

ever receiving a Pap test [14]. Besides socio-demographic

factors, lack of barriers to health care, a family history of

cancer, and an increased perception of the seriousness of

cancer were related to an increased likelihood of breast and

cervical cancer screening among this population [14]. This

study, however, is limited by a very low response rate (209

questionnaires returned out of 1,200 mailed out), which can

hinder the reliability and generalizability of results.

The second study, conducted with Vietnamese women

in Seattle (WA) reported strong associations between Pap

testing and the following beliefs: that regular Pap testing

could reduce the risk of cancer, that Pap testing is neces-

sary even if women do not have any symptoms, are sexu-

ally inactive, or post-menopausal [25]. The authors also

found that recommendations by doctors and having asked

doctors for Pap testing both were associated with adher-

ence to regular testing guidelines [25]. Yet, the study is

limited in its generalizability as it included only Viet-

namese women in Seattle and only households with listed

phone numbers and complete address were eligible for

interviews.

Results from Other Research

Age and marital status have been frequently reported as

important determinants of Pap testing among Vietnamese

American women [17]. Younger women were more likely

than older women to have obtained a Pap test in several

studies [19, 26], while the opposite was observed in others

[27, 28]. Married women are much more likely to have a

Pap test than unmarried women [14, 19, 26, 27, 29–31].

This association is likely related to a common, strong belief

among Asian women that Pap testing is only for women

who are married or already have a child; testing before

marriage may imply that a woman has premarital sex, an

unacceptable behavior in Vietnamese culture [11].

Access to health care is important to Pap testing among

Vietnamese American women. High costs are among major

barriers to Pap testing [9, 17, 32, 33]. Women who have a

higher income are more likely than others to have a Pap

test [27]. Having a regular physician is also an important

facilitating factor for Pap testing among Vietnamese

women [9, 21, 25, 30], as is health insurance [9, 23, 26, 27,

31, 32].

Knowledge and awareness related to cancer and

screening services is a strong predictor of screening

behavior among Vietnamese and other Asian women in the

United States [11, 17, 23, 25, 33, 34]. Awareness that Pap

tests are effective in reducing one’s risk of developing

cervical cancer and/or increase one’s chance of having

cervical cancer cured is associated with an increased

likelihood of having a test [9].

Cultural beliefs related to Pap testing have strong influ-

ences on screening behaviors among Asian women. Beliefs

that do not put emphasis on preventive care are theoretically

important barriers to cancer screening, although the empir-

ical evidence is not consistent [23, 29, 35, 36]. Many believe

that cancer screening is not necessary if one is generally

healthy [14, 32, 37]; it could also reveal problems and cause

concerns, while access to care may be limited [38].

Acculturation, which is the level of assimilation to the

host culture, has generally been found a significant deter-

minant of Pap testing among Vietnamese and other Asian

American women [27, 30, 32, 39–41]. However, in most of

previous studies with Vietnamese American women,

acculturation has been measured simply by the number of

years living in the US and/or English language proficiency

[26, 27, 30, 32, 33]. Few recent studies have examined a

composite measure of acculturation [15, 17]. This study

will overcome this limitation by employing a comprehen-

sive, standardized measure of acculturation [42].

Methods

Participants

As mentioned above, this study is part of the HAPP project

implemented by BPSOS in five cities: Houston (TX),

Springfield (MA), Falls Church (VA) (including nearby

Vietnamese communities in Washington, DC and Mary-

land), Camden (NJ), and Charlotte (NC). Eligible partici-

pants—Vietnamese American men and women age 18 or

older—were recruited by convenience sampling from a

variety of community locations and groups to represent the

Vietnamese American community within each city to the

extent possible. Sample sizes varied between 53 in Houston

to 315 in Falls Church, with a total sample of 696 Viet-

namese Americans. Only women who had heard of cervical

cancer and never had a hysterectomy were asked questions

about Pap testing; the study sample therefore was limited to


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265 women who had heard of cervical cancer and did not

have missing information on other questions, instead of a

total of 348 women in the sample.

Data Collection

The survey was conducted in the spring and summer of

2010 to assess knowledge, attitudes, and practices related

to cancer screening among Vietnamese Americans. One-

on-one interviews were conducted in English or Vietnam-

ese by BPSOS bilingual staff at the five branch offices. The

questionnaire included modules on women’s socio-demo-

graphic characteristics, acculturation (Appendix), overall

health status and practices, knowledge of risk factors,

attitudes, and practices related to the five types of cancer

that are focus of HAPP. The study protocol was reviewed

and approved by the Institutional Review Board at Tulane

University.

Measures

The outcome of interest was a woman’s use of Pap testing,

measured by two binary indicators: whether a woman ever

had a Pap test and whether she had it within 12 months

before the survey.

Independent variables included a woman’s socio-demo-

graphic characteristics, access to health care and health

information, knowledge related to cervical cancer, and four

components of the HBM, including: perceived susceptibil-

ity, perceived benefits, cues to action, and perceived barriers

that are related to Pap testing. Socio-demographic charac-

teristics included age, marital status, education, whether a

woman was worried about paying rent or mortgage in the

last 12 months, and the level of acculturation. Being worried

about paying rent or mortgage was used as a proxy for socio-

economic status. Acculturation was constructed by factor

analysis, using scores from 17 questions included in the

standardized module (Cronbach’s alpha is .87). The higher

score represents a higher level of assimilation to the host

culture (i.e. being more Americanized). The three questions

on Vietnamese language proficiency were mathematically

reversed so that the higher score still meant one’s being

further removed from the original culture. Missing or non-

informative responses to each question were minimal and

recoded to the median score calculated from all informative

responses to the same question. The score was then

dichotomized to low and high acculturation levels at the

median score of the total sample. Hypothetically, those who

are being more assimilated to the host culture are more

likely to be exposed to information and more receptive to

modern medical knowledge and practices.

Access to care was measured by two binary indicators:

whether a woman had health insurance and whether she

had a family doctor. Participants were also asked about a

number of potential sources for health information,

including TV, radio, newspapers, etc., and BPSOS. Pre-

liminary analysis showed that these sources were not sig-

nificantly associated with Pap testing; therefore they were

not included in the final analyses. On the other hand,

because BPSOS’s HAPP program employed a number of

communication channels to promote cancer screening, we

controlled for this source for health information in the

multivariate analyses for programmatic purposes. Knowl-

edge of risk factors was an additive score of correct

responses to questions on risk factors of cervical cancer,

including having HPV and HIV, using oral pills for a long

period of time, giving birth to many children, and smoking.

Women’s perceived risk of cancer was used to measure

perceived susceptibility. Women’s belief that cancer can be

detected early with appropriate screening was a measure of

perceived benefits of screening practices. Having a family

member or friend diagnosed with cancer was hypotheti-

cally a cue to action, motivating women to learn more

about and get screened for cancer. Finally, perceived

(attitudinal) barriers related to Pap tests were measured by

whether they agreed, neither agreed nor disagreed or dis-

agreed with two statements: ‘‘It is embarrassing to get a

Pap test’’ and ‘‘Only married women should get a Pap

test’’. Only the last response (i.e. disagree) was deemed to

indicate positive attitudes toward the practice.

Analysis

Descriptive and bivariate analyses were used to examine

two Pap testing outcomes and how they varied by women’s

characteristics. Multivariate logistic regressions were then

employed to assess the associations between Pap testing

and four components of the HBM, controlling for other

factors. Because of the small sample size in each city,

analyses were carried out with the pooled sample.

Results

The first column of Table 1 presents the distribution of the

study sample. The women were 44 years old and had

12 years of schooling on average. The majority (57 %) of

them were married at the time of the survey. Nearly three-

quarters of the women were worried about paying rent or

mortgage in the 12 months before the survey. Access to

care did not seem limited: 73 % of the women had health

insurance and four in five of them had a family doctor.

BPSOS communication activities reached just over half

(55 %) of the women. Cancer among family members and

friends was not uncommon: 44 % of the women reported

having a family member or a friend who was diagnosed


123

with cancer. About 40 % of the women considered them-

selves at some risk of cervical cancer; yet knowledge of

risk factors was not high: of the four risk factors asked,

women only knew 1.2 on average. Nearly every woman

(94 %) agreed that cancer could be detected early with

appropriate screening. Nevertheless, attitudes toward Pap

testing left much for improvement: a significant proportion

(15 %) of the sample believed that it was embarrassing to

get a Pap test and as many as 35 % believed that only

married women should get a Pap test.

Variations in Pap Testing

Three in four women had ever received a Pap test; 45 %

received it within the last 12 months before the survey. The

next two columns of Table 1 show the distribution of these

two outcomes across women’s characteristics.

Ever use of Pap testing varied significantly by women’s

marital status, perceived risks of cervical cancer, attitudes

toward cancer screening, as well as two attitudinal items

related to Pap testing (p \ .05 or p \ .01). It also seemed

to vary by a woman’s age, health insurance coverage, and

having received health information from BPSOS, although

these variations were only marginally significant (p \ .10).

The proportion of women who had a Pap test within the

last 12 months also varied significantly by several indi-

vidual characteristics. Among women who had access to

health care, measured by having health insurance coverage

and a family doctor, the proportion of recent Pap testing

was much higher than that among women who did not have

the same access to health care (p \ .001; p \ .01, respec-

tively). The proportion of women who supported cancer

screening practices receiving a recent Pap test was nearly

three times as much as that among those who did not

support screening practices (p \ .05). Similarly, Pap test-

ing was remarkably more common among women who

disagreed that it was embarrassing to get a Pap test or that

only married women should get a Pap test, compared to

other women (p \ .05; p \ .01, respectively).

Factors Influencing Pap Testing

Table 2 presents findings from the multivariate models pre-

dicting the odds of ever and recent use of Pap tests. The first

model shows few women’s characteristics that were associ-

ated with ever use of Pap testing. Women’s age and marital

status both were significantly related to ever use of Pap testing.

Compared to younger women, older women were more than

two times as likely to have ever obtained a Pap test (p \ .05);

similar differences were found between married and unmar-

ried women (p \ .05). There was also a slight increase in the

odds of having a Pap test with higher education (p \ .10).

While it was not strongly significant, attitudes toward Pap

testing might be positively associated with ever use of Pap

test: women who disagreed that it was embarrassing to get a

Pap smear test were 2.06 as likely as those who agreed with the

statement to have received a Pap test (p \ .10).

Table 1 Sample description and variations in the use of Pap test

(ever and within the last 12 months) by women’s characteristics, 2010

Women’s characteristics Distribution

% or mean

(s.d.)

Ever

use (%)

Use within

last 12

months (%)

Age group (median = 43) 44.2 (15.7) 69.6� 48.6

Younger than median 48.4 79.5� 42.2

Older than median 51.6

Currently married

No 42.8 68.0* 39.3�

Yes 57.2 79.6* 49.7�

Number of years of education 12.0 (4.3) - -

Level of acculturation

Low 50.9 75.9 42.8

High 49.1 73.4 47.9

Worried about paying rent or mortgage last 12 months

Never/rarely 27.1 70.1 42.3

Sometimes/usually/always 72.9 76.3 46.4

Has health insurance

No 27.1 67.5� 28.2***

Yes 72.9 77.3� 51.7***

Has a family doctor

No 20.0 67.9 29.8**

Yes 80.0 76.3 49.1**

Has received health information from BPSOS

No 44.6 69.8� 42.5

Yes 55.4 78.5� 47.5

Perceived risk of cervical cancer

No 60.9 70.0* 43.3

Yes 39.7 82.1* 48.2

Has a family member/friend diagnosed with cancer

No 56.1 74.2 44.4

Yes 43.9 75.2 46.4

Knowledge of risk factors 1.2 (1.3) - -

Cancer can be detected early with appropriate screening

Disagree 6.0 52.9* 16.7*

Agree 94.0 76.0* 47.2*

It is embarrassing to get a Pap test

Agree 15.1 58.1** 27.9*

Disagree 84.9 77.6** 48.6*

Only married women should get a Pap test

Agree 35.3 68.0* 35.0**

Disagree 64.7 78.7* 51.4**

Total 74.7 45.3

� p \ .10; * p \ .05; ** p \ .01; *** p \ .001 denoting the differ-

ences in the use of Pap smear between groups


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The multivariate model predicting Pap testing within the

last 12 months, presented in the last column of Table 2,

also shows that several women’s characteristics were

associated with recent Pap testing. Having health insurance

was the strongest predictor of recent Pap testing: women

who had health insurance were about three times as likely

as those who did not to have a Pap test in the last

12 months (p \ .01). Married women may be more likely

than unmarried women to get a Pap test recently, although

the association was not strongly significant (p \ .10). Also

similar to the findings with ever use of Pap testing, there

was some evidence of associations between attitudes

toward Pap testing as well as cancer screening and recent

Pap testing.

Reasons for Not Having a Pap Smear Test

Table 3 presents reasons that were cited by women who

did not obtain a Pap test within the last 12 months. The

most common reason, cited by a third of these women, was

that they were feeling well and did not see any reasons for

a test. Having no health insurance was cited by a quarter of

non-users, as was not being recommended by a doctor.

These reasons were followed by the perceived prohibitive

costs of the test (19 %) and time constraints (15 %). Very

few women (4.8 % of non-users) reported embarrassment

as a reason for not getting the test. Other reasons were cited

by few women.

Discussion

The current study reports the rates of ever having a Pap test at

nearly 75 % and of receiving the test within the last 12 months

at 45 % among Vietnamese women in the study five cities,

which is consistent with results found elsewhere [9, 10, 17–

20]. Several components of the HBM measured in this study

were potentially associated with Pap testing among Viet-

namese American women. Women’s perceptions of their risk

Table 2 Multivariate associations between individual factors and

Pap testing (ever and within the last 12 months) among Vietnamese

American women, 2010

Women’s characteristics Ever use

O.R. (s.e.)

Use in last 12 months

O.R. (s.e.)

Age group

Younger than median 1.00 1.00

Older than median 2.22 (.77)* .90 (.26)

Currently married

No 1.00 1.00

Yes 1.92 (.62)* 1.69 (.47)�

Number of years of education 1.07 (.04)� 1.04 (.04)

Level of acculturation

Low 1.00 1.00

High 1.08 (.04)� 1.19 (.36)

Worried about paying rent or mortgage last 12 months

Never/rarely 1.00 1.00

Sometimes/usually/always 1. 24 (.42) 1.17 (.35)

Has health insurance

No 1.00 1.00

Yes 1.47 (.57) 2.45 (.87)*

Has a family doctor

No 1.00 1.00

Yes .98 (.41) 1.12 (.45)

Has received health information from BPSOS

No 1.00 1.00

Yes 1.41 (.44) 1.18 (.32)

Perceived risk of cervical cancer

No 1.00 1.00

Yes 1.81 (.61)� .92 (.26)

Has a family member/friend diagnosed with cancer

No 1.00 1.00

Yes .76 (.24) .93 (.25)

Knowledge of risk factors .90 (.12) .92 (.26)

Cancer can be detected early with appropriate screening

Disagree 1.00 1.00

Agree 2.11 (1.22) 3.39 (2.34)�

It is embarrassing to get a Pap test

Agree 1.00 1.00

Disagree 2.06 (.84)� 1.86 (.76)

Only married women should get a Pap test

Agree 1.00 1.00

Disagree 1.37 (.47) 1.35 (.41)

� p \ .10; * p \ .05

Table 3 Reasons for not having a Pap test among Vietnamese

American women who did not have a Pap smear within the last

12 months, 2010

Reason %

1. Lack of knowledge 3.5

2. Feeling well/no health problems 33.8

3. Language problems/Doctor does not speak Vietnamese 1.4

4. No doctor 3.5

5. No time 15.2

6. No insurance 25.5

7. High costs 18.6

8. Don’t know where to go 2.8

9. Embarrassment/shame 4.8

10. Not suggested by doctor 25.5

11. Not sure if insurance covers it 1.4

12. There is no female doctor .7

13. Others 2.1


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of getting cervical cancer were marginally related to ever use

of Pap testing. It is possible that women were motivated to get

a Pap test if they saw themselves at risk of getting cervical

cancer. On the other hand, because both questions were asked

at the time of the survey, we could not rule out the possibility

that some women might feel at risk because of the test results

that they received.

There is also some evidence that perceived benefits,

measured by women’s belief that cancer can be detected

early with appropriate screening, were associated with Pap

testing (both ever and recent use), although the associations

did not reach the significance level of .05. Had we had a

larger sample size, the results may have been statistically

significant. Similar results were seen with the two measures

of barriers to Pap testing: a higher likelihood of ever or recent

use of Pap tests was observed among women who disagreed

with either attitudinal statement, compared to other women.

Only one of these associations was marginally significant at

the .10 level, perhaps due to the small sample size. Our

stratified analysis by marital status also showed positive

associations between disagreement with the beliefs that only

women should get a Pap test and that it was embarrassing to

get a Pap test and Pap testing (ever and recent use) among

both married and unmarried women. Although only one of

these associations reached the statistical significance level of

.10, their odds ratios were substantial, ranging from 1.28 to

3.23. (results not shown). The results suggest that it may be

important to promote preventive benefits of Pap testing and

to help women overcome the traditional beliefs and mis-

conceptions related to Pap testing. Despite the finding that

married women were potentially more likely than unmarried

women to have a recent Pap test, the results indicate that

interventions promoting Pap tests should target both

unmarried and married women.

Having a family member or a friend diagnosed with

cancer, a measure of cues to action, was not related to

either outcome. It is plausible that the types of cancer that

family members or friends have (e.g. lung cancer) may not

be directly related to cervical cancer per se. While a better

measure of cues to action may be a question that directly

asks about cervical cancer, including this information did

not change our results (not shown). It is therefore likely to

reflect the true relationships between this measure of cues

to action and Pap testing.

Having health insurance was the most important pre-

dictor of recent Pap testing. In addition, among women

who did not have a Pap test recently, having no insurance

was the second most important barrier; high costs were also

a common reason for not having a Pap test. These results

underline the importance of financial access to Pap testing.

In this study, financial access seemed more important than

having a regular source of care, as results showed that

having a family doctor was not an important determinant of

Pap testing. It is possible that access to a culturally

appropriate care provider in terms of gender and ethnicity

may be important to Pap testing among Vietnamese

Americans; unfortunately, our small sample size did not

allow such investigations.

Having received health information from BPSOS and

knowledge of cervical cancer risk factors were not shown

in this study to be significantly related to Pap testing,

although the odds ratios were [1 for both outcomes.

Unfortunately, women were not asked for specific strate-

gies of communication that BPSOS might have employed;

thus, a detailed analysis of the potential effectiveness of

each strategy was not possible. In the subsequent evalua-

tion of the HAPP project, questions pertaining to specific

communication strategies by BPSOS have been included.

Results also show that the most important reason for not

having a Pap test may be related to the lack of priority on

preventive care among Vietnamese women: feeling well

was the most frequently cited reason for not having a Pap

test. It indicates that more work is needed to change nor-

mative beliefs that put emphasis on treatment rather than

prevention of diseases among Vietnamese women. Strate-

gies to reach this goal should include, among others, those

that target Vietnamese women through their doctors, as one

in four women said they did not have a Pap test because it

was not suggested by their doctors.

A limitation of this study is the convenience sampling

scheme. Because there were no existing sampling frames

that cover the entire Vietnamese population in the project

cities, BPSOS staff were asked to recruit participants from

a variety of venues, ranging from health fairs, community

events, to small business and shops (such as nail and hair

salons, supermarkets, restaurants), churches, temples,

phone books, and other population registries. This could

affect the representativeness of the sample. However,

because our results were consistent with previous studies

with Vietnamese American women elsewhere, we believe

this is not a major limitation.

Only women who had heard of cervical cancer were

included in this study. Because women who never heard of

cervical cancer were unlikely to have received a Pap test,

this exclusion could result in an underestimation of the

prevalence of Pap testing among Vietnamese Americans.

Had all surveyed women included in the analysis, the pro-

portions of ever and recent Pap testing could drop to 58.1

and 35.3 %, respectively. Unfortunately, women who never

heard of cervical cancer were not asked any other questions

related to this type of cancer and Pap test, which prohibited

us from any further analyses. On the other hand, the study

women were very similar to the excluded women in basic

socio-economic characteristics, including age, marital sta-

tus, education, and the number of years living in the US

(results not shown). The study women were more likely than


123

excluded women to own a house and to be worried about

paying rent or mortgage. However, as these factors were not

significantly associated with the outcomes, we believe that

the exclusion did not substantially change the results

regarding individual factors that influenced the outcomes.

Another limitation is the small sample size, which may

have resulted in a lack of statistical significance of several

findings. The small sample size also limited our analyses in

several aspects; for example an examination of the asso-

ciation between gender and ethnicity of the family doctor

and Pap testing was not possible. Furthermore, we only

examined individual-level factors in this study; future

studies should investigate health care structural factors and

the interactions between them and individual-level factors

that may influence screening behaviors.

Despite the limitations, the study adds evidence to the

current body of literature on cancer screening among

Vietnamese American women. Results indicate that health

care interventions should aim to make Pap testing more

financially accessible to Vietnamese American women,

either through increased health insurance coverage or

making doctor visits more affordable. The study also sug-

gests that future communication and education programs

should emphasize preventive benefits of cancer screening

and change traditional, attitudinal beliefs that may prevent

women from accessing Pap tests. Several important areas

should be addressed in future research, including the

effectiveness of various communication strategies, the role

of gender and ethnicity of health care providers, and the

influence of health care structural factors on cancer

screening behavior among Vietnamese immigrants.

Contribution to the Literature

This study employed the Health Belief Model to assess the

role of personal characteristics, beliefs and norms on Pap

testing, which had not been frequently done with the

Vietnamese population. The study adds to the currently

limited body of literature on the application of the HBM

model in explaining health care behavior among Viet-

namese immigrants. We used a comprehensive measure of

acculturation that has been standardized for Southeast

Asian populations, although it did not prove to be impor-

tant to cancer screening practice in this study. We also

recruited women from five different locations in the United

States, which may contribute to an increased representa-

tiveness of the sample, compared to much of the existing

research that has focused only on Vietnamese women in

California or Texas.

Acknowledgments This study is conducted as part of the Health

Awareness and Prevention Project: A Cancer Focus, funded by

Centers for Disease Control and Prevention. Boat People SOS

(BPSOS) is the implementing agency and Tulane University is the

evaluator of the project. The author would like to thank BPSOS staff,

including the project managers (Quynh Nguyen and Tranh Nguyen)

and BPSOS branch staff in Houston (TX), Springfield (MA), Camden

(NJ), Charlotte (NC), and Falls Church (VA) (including nearly MD

and DC areas) for their contributions to the evaluation of this project.

Special thanks also go to Quyen To for his assistance in the data entry

and Soham Rajpara for his contribution to the literature review for

this study.

Appendix

Questions that were used to measure acculturation among

Vietnamese immigrants.

Questions 1–6 employed a 4-point Likert scale:

1 = very well, 2 = pretty well, 3 = not too well, and

4 = not at all.

1. How well do you speak English?

2. How well do you write English?

3. How well do you understand English?

4. How well do you speak Vietnamese?

5. How well do you write Vietnamese?

6. How well do you understand Vietnamese?

Questions 7–17 employed a 5-point Likert scale: 1 = only

Vietnamese, 2 = mostly Vietnamese, 3 = Vietnamese and

English/American equally, 4 = mostly English/American,

and 5 = only English/American. ‘‘Not applicable’’ cases

were recoded to the median score of the other cases.

7. Which language, Vietnamese or English, are you

most likely to use with your spouse?


most likely to use with your children?


most likely to use with your parents?


most likely to use with your friends?


most likely to use with your neighbors?


most likely to use at work?


most likely to use at family gatherings?

14. Why types of close friends to you see every day?

15. Why types of neighbors to you see every day?

16. Why types of coworkers to you see every day?

17. Why kind of food do you prefer?

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Predictors of Cervical Cancer Screening Among Vietnamese American Women