Cervical Cancer Screening Among Asian Canadian Immigrant and Nonimmigrant Women

Transcription

1 Cervical Cancer Screening Among Asian Canadian Immigrant and Nonimmigrant Women Hui Xiong, MSc; Madonna Murphy, MSc; Maria Mathews, PhD; Veeresh Gadag, PhD; Peizhong Peter Wang, MD, PhD Objectives: To examine whether Pap smear screening and determinants of screening for Asian immigrants are different from those for nonimmigrants in Canada. Methods: Data from the Canadian Community Health Survey Cycle 2.1 (2003) were used. Explanatory and multivariate logistic regression analyses were performed to compare rates and determinants of Pap smear screening between Asian immigrants and nonimmigrants. Results: In this study, 64,604 women were included. Asian immigrants had significantly lower rates of Pap smear screening (52%) compared to nonimmigrants (72%). Lack of necessity and time are important barriers. Conclusion: Pap smear screening should be promoted, particularly in recent Asian immigrants. Key words: cervical cancer screening, Pap smear screening, Asian immigrant women, immigrants Am J Health Behav. 2010;34(2): The Asian immigrant population is the fastest-growing ethnic group and one of the largest visible minorities Hui Xiong, title???; Maria Mathews, Associate Professor of Health Policy/Health Care Delivery; Veeresh Gadag, Professor of Biostatistics, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John s, Canada. Madonna Murphy, Epidemiologist, Research and Evaluation Department, Newfoundland & Labrador Centre for Health Information, St. John s, Canada. Peizhong Peter Wang, Associate Professor of Epidemiology, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, St. John s, Canada and Visiting Professor, School of Public Health, Tianjin Medical University, Tianjin, China. Address correspondence to Ms Xiong, Division of Community Health and Humanities, Faculty of Medicine, Memorial University of Newfoundland, 300 Prince Philip Drive, St. Johns, Canada NF A1B 3V6. hxiong@mun.ca in Canada. 1 Although cervical cancer is the 11 th most frequently diagnosed cancer among Canadian women, 2 it is one of the most common cancers among women in India, Korea, Philippines, Singapore, Thailand, and China, 3,4 as well as among Asian women living in North America. 5 The variation in cervical cancer incidence rates may be due to differences in Pap smear screening, along with sexually transmitted infections. 3 Cervical cancer is a preventable cancer, and Pap smear screening can reduce the incidence of and mortality from cervical cancer. Guidelines of Pap smear screening have been developed for women and their physicians to follow. The Canadian Task Force on Preventive Health Care recommends annual Pap smear screening for women who are sexually active or 18 years of age or older and screening every 3 years for women with 2 previous normal smears until age Am J Health Behav. 2010;34(2):

2 Cervical Cancer Screening Although Pap smear screening leads to early detection of cervical cancer, 2,7,8 Asian immigrant women have yet to fully take advantage of this procedure and consequently are more likely to have this disease detected at later stages Variation in screening could explain part of the difference in survival rates. 18 Research has identified some of the barriers for women who have not had Pap smear screening. Being older, having low socioeconomic status, being non-english speaking, being born outside Canada, being a recent immigrant, and being single are negatively associated with Pap smear use. 9,10,16,19-25 Other barriers to Pap smear screening include education, 9,16,21,26 health insurance (US), 16,26 having a regular doctor, 9,16,27 the gender of the physician, chronic condition, 9 fear (painful or modesty), 25 and smoking status. 9 Lack of necessity for the screening 9,27 and lack of physician recommendation 27 have also been identified as barriers to the screening. Few studies measure screening rates and risk factors for nonparticipation in Pap smear screening among certain Asian immigrant groups in Canada. 11,12,31 However, all these studies have various limitations. Gupta s study is based on small samples of South Asian women. 31 Hislop s study was conducted 8 years ago and is a community-based study in Chinese women, so findings from this study cannot be generalized to represent the current status of Asian immigrant women. 11 McDonald s study is very recent, based on national data, and it compared differences in Pap smear use between immigrant and native-born women. 12 However, this study did not examine barriers associated with Pap smear use among Asian immigrant women. Because cervical cancer screening should be available to all women at risk, and Asian immigrant women have low Pap smear use, more research is needed to address this preventive health-screening behavior among Asian immigrant women and to understand why they are not screened or are screened irregularly. A better understanding of barriers to screening for Asian immigrant women is crucial to assist public policy and decision makers developing appropriate strategies that encourage regular screening, thus increasing the overall level of this population coverage. This is a national population-based study including a variety of Asian immigrant women, and results from this study can be generalized to Asian immigrant women in Canada. This study contributes new data on cervical cancer screening and extends current information in the literature about Pap test screening rates in Asian immigrant ethnic populations residing in Canada. The objectives of the present study were 3-fold. First, it examined whether Pap smear screening is being adequately used by Asian immigrant women. Second, it assessed whether the determinants of Pap smear screening use in this population are different from those of nonimmigrant women. Third, it examined whether there are differences in the reasons for not having Pap smears within the last 3 years between Asian immigrant women and nonimmigrant women, in order to gain better understanding of their screening behavior. METHODS Data Source The cross-sectional Canadian Community Health Survey (CCHS) Cycle 2.1 (2003) was used in this study. The CCHS, conducted by Statistics Canada, collects a very broad spectrum of health information on more than 135,000 Canadians every second year. The CCHS 2.1 provides individual-level information on various health determinants, health status, health care use, and socioeconomic and demographic attributes for 126 health regions across Canada. It is weighted to represent approximately 98% of the Canadian population aged 12 and older. In order to remove the barrier of language, the survey was conducted in a wide range of language competencies. The survey response rate was 80.7%. 32 Based on the CCHS 2.1 questionnaire, 33 an Asian immigrant is defined as anyone who was born outside of Canada and was not born a Canadian citizen and whose racial origin is Asian. Asian immigrants included Korean, Filipino, Japanese, Chinese, South Asian (East Indian, Pakistani, or Sri Lankan), South East Asian (Cambodian or Indonesian), Laotian, Vietnamese, Arab, and West Asian (Afghan or Iranian). Dependent Variables Self-reported screening history was used as an outcome variable. It was ex- 132

3 Xiong et al plored in 2 different approaches: ever having had a Pap smear and having had a Pap smear recently. For cervical cancer screening, women aged 18 years and older were asked, Have you ever had a Pap smear test? Women were considered screened if they responded, Yes and then were asked, When was the last time? The choices included (1) less than 6 months ago, (2) 6 months to less than 1 year ago, (3) 1 year to less than 3 years ago, (4) 3 years to less than 5 years ago, and (5) 5 or more years ago. The ever having had a Pap smear variable was ever had vs never had. The having had a Pap smear within the last 3 years variable was <3 years had vs >3 years had/never had. Based on guidelines of the Canadian Task Force, every 3 years for women aged 18 and over up to the age of 69 is a commonly accepted screening interval. 34 The reasons that respondents have not had a Pap smear test within the last 3 years prior to the interview were also assessed. The reasons include having not gotten around to it, respondent s not thinking it was necessary, doctor s not thinking it was necessary, personal or family responsibilities, respondent s not being available at time required, screening not being available at all in the area, waiting time being too long, having transportation problems, having language problem, cost, respondent s not knowing where to go /being uninformed, fearful (eg, painful, embarrassing, find something wrong), having had a hysterectomy, hating / disliking having one done, being unable to leave the house because of a health problem, and other reasons. Independent Variables Immigrant status was categorized as nonimmigrant, other immigrant, and Asian immigrant. Immigrants were those who were born outside of Canada and were not born Canadian citizens. Asian immigrants were identified by the culture/racial question People living in Canada come from many different cultural and racial backgrounds. Are you? Other independent variables included demographic, socioeconomic status, health status, health care source, and lifestyle. The demographic variables included age (18 to 29, 30 to 39, 40 to 49, 50 to 59, and >60 years), marital status (married/common-law, widowed/separated/ divorced/single/never married), ability to speak English/French (yes vs no), and length of residence (recent immigrant: residence in Canada less than 10 years, long-term immigrant: residence in Canada 10 years or more). The length of residence was obtained from the number of years since emigrating to Canada. The 10 years cut-point on length of residence was based on previous research. 35 Canada has universal health coverage for all Canadian residents. The Canadian law requires that new immigrants in Canada be provided with medical insurance within 3 months after arrival, and Pap smear screening is provided free of charge. As a result, insurance status was not a predictor variable in this study. The socioeconomic variables included highest level of education (less than secondary school graduation, secondary school graduation, some postsecondary/ postsecondary school graduation) and household income. Based on Statistics Canada s definition in CCHS 2.1, household size and household income were taken into account. Although Statistics Canada classifies household income into 5 levels, due to sample size and a high proportion of not stated, household income categories here were also combined into 5-level categories: lowest/ lower-middle income, middle income, upper middle income, highest income, and not stated. The health status was identified by the number of chronic diseases (0, 1, 2, 3+) respondents had. Health care source was defined if respondents reported having a regular doctor (yes vs no), The lifestyle variable included smoking status: nonsmoker (former smoker/ never smoked) vs current smoker (occasional smoker/daily smoker). Statistical Analysis The statistical analysis was based on data from the Canadian Community Health Survey cycle 2.1 (2003). Self-reported screening histories were used as outcome variables; demographic characteristics, socioeconomic status, health status, health care source, and personal lifestyle were used as predictive variables. Explanatory analysis was performed to compare rates of Pap smear screening use between Asian immigrant and the rest of the corresponding nonimmigrant Canadian women. Two series of multivariate logistic regression model analy- Am J Health Behav. 2010;34(2):

4 Cervical Cancer Screening ses were conducted to examine whether Asian immigrant women as a whole, or stratified Asian immigrant women by length of residence in Canada, had lower odds of reporting a Pap smear than nonimmigrants did, after adjusting for demographic characteristics, socioeconomic status, health status, and lifestyle. Each series was run separately for the outcomes as ever having had a Pap smear and having had a Pap smear within the last 3 years. Furthermore, stratified multivariate logistic regression was used to predict the odds of ever having had a Pap smear and the odds of having had a Pap smear within the last 3 years by immigrant status and to explore whether different risk factors exist between Asian immigrant and nonimmigrant women. In order to take into account the unequal probabilities of selection, the rescaled weights were used to produce descriptive estimates. This was achieved by dividing the original weight by the mean original weights. The amount of missing data for all variables included in this study was negligible (less than 5%), with the exception of household income. Some amount of missing values were suppressed by Statistics Canada due to small cell size (ie, less than 30 in unweighted form). Therefore, these missing data were deleted in this study prior to data analyses, and missing categories for these variables were not created. Missing household income information ranged from 13.3% among nonimmigrant women to 22.2% among recent Asian immigrant women. A missing category was introduced in the household income variable. The bootstrap resampling method was performed to estimate coefficients of variation, p-values, and significance tests. Statistical significance was measured at the 95% confidence interval level. The statistical analyses were performed using SAS software package version 9.1 (SAS Institute Inc, Cary, NC) through the Statistics Canada remote access service. RESULTS In this study, the number of respondents aged 18 years and older was 55,654 nonimmigrant women, 6830 other immigrant women, and 2120 Asian immigrant women in Canada (Table 1). The social demographics differed substantially among the 3 groups on the basis of immigrant status. Asian immigrant women were younger on estimated average of age (Mean (M)=42.09, Standard deviance (SD)=0.41) than nonimmigrant women (M=45.52, SD=0.07) and other immigrant women (M=51.63, SD=0.27). Asian immigrant women had postsecondary education (61%) similar to those of nonimmigrant women (60%) and other immigrant women (59%). Only 19% of Asian immigrant women were in the highest household income level compared to 30% of nonimmigrant women and 25% of other immigrant women. The estimated average of number of chronic conditions (M=1.33, SD=0.05) reported by Asian immigrant women was lower than that reported by nonimmigrant women (M=2.16, SD=0.01) or by other immigrant women (M=2.20, SD=0.04). Only 7% of Asian immigrant women were current smokers compared to nonimmigrant women (25%) and other immigrant women (15%). Asian immigrant women had significantly lower rates of ever having had a Pap smear, and of having had a Pap smear within the last 3 years than those of nonimmigrant women (Table 1). Eightyeight percent of nonimmigrant women, 83% of other immigrant women, and 60% of Asian immigrant women reported ever having had a Pap smear. Seventy-two percent of nonimmigrant women, 64% of other immigrant women, and 52% of Asian immigrant women reported having had a Pap smear within the last 3 years. Furthermore, after taking into account the length of residence, both recent and longterm Asian immigrant women had significantly lower rates of ever and recent Pap smear use than those of nonimmigrant women. Logistic regression analyses demonstrated significant differences between Asian immigrant women and nonimmigrant women for cervical cancer screening, after adjusting for demographic factors, socioeconomic status, health status, and lifestyle variables (Table 2). Furthermore, while taking into account length of residence in Canada for Asian immigrant women, the low rates of ever and recently having had a Pap smear persisted. Both recent and long-term Asian immigrant women were less likely to report cervical cancer screening than were nonimmigrant women. Other immigrant women also reported lower rates of ever and recently having had a Pap 134

5 Xiong et al Table 1 Characteristics of Study Population and Prevalence of Pap Smear Use, Women Aged 18 Years and Older, by Immigrant Status a Recent Long-term Non- Other Asian Asian Asian Immigrant Immigrant Immigrant Immigrant Immigrant (%) (%) (%) (% (%) Characteristics (n=55,654) (n=6830) (n=2120) (n=800) (n=1320) Age Marital Status All others Married/Common-law Education Less than secondary Secondary Postsecondary Household Income Lowest income/lower middle income Middle income Upper middle income Highest income Not stated Ability to Speak English/French No Yes Has a Regular Doctor No Yes No. of Chronic Diseases Smoking status Nonsmoker Current smoker Pap smear Ever had Pap smear * 60.2* 57.3* 78.7* Had Pap smear within the last 3 years * 52.2* 48.4* 56.7* Data source: The Canadian Community Health Survey, cycle 2.1 (2003) Note. not applicable * Significantly different from nonimmigrant (P<0.05), using Bootvar 3.0 (Statistics Canada) a All percentages are probability weighted smear than those of nonimmigrant women in age-adjusted models and in models based on other factors. Stratified multivariate logistic regression analyses were performed separately for nonimmigrant, other immigrant, and Am J Health Behav. 2010;34(2):

6 Cervical Cancer Screening Table 2 Odds Ratios for Pap Smear Screening, Women Aged 18 Years and Older, by Immigrant Status Ever Had Pap Smear Had Pap Smear Within the Last 3 years Age-Adjusted OR Adjusted OR b Age-Adjusted OR Adjusted OR b Immigrant status (95% CI) (95% CI) (95% CI) (95% CI) Nonimmigrant a Other Immigrant 0.69( )* 0.69( )* 0.92( ) 0.90( )* Asian Immigrant 0.22( )* 0.28( )* 0.43( )* 0.50( )* Recent Asian Immigrant(<10yr) 0.14( )* 0.18( )* 0.23( )* 0.30( )* Long-term Asian Immigrant (>10yr) 0.33( )* 0.38( )* 0.59( )* 0.69( )* Data source: The Canadian Community Health Survey, cycle 2.1 (2003) Note. OR =odds ratio, CI=confidence interval. * Significantly different from reference category, P<0.05 a b Reference category Adjusted for age, marital status, education, household income, ability to speak official languages, has a regular doctor, number of chronic diseases, and smoking status. Asian immigrant women to examine whether Asian immigrants had different risk factors for low rates of cervical cancer screening compared with the nonimmigrant women (Table 3, 4). In general, the factors that were examined in this study affect both immigrants and nonimmigrants in similar manners for having ever been screened (Table 3). However, Table 4 shows that age affects immigrants and nonimmigrants differently. Nonimmigrant women aged 50+ were less likely to report having had a Pap smear within the last 3 years than were women aged Asian immigrant women aged were more likely to report having had a Pap smear within the last 3 years than were women aged The ability to speak English or French was not an independent predictor for ever and recent Pap smear screening use in Asian immigrant women, although it was significantly associated with higher rates of Pap smear screening in nonimmigrant women. Smoking was not significantly associated with Pap smear screening in Asian immigrant women. Table 5 shows the most common reasons for not having a Pap smear within the last 3 years across the 3 groups. Among women not having a Pap smear recently, Asian immigrant women were more likely to report that they did not get around to having a Pap smear than were nonimmigrant women. Nonimmigrant women were less likely than other immigrant and Asian immigrant women to report that the reason for not having a Pap smear recently was that they did not think it was necessary. There were no significant differences in reporting that doctor did not think it was necessary as a reason for not having had a recent Pap smear among 3 groups. Few Asian immigrant women reported having had a hysterectomy as the reason for not having a recent Pap smear, and the proportion was significantly lower than in nonimmigrant women. DISCUSSION The purpose of this study was to understand barriers to screening for Asian immigrant women. Asian immigrant women had lower rates of cervical cancer screening use than nonimmigrant women. These findings are similar to those of previous studies. 12,20,21,31 Even after many years in Canada, long-term Asian immigrant women had lower rates of Pap smear use than those of nonimmigrant women, a result consistent with a previous study

7 Xiong et al Table 3 Logistic Regression for Ever Having Had Pap Smear, Women Aged 18 Years and Older, by Immigrant Status Odds Ratio (95% Confidence interval) b Characteristics Nonimmigrant Other Immigrant Asian Immigrant Age a ( )* 1.85( )* 2.50( )* ( )* 2.52( )* 3.47( )* ( )* 3.82( )* 3.99( )* ( )* 3.29( )* 3.81( )* Marital Status All others a Married/Common-law 3.04( )* 1.54( )* 3.22( )* Household Income Lowest/lower-middle income a Middle income 0.93( ) 1.40( ) 0.97( ) Upper middle income 1.09( ) 1.85( )* 1.01( ) Highest income 1.07( ) 3.00( )* 1.06( ) Not Stated 0.79( ) 1.26( ) 0.76( ) Education Less than secondary a Secondary 1.42( )* 1.69( )* 1.89( )* Postsecondary 2.14( )* 1.77( )* 2.33( )* Ability to Speak English/French No a Yes 1.30( ) 1.18( ) Has a Regular Doctor No a Yes 1.85( )* 1.39( ) 2.37( )* No. of Chronic Diseases 0 a ( )* 1.68( )* 1.66( )* ( )* 1.36( ) 2.63( )* ( )* 2.37( )* 2.43( )* Smoking Status Nonsmoker a Current smoker 1.64( )* 2.24( )* 1.71( ) Data source: The Canadian Community Health Survey, cycle 2.1 (2003) Note. * Significantly different from reference category, P<0.05. a Reference category. b Adjusted for age, marital status, education, household income, ability to speak official languages, has a regular doctor, number of chronic disease, and smoking status. Pap smear screening should be promoted, particularly in recent Asian immigrant women. Despite similar determinants of Pap smear use observed in the study for immigrant and nonimmigrant women, perceived lack of necessity and lack of time are more important barriers to the screening for Asian immigrant women than for nonimmigrant women. These results suggest that knowledge of, attitudes toward, and health beliefs concerning preventive health screening may influence the screening behaviors in Asian immigrant women. Am J Health Behav. 2010;34(2):

8 Cervical Cancer Screening Table 4 Logistic Regression for Having Had Pap Smear Within the Last 3 Years, Women Aged 18 Years and Older, by Immigrant Status Odds Ratio (95% Confidence interval) b Characteristics Nonimmigrant Other Immigrant Asian Immigrant Age a ( )* 1.43( ) 1.88( )* ( ) 1.33( ) 2.58( )* ( )* 0.97( ) 2.39( )* ( )* 0.44( )* 1.50( ) Marital Status All others a Married/Common-law 1.85( )* 1.45( )* 3.09( )* Household Income Lowest/lower-middle income a Middle income 0.92( ) 1.37( ) 1.24( ) Upper middle income 1.07( ) 1.57( )* 1.34( ) Highest income 1.14( ) 1.93( )* 1.18( ) Not Stated 0.85( )* 1.41( ) 1.03( ) Education Less than secondary a Secondary 1.31( )* 1.09( ) 1.58( ) Postsecondary 1.72( )* 1.54( )* 2.05( )* Ability to Speak English/French No a Yes 2.19( )* 1.25( ) 1.08( ) Has a Regular Doctor No a Yes 2.49( )* 1.75( )* 3.01( )* No. of Chronic Diseases 0 a ( )* 1.54( )* 1.47( )* ( )* 1.26( ) 1.81( )* ( )* 1.38( )* 2.09( )* Smoking status Nonsmoker a Current smoker 1.00( ) 1.11( ) 1.50( ) Data source: The Canadian Community Health Survey, cycle 2.1 (2003) Note. * Significantly different from reference category, P<0.05. a Reference category b Adjusted for age, marital status, education, household income, ability to speak official languages, has a regular doctor, number of chronic disease, and smoking status. The significant differences in ever and recent Pap smear use between Asian immigrant and nonimmigrant women persisted, even after adjusting for age and other demographic factors, socioeconomic status, health status, and lifestyle factors. These results are similar to previous studies that found that women with Asian backgrounds were less likely to have a Pap smear than nonimmigrants. 9-11,36,37 The findings from this study suggest that demographic and socioeconomic 138

9 Xiong et al Table 5 Top Reasons for Not Having Pap Smear Within the Last 3 Years, Women Aged 18 Years and Older, by Immigrant Status Non Other Asian Immigrant a Immigrant Immigrant Have not gotten around to it * Respondent did not think it was necessary * 45.4* Doctor did not think it was necessary Did not know where to go / uninformed E 5.3E Fear 2.3 F F Have had a hysterectomy * 3.3*E Hate / dislike having one done 3.8 F F Other 1.4 F F Data source: The Canadian Community Health Survey, cycle 2.1 (2003) Note. E = Coefficient of variation between 16.6% and 33.3%. Estimates are considered marginal and are associated with high sampling variability. F = Coefficient of variation greater than 33.3%, estimate suppressed. * Significantly different from nonimmigrant (P<0.05), using Bootvar 3.0 (Statistics Canada) a Reference group factors may not contribute to the major differences in Pap smear use between nonimmigrant and Asian immigrant women. Women s interaction with the health care system, doctor s recommendations, or health care-provider biases may mediate the observed association and may have little to do with the woman s sociodemographics. Moreover, recent Asian immigrant women may be unfamiliar with the Canadian health care system. The impact of age on Pap smear use seemed to be different between Asian immigrants and the other 2 groups. The patterns of recent Pap smear use vary by age among Asian immigrant and nonimmigrant women. There were no differences in recent Pap smear use between age-groups in non-asian immigrant women. Asian immigrant women aged and 60+ are less likely to report having had a Pap smear within the last 3 years than are women aged For women aged 18-29, several studies suggest that cultural barriers to screening may play an important role, such as openness about sexuality and prevention orientation. 31,38 These women may have a lack of sexual knowledge due to Eastern cultures. A study conducted among female university students found that Asian Canadian women had a significantly lower level of sexual knowledge compared with European Canadian women. 39 For women aged 60+, this study suggests that the lack of need to have a Pap smear may be a major barrier to screening, so that they are not aware of any risk of cervical cancer. These findings reflect a need for education about sexual health, cervical cancer risk, and knowledge of cervical cancer screening for Asian immigrant women aged and 60+ to increase frequency of Pap smear use. Consistent with previous studies, 11,36 the ability to speak English or French was not significantly associated with Pap smear use for Asian immigrant and other immigrant women, after adjustment for other potential confounding factors. A recent study has shown that both nativeborn Asian Canadian women and Asian immigrant women who arrived in Canada as children had significantly lower rates of Pap smear use, although they should not have language and health care access barriers to screening. 12 Asian American women who were fluent in English also exhibit lower rates of Pap smear Am J Health Behav. 2010;34(2):

10 Cervical Cancer Screening screening. 24 However, language barrier is still a concern among Asian immigrant women. The positive direction of association between language ability and screening behavior in this study can be explained in 2 reasons. One reason is that since 1960, 6 provinces in Canada have gradually launched provincial cervical cancer programs: British Columbia, Nova Scotia, Alberta, Manitoba, Ontario, and Prince Edward Island. 40 These programs target all women aged (usually) in their provinces. Another reason is that Ontario, Manitoba, and British Columbia cervical screening programs offer translated information materials about the Pap smear test and cervical cancer both for women and health care professionals. Most materials are available in English, French, Arabic, Chinese, Farsi, Hindi, Italian, Portuguese, Punjabi, Somali, Spanish, Tagalog/Filipino, Tamil, Urdu, and Vietnamese Alberta Cervical Cancer Screening Program will remind women when Pap tests or follow-up are overdue through a follow-up reminder system for physicians. 44 Therefore, efforts are needed to provide culturally and linguistically appropriate cervical cancer information and education for Asian immigrant women in all provinces in Canada. This study found similar factors influencing immigrant and nonimmigrant women to have a Pap smear. However, lack of necessity and lack of time are particularly important barriers for Asian immigrant women indicating that Asian immigrant women who did not have a recent Pap smear are not aware of this preventive health service, and they may have a low level of knowledge about cervical cancer and the benefits of screening. Although it is well known that the level of knowledge about cervical cancer and screening and availability of time are associated with Pap smear use, 31,36,45-47 Gupta found that the length of residence in Canada is not strongly associated with level of knowledge relevant to screening. 31 This argument is supported by the present study s findings that long-term Asian immigrant women were less likely to have a Pap smear than nonimmigrant women were. Therefore, improving the knowledge of cervical cancer and the necessity of screening among Asian immigrant women may increase the rate of Pap smear use in this population. 48,49 In addition, several studies suggest that patient-provider interaction regarding cervical cancer screening and prevention may be a barrier to Pap smear screening use for Asian immigrant women This study found that many Asian immigrant women who did not have a Pap smear reported that their doctors did not think a Pap smear was necessary for them, and this finding is consistent with previous research. 45 However, other studies indicate that physicians recommendations regarding screening play an important role in Pap smear screening in immigrant women. 36,55 The findings suggest the need for interventions to strengthen the screening services of health care providers for Asian immigrant women. The strength of this study is that it is a national population-based study including a variety of Asian immigrant women. Results from this study can be generalized to Asian immigrant women in Canada. This study also examined the reasons for not having had a recent Pap smear on a national level. The present study has several limitations. First, the study relied on the use of self-reported data, which may result in over- or underestimation of receipt of Pap smear due to inaccurate recall. Second, Asian immigrants are a heterogeneous population, and analyses for specific Asian immigrant subgroups could not be conducted due to sample size limitation. Only sample sizes of Chinese, Filipino, and East Indian subgroups were large enough to allow an estimation of Pap smear screening rates. Because some cell counts in unweighted form were less than 30 when the rates of the screening were estimated, Statistics Canada suppressed these cells. Third, the information on level of knowledge about risk factors of cervical cancer and the value of screening is not available in the CCHS 2.1. Therefore, it was not possible to assess the effects of these factors on screening behavior. For example, a Canadian study has shown that Chinese immigrant women with a high knowledge of cervical cancer and screening were more likely to receive Pap smear screening. 46 Fourth, some of the results may be subject to different interpretations. For example, the category of not having enough time for pap screening may be representative of a host of fears or excuses, even though the perception may be lack of time. Fi- 140

11 Xiong et al nally, the only measure of acculturation was the length of residence and the ability to speak English/French variables. Other variables such as close contacts with people of the same origin were not available. The results of this study also have implications for health practice and policy. First, Asian immigrant women aged and 60+ years were less likely to receive Pap smears compared to Asian immigrant women aged years. This finding would support the development of culturally and linguistically appropriate education programs about the risk factors related to cervical cancer and about the importance of preventive health screening for Asian immigrant women aged and 60+. It is clear that identifying effective interventions enhancing cervical cancer screening rates in Asian women is an important public health research question in future studies. Second, despite the lower use rates among Asian immigrant women, the rates of Pap smear screening increased with the length of residence in Canada. This suggests that recent immigrants might be less aware of the cervical cancer screening, and length of residence in Canada might have some influence on Asian immigrant women s behaviors. Understanding the mechanisms that influence Asian immigrant women s screening behaviors over time is an important area for future research. Third, lack of necessity and lack of time are particularly important barriers to the screening for Asian immigrant women. Thus, effective interventions to increase knowledge of cervical cancer and perceived need for care are also needed to increase screening in Asian immigrant women. The results of this study also suggest that women s interaction with the health-care system, health care-provider biases, and needs for health care should be included in future studies of preventive health use, and it would be helpful to develop more effective interventions. In summary, the results indicate that Pap smear screening use is less common in Asian immigrant women than in nonimmigrant women and the length of resident in Canada only partially explained the difference. Lack of necessity and lack of time are important barriers to screening for Asian immigrant women. The unique cultural, language, and health needs of Asian immigrants must be addressed in both health promotion and provision. Given the lower rates of Pap smear screening in Asian immigrant women, targeted efforts are required to increase preventive health-screening rates for this population. Education and information programs on the risk factors of cervical cancer and follow-up reminder processes are necessary for Asian immigrant women, especially for recent immigrants and those aged and 60+. This can be achieved by using media campaigns, lay health advisors, and a follow-up reminder system. In addition, it is essential to design an intervention to investigate the level of knowledge of cervical cancer and screening in Asian immigrants and other barriers (eg, motivation, fear, and modesty etc.) that prevent them from using Pap smear screening. Acknowledgments This study was partially supported by the Newfoundland and Labrador Centre for Applied Health Research (NLCAHR) through research development grant and the Canadian Institute of Health Research (CIHR) team grant CTP Ms. Hui Xiong is a recipient of Dean s Fellow Award (2008), Faculty of Medicine, Memorial University of Newfoundland.. REFERENCES 1.Statistics Canada. Immigrant population by place of birth and period of immigration (2001 Census) (online). Available at: www40.statcan.ca/l01/cst01/demo24a.htm. Accessed September 2, Canadian Cancer Society/National Cancer Institute of Canada. Canadian Cancer Statistics Toronto, Canada, Available at: on%20cancer%20statistics/cancer%20 statistics%20publications.aspx?sc_lang=en. Accessed October 3, Canadian Cancer Society/National Cancer Institute of Canada. Canadian Cancer Statistics Toronto, Canada, Available at: 20cancer%20statistics/Cancer%20 statistics%20publications.aspx?sc_lang=en. Accessed October 3, International Agency for Research on Cancer. Cancer incidence in five continents. volume VIII. Lyon: IARC, p Parker SL, Davis KJ, Wingo PA, et al. Cancer Am J Health Behav. 2010;34(2):

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