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Having more knowledge of cervical cancer does not increase uptake of screening in Chinese women: Findings from a New Zealand study

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Having more knowledge of cervical cancer does not increase uptake of screening in Chinese women: Findings from a New Zealand study

THE NEW ZEALAND
MEDICAL JOURNAL
Journal of the New Zealand Medical Association
NZMJ 4 July 2008, Vol 121 No 1277; ISSN 1175 8716 Page 106
URL: http://www.nzma.org.nz/journal/121-1277/3154/ ©NZMA
Having more knowledge of cervical cancer does not increase
uptake of screening in Chinese women: findings from a
New Zealand study
The New Zealand National Cervical Screening Programme (NCSP) reported a low
coverage rate of about 45% among Asian women.
1
Little is known about the reasons
for the low coverage. This pilot study examined the knowledge of risk factors of
cervical cancer and its association with the uptake of cancer screening practices in
Chinese women living in Auckland.
The survey was conducted between November 2006 and February 2007. Women were
eligible if they (1) were born in Mainland China; (2) resided in Auckland New
Zealand, and (3) were aged 20 to 69. A community-based survey was conducted with
support from the Chinese New Settlers Services Trust (CNSST) who helped us to
recruit participants via access to their database. Ethics approval was obtained from the
AUT Ethics Committee. Details of the project design and recruitment have been
reported elsewhere.
2
Participants were asked to identify the risk factors of cervical cancer from 12
questions that were provided. A knowledge score was calculated by adding the total
number of correct responses for each participant.
Of the 234 participants, 65% reported ever being screened in New Zealand and 56%
reported they were recently screened in New Zealand. Less than two-thirds (62%)
knew that the purpose of the cervical smear test was to detect abnormal cells that can
develop into cervical cancer.
More than half of the respondents identified the risk factors of being older (75.2%),
having a sexually transmitted disease (62.4%), having multiple sexual partners (59%),
or having sexual activity with a man who has had multiple sexual partners (52.7%).
However, only 42.3% identified the lack of 3-yearly smear tests. Approximately one-
third of participants recognised the following as risk factors: human papillomavirus
infection, smoking, or having intercourse at an early age. Only about one in five
considered that giving birth to many children (20.9%) or using contraceptive pills
(17.1%) put women at higher risk for cervical cancer.
The mean knowledge score of risk factors of cervical cancer was 4.9 (SD 2.8).
Women with qualifications at tertiary level and above and those who could converse
in English had more knowledge than those with secondary or lower levels of
education or those who could not converse in English. One unit increase of
knowledge score, the odds ratio (OR) of ever being screened was 1.05 (95%CI: 0.95–
1.15). The adjusted OR remained non-significant after controlling for
sociodemographic factors (adjusted OR 1.06; 95%CI: 0.96–1.16).
Our findings have significant implications for health promotion and prevention. While
more than half the participants recognised some cervical cancer risk factors associated
with sexual activities such as having a sexually transmitted disease, having multiple
NZMJ 4 July 2008, Vol 121 No 1277; ISSN 1175 8716 Page 107
URL: http://www.nzma.org.nz/journal/121-1277/3154/ ©NZMA
sexual partners, and having sexual activity with a man who has had multiple sexual
partners, it was of concern that the major risk factors (human papillomavirus infection
and not having regular 3-yearly smear tests) were not widely known.
Studies in North America have shown that 72% to 84% Chinese immigrants
recognised the importance of obtaining regular smear tests in reducing a women’s risk
of cervical cancer.
3–4
This knowledge gap could be attributed to a number of factors such as the lack of a
targeted programme for Chinese and other Asian groups in New Zealand and the
previous lack of exposure to an organised population health programme in China for
women from mainland China.
We also found that having more knowledge of cervical cancer did not lead to an
increase in the uptake of cervical cancer screening. This contradicts the results of
other studies in the US general population or Chinese women living in North
America, where greater knowledge of cervical cancer has been associated with
receiving adequate cervical smear testing compared to women with a lower
knowledge of cervical cancer risk factors,
3–-6
but is similar to a South African study.
7
Yu and Rymer argue that women see the smear test as irrelevant in terms of their
behaviour, therefore those who do not perceive themselves to be at risk will see no
reason to go through with the test.
7
Our findings suggest that although women may be
aware of some risk factors for cervical cancer, they may not fully comprehend the
purpose or benefits of routine screening, thus highlighting the importance of
educating Chinese women about the importance of routine smear tests.
A limitation of our study was that only women living in the Auckland regional area
took part and our principal method of recruitment via CNSST networks could have
caused a selection bias. There may also have been measurement error as a result of
using a self-reported assessment of screening. In addition, as a pilot study, our sample
size was small.
Despite these limitations, this study has identified a significant issue which is that the
majority of Chinese women in this study did not recognise the importance of regular
cervical screening to prevent cervical cancer.
Our findings suggest there is a need to educate Chinese women and their families in
order to increase awareness and understanding of cervical cancer and the benefits of
cervical screening as well as increasing the cultural competence of services and staff
to enhance the uptake of cervical cancer screening among their clients.
Acknowledgements: This study was supported by AUT University internal contestable grant 06/183,
and the Chinese New Settlers Services Trust (CNSST) assisted us with recruitment.
In addition we thank the women for participating in the survey and focus group interview, and the
following people and organisations for providing us with invaluable support and useful information: Dr
Debbie Payne (AUT University); Dr Wilson Young (Auckland District Health Board); Dr Kumanan
Rasanathan (Ministry of Health); Ruth Davy and Betty Ling (Women’s Nursing, Education and Health
Promotion); and Jane McEntee, Hazel Lewis, Diane Casey, and Madhumati Chatterji (National
Cervical Screening Programme).
NZMJ 4 July 2008, Vol 121 No 1277; ISSN 1175 8716 Page 108
URL: http://www.nzma.org.nz/journal/121-1277/3154/ ©NZMA
Wanzhen Gao
Biostatistician/Data Manager, Centre for Asian and Migrant Health Research
Ruth DeSouza
Senior Research Fellow/Co-coordinator, Centre for Asian and Migrant Health Research
Janis Paterson
Co-Director, Centre for Asian and Migrant Health Research
Tongjing Lu
Research Assistant, Centre for Asian and Migrant Health Research
National Institute for Public Health and Mental Health Research, Faculty of Health and Environmental
Sciences, AUT University, Auckland
References:
1. Ministry of Health. Cervical screening in New Zealand: A brief statistical review of the first
decade. Wellington: Ministry of Health; 2005.
2. Gao W, Paterson J, Desouza R, Lu T. Demographic predictors of cervical cancer screening in
Chinese women in New Zealand. N Z Med J. 2008;121(1277).
http://www.nzma.org.nz/journal/121-1277/3133
3. Ralston JD, Carey Jackson J, Tu S-P, et al. Knowledge of cervical cancer risk factors among
Chinese immigrants in Seattle. Journal of Community Health. 2003;28(1):41–57.
4. Hislop TG, Teh C, Lai A, et al. Pap screening and knowledge of risk factors for cervical
cancer in Chinese women in British Columbia, Canada. Ethnicity and Health. 2004;9(3):267–
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5. Pearlman DN, Clark MA, Rakowski W, Ehrich B. Screening for breast and cervical cancers:
the importance of knowledge and perceived cancer survivability. Women Health. 1999;28:93–
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6. Mamon JA, Shediac MC, Crosby CB, et al. Inner-city women at risk for cervical cancer:
behavioral and utilization factors related to inadequate screening. Prev Med. 1990; 19:363–76.
7. Yu CKH, Rymer J. Awareness of cervical smear testing and cervical cancer. Contemporary
Reviews in Obstetrics and Gynaecology. 1998;10(2):127–33.
... Although several studies have documented a relationship between knowledge and practice (Ferdous et al, 2014), other researchers argue that people may not put knowledge into practice because they may not know how important such knowledge is (Gao, 2008). The study by Gao (2008), for example, demonstrated that having more knowledge on cervical cancer did not necessarily increase the uptake of screening. ...
... Although several studies have documented a relationship between knowledge and practice (Ferdous et al, 2014), other researchers argue that people may not put knowledge into practice because they may not know how important such knowledge is (Gao, 2008). The study by Gao (2008), for example, demonstrated that having more knowledge on cervical cancer did not necessarily increase the uptake of screening. Further studies exploring factors influencing the transfer of good practice should be conducted so that policies that aim to reduce women's risk of cervical cancer can be implemented. ...
Article
Full-text available
This pilot study examined the cervical cancer screening practices of Chinese women living in Auckland and the association with social demographic factors. A community-based survey was conducted and 234 questionnaires were administrated to ascertain the uptake of cervical screening. Participants were asked whether they had ever been screened in New Zealand and whether it had occurred in the previous 3 years. One hundred and fifty-two (65.0%; 95% CI: 58.5-71.1) respondents reported having been screened in New Zealand and 56.0% (95% CI: 49.4-62.4) reported they were screened in the last 3 years. Factors independently associated with cervical cancer screening practice included age and duration of residence in New Zealand. The most frequently cited reason for never having had a smear test was that "thought it is unnecessary" (39%), followed by "don't know where to go" (36.6%). The uptake of cervical cancer screening is lower among women migrants from Mainland China living in New Zealand than that of the national New Zealand average. In addition, it is lower than that of Chinese women living in North America. The study highlights the information needs of new immigrants and older or younger women.
Article
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Chinese American immigrants are a growing part of the United States population. Cervical cancer is a significant cause of morbidity and mortality among Chinese Americans. Pap smear testing is less common in Chinese American immigrants than in the general population. During 1999, we conducted a community-based survey of Chinese American women living in Seattle. We assessed knowledge of cervical cancer risk factors and history of Pap smear testing along with socioeconomic and acculturation characteristics. The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample included 472 women. Most cervical cancer risk factors were recognized by less than half of our participants. Factors independently associated with knowledge of cervical cancer risk factors included marital status, employment, and education. Respondents with the highest knowledge had greater odds of ever receiving a Pap smear, compared to those respondents with the lowest knowledge (OR 2.5; 95% CI: 1.1,5.8). Our findings suggest a need for increased recognition of cervical cancer risk factors among Chinese American immigrants. Culturally and linguistically appropriate educational interventions for cervical cancer risk factors should be developed, implemented and evaluated.
Article
This study investigated the relationships between health care utilization, knowledge, attitudes, sociodemographic characteristics, and adequacy of cervical cancer screening among a random sample of women from inner-city neighborhoods with high rates of cervical cancer mortality. Of 416 women interviewed, 30.3% reported hysterectomies; women with intact uteri (N = 290) are the subjects of this analysis. Over two-fifths (44.1%) reported not receiving adequate Pap testing during the previous 4 years. Compared with adequately screened women, they were more likely to be 45 years or older, have no medical insurance, report never having been to an obstetrician-gynecologist, recall never having been told by a medical provider how often to get a Pap test, rely on providers for adequate screening, report not seeking care as often as they think they should, have less knowledge of risk factors for cervical cancer, and believe that women should get Pap tests less than yearly. Separate models for younger and older women showed that these factors vary by age, demonstrating the need for interventions to be sensitive to age subgroups. These findings suggest that cancer control activities should place more emphasis on motivating women as well as influencing the health care delivery system to maximize reductions in cervical cancer.
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A cross sectional survey consisting of a questionnaire of 650 randomly selected women aged 15 to 78 years was performed to gain an insight into women's attitudes to and awareness of smear testing and cervical cancer. Their general health and screening history were noted along with their knowledge of the smear test and cervical cancer. Of the respondents, 80.5 per cent had had at least one smear test and 71.5 per cent of these women have regular smears. The majority of the women (66.9 per cent) thought the test 'no problem' and those who found the test 'embarrassing, painful or troublesome' were of a younger age group. Overall, 76.2 per cent perceived the disease to be a common one. 32.6 per cent of the respondents thought the age group 40s to 50s to be most affected by cervical cancer. On the whole, women appeared to be well informed of the link between the number of sexual partners and cervical cancer as well as recognising smoking to be a contributing factor. A substantial proportion (91.7 per cent) of women were of the attitude that cancer can be treated if detected early enough. The perceived barrier such as embarrassment and discomfort played a part in women's decision in returning for a regular smear. By influencing the awareness and perceptions through public health education as well as creating an appropriate environment for the test, this can indeed help to reduce personal perceived barriers and increase the uptake of smear testing.
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This study examines the association between recent screening for breast and cervical cancers, knowledge of cancer risk factors, and perceptions of surviving cancer. Data were from the Cancer Control Supplement to the 1992 National Health Interview Survey (NHIS-CCS). The dependent variable combined breast and cervical cancer screening practices into a single composite index. Two independent variables combined women's knowledge about breast and cervical cancers into single indicators--one representing risk factor knowledge, the other representing perceived likelihood of surviving breast and cervical cancers following early detection. Multivariate analysis showed that recency of screening for both breast and cervical cancers was associated with knowledge of cancer risk factors and perceptions of surviving cancer. Education, household income, and smoking status also were correlates of comprehensive screening. Significant interactions between income and perceived survivability, and between education and perceived survivability suggested that the effects of income and education on comprehensive screening varied with perceptions about surviving cancer. The study suggests that knowledge and attitudinal questions can be combined for two diseases to enhance understanding of who is most likely to be screened comprehensively for breast and cervical cancers. Although national trends show that large percentages of women over age 50 are having mammograms and Pap tests, this progress is not likely to be sustained unless existing barriers are eliminated. Limited knowledge about breast and cervical cancer risk factors and misperceptions about survival from cancer represent two of these barriers.
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Cervical cancer is a significant cause of mortality and morbidity for Chinese Canadian women, due in part to inadequate Pap screening. A community-based survey was conducted involving 528 Chinese immigrant women residing in British Columbia, Canada, in order to identify barriers and facilitators to Pap testing. This paper addresses the relationship between knowledge level about cervical cancer risk factors and Pap screening practices. Female trilingual Chinese interviewers conducted personal at-home interviews about knowledge of cervical cancer risk factors, history of Pap screening, sociodemographic and acculturation factors. The average summary score for knowledge about cervical cancer risk factors was 5.2/10, and knowledge level was significantly associated with the woman's educational level and the gender of the doctor providing usual care. Seventy-four per cent of respondents reported ever having received a Pap test, and 56% reported having received a test within the last two years. Respondents with the highest knowledge were more likely to have ever received a Pap test (OR 6.4, 95% CI: 2.6, 15.9), and to have recently received a test (OR 3.1, 95% CI: 1.4, 6.7). The average knowledge level about cervical cancer risk factors is low in Chinese Canadian women, especially among those with less education and who receive their usual care from a male doctor. Knowledge of these risk factors influences Pap screening behaviour. Culturally and linguistically appropriate education interventions addressing Pap testing and risk factors for cervical cancer are needed in the Canadian Chinese community. Educational resources are also needed for their primary care givers.
Cervical screening in New Zealand: A brief statistical review of the first decade. Wellington: Ministry of Health
  • Ministry
  • Health
Ministry of Health. Cervical screening in New Zealand: A brief statistical review of the first decade. Wellington: Ministry of Health; 2005.