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Cervical screening among immigrant Vietnamese women seen in general practice: current rates, predictors and potential recruitment strategies

Cervical screening among immigrant Vietnamese women seen in general practice: current rates,... Margaret Lesjak Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales rates among Vietnamese women attending Vietnamese-speaking general practitioners (GPs) in Sydney, their recall of opportunistic recruitment by these GPs and their preferences for strategies to encourage screening. Method:Women born in Vietnam aged 1869 years were recruited through the waiting room of their GP and completed questionnaires in either Vietnamese or Chinese before and after their consultation. Results: Of 355 women seen during the survey period, 170 were ineligible. Of those eligible, 118 women (64% response rate) completed waiting room questionnaires. O 86 women ‘at risk, 56 f (65%) reported having a cervical smear within two years or due on that day; 26 (86%)of those 30 women overdue for screening reported visiting a GP at least twice in the past six months. After adjustment for age and education, women who were more acculturated or had resided in Australia for the most years remained significantly more likely to be screened (p0.027 and ~ 0 . 0 3 7 respectively).In the follow-up questionnaire, returned by 49 women (52%) who agreed to receive it, recall of opportunistic advice from the GP was low. Female GPs, free screening and more information in Vietnamese were the three most popular recruitment strategies. Conclusion: Study confirms low participation rates in cervical screening by Vietnamese women using self-report. Recent immigrants and the least acculturated are least likely to be screened. Implications: A community-based strategy involving Vietnamese-speaking GPs shows promise, inviting behavioural evaluation. (AustNZJPubfic Hea/th 1999;23: 168-173) Myna Hua Health Promotion Unit, Central Sydney Area Health Service, New South Wales Jeanette Ward Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales heVietnamese inAustralia are a relatively young immigrant community, arriving after the fall of South Vietnam in 1975. Vietnamese-born people are now the fourth-largest non-English speaking migrant group in Austra1ia.l In NSW, women born in Vietnam have the highest incidence of cervical cancer (agestandardised incidence rate 173; 95% CI 118-244) of the four overseas-born migrant groups who have a higher age-standardised incidence than the Australia born.2 Cervical cancer is also common among Vietnamese women resident in the United States and their participation in screening by Papanicolaou (pap) smear has been shown to be I O W . ~ . ~ What little information is available about Vietnamese immigrant women in Australia also suggests low rates of participation in cervical screening. Data based on self-report from the 1989-90 National Health Survey demonstrated that only 57% of ‘women born in Asia’ ever had had a pap smear.6 Sharan,’ Adamson and Taylor,s and Krasovitsky and Munir’ produced the earliest reports showing that Vietnamese women were the least likely of women from non-English speaking backgrounds to have ever had a pap smear. While not always employing replicable methods, subsequent projects have consistently shown that Vietnamese women are not participating to any great extent in cervical screening.I0-’* Although little is known of the use of general practice by Vietnamese immigrants for general health care, general practitioners (GPs) remain the main providers of cervical screening for Vietnamese women who have ever had a smear. io-’3 The region defined by the geographic boundaries of the Central Sydney Area Health Service (referred to here as Central Sydney) is ideal for ethnic health research because of its high proportion of residents who are overseas-born and speak languages other than English at home.19 The Vietnamese community is the fifthlargest of such groups in Central Sydney, speaking either Vietnamese or Chinese (mostly Cantonese).lg There are some 157,518 women aged 20-69 years in Central Sydney of whom an estimated 3,614 (2%) areVietnam born.19Therate of cervical cancer in Central Sydney is high compared to NSW as a whole.20 Vietnamese-born women represent a key group for recruitment to cervical screening.? We conducted this study to determine prevalence and predictors of cancer screening among Vietnamese women seen in general practice in Central Sydney. We enhanced earlier study designs2?by also assessing the rate of opportunistic re- Submitted: June 1998 Revision requested: October 1998 Accepted: January 1999 Correspondence to: Assoc. Prof. Jeanette Ward, Director, Needs Assessment & Health Outcomes Unit, Locked Bag 8, Newtown, NSW 2042. Fax: +61 2 9515 3334; e-mail: jward@nah.rpa.cs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 2 Cervical screening among immigrant Vietnamese women seen in general practice cruitment by Vietnamese-speaking general practitioners (VSGPs) of women overdue for cervical screening. Given the high incidence of cervical cancer,* we included additional questions to assess Vietntlmese women’s preferences for strategies to encourage their attendance for screening. Survey administration All GPs in Central Sydney offering consultations in Vietnamese were approached about the study involving self-administered surveys in Vietnamese or Chinese of consecutive female Vietnamese patients aged between 18 and 69 years attending their surgeries. If agreed, ML briefed their receptionists about the study requirements. For a specified period, receptionists approached all Vietnamese women to participate in a women’s health study. Receptionists were required to keep tally sheets of ineligible and non-consenting women for this time period. Women were considered ineligible if they were not literate enough in either Chinese or Vietnamese to complete the questionnaire, were too sick or had refused or competed a questionnaire previously. Having completed the questionnaire, consenting women were also asked to provide their name and address for a follow-up questionnaire lo be sent to them within a week of attending the surgery. The follow-up questionnaire was mailed with a reply-paid envelope to enhance return. One follow-up call, by MH, was made to women who had agreed to being sent the second questionnaire but who had not returned it after four weeks. Remaining nonrespondents were sent a second copy of the mailed questionnaire with an accompanying written note of encouragement in Vietnamese by MH to return it. Recruitment of eligible women by receptionists was monitored by ML through personal visits and telephone contact. GP about cervical screening by asking, ‘To the best you can remember, did this doctor ask you when you had your last pap smear?’(‘Yes’ ‘No’ ‘Can’t remember’) then ‘Advise you to have a pap smear?’ (same response sets) and ‘Advise you to make another appointment for a pap smear‘?’ (same response sets). Women were asked to indicate their opinion about two attitudinal statements as follows: ‘Do you think a GP should talk to women about pap smears?’, as well as ‘Do you think your GP should talk to you about pap smears?’. A separate optional section listed 13 potential cervical screening recruitment strategies. Women could respond as follows: ‘Would help a lot’, ‘Would help a little’, ‘Would make no difference’, ‘Already happens’. Using a recognised method,24questionnaires were translated and back-translated into Chinese andVietnamese by independent bilingual professionals and pilot tested outside the study area. Copies in English, Chinese or Vietnamese are available on request. Statistical analysis Demographic characteristics of the sample were compared to the 1996 Census data.” National policy is that all women aged 18 to 70 years who have ever been sexually active have a pap smear every two years.*5 Pap smears may cease for women over 70 if they have had two normal smears in the past five years. After excluding women who reported having had a hysterectomy or were single (a proxy for ever having had sexual intercourse with a male partner in ethnic health research),22those remaining women were defined as ‘at risk’ for cervical cancer. For those women ‘at risk’, we assessed knowledge and calculated selfreported participation in cervical screening. We used logistic regression to determine predictors of a pap smear within two years among those women ‘at risk’ and who knew what a pap smear was. For univariate analysis, we used age (<40 vs. 240 years), education (<I2 years vs. 212 years), years of residence (continuous), health status (good vs. faidpoor), acculturation (continuous) and the number of visits to a GP in the past six months (categorised into < 2 vs. 22 on the basis of cell sizes). The independent variables (age, education, acculturation and years of residence) used for multiple logistic regression were selected on the basis of a review of the literature and/or significance after univariate analysis. Crude and adjusted odds ratios and 95% confidence intervals were calculated from logistic regression analysis using SAS. Questionnairecontent The waiting-room questionnaire commenced with asking nine standard socio-demographic questions, three introductory health questions (not reported here) and two health status questions as follows: ‘In general, would you say your health is excellent, very good, good, fair or poor?’ and ‘At this moment, how would you rate your health?’ (same response sets given). Women were also asked to indicate their reason(s) for attendance from a list of 15 fixed responses. We included a validated eight-item acculturation scale which ‘medium’ categoriscs respondents into three levels: ‘low’ ( 4 ) , (8-10) and ‘high’(>10).23Four questions were asked about cervical scteening, as follows ‘Do you know what a pap smear is?’, ‘When was your last pap smear?’, ‘Who took your last pap smear?’ and ‘Have you had a hysterectomy?’. Results Of the 11 Vietnamese-speaking GPs in Central Sydney, three were excluded, as less than 50% of their patients were Vietnamese. However, all three practised outside the suburb where the majority ofVietnamese in Central Sydney reside. Of the remaining eight, six agreed to participate (75%). The two refusing GPs were both male. Of the six participating GPs, four were male and, except for one with a part-time partner, all were in solo practice. Their ages ranged from 32 to 57 years, with a mean of 44 years Mailed follow-up questionnaire The follow-up questionnaire examined women’s views of opportunistic health discussions by her VSGP. For women known from the waiting room questionnaire to be unscreened and at risk, we assessed their recall of an opportunistic discussion by the 1999 VOL. 23 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Leiak. Hua and Ward Table 1 : Socio-demographic characteristics of 118 Vietnamese women in the sample.” 1996 CensuslBAge 20-39 40-69 Sample Age 20-39 40-69 2,363 1.351 60 48 12 76 19 68 23 21 51 38 31 32 38 and they had practised as a GP for 1-21 years (mean 11 years). Data were collected in December 1997 before the Christmas holiday period and resumed for the first three weeks of January 1998. From tally sheets completed by receptionists, we calculated that 355 women attended during the survey period. Of these, 170 were ineligible (47 were notvietnamese, 37 were outside the age rangt., 30 had refused previously, 26 were accompanying patients, 15 were too sick/forgot glasses, 14 had literacy difficulties and three had already completed a questionnaire) Of 185 eligible women, 118 participated (64% consent ratc) There was no significant difference between the mean age of consenters (41 years) and non-consenters (39 years). The questionnaire was completed by 113 (96%) in Vietnamese and five (4%) in Chinese. Compared to the available Census data, women in the 20-39 age group were under-represented @=0.0089) and women aged 40-69 years were over-represented (p=0.0097) (Table I ) . Among the most commonly cited main reasons for migrating, 52 (46%) respondents had migrated primarily because they were refugees; 42 (37%) migrated to reunite with their families and 1 1 (10%) migrated with their spouse. Family reunion was significantly associated with being a resident of Australia for less than 10 years (family reunion) @=O.OOl, x2 = 16.3,df-I), while refugee status was significantly associated with more than 10 years’ residence in Australia @=O.OOl, xz = 26.4, d p l ) . Six (5%) women had had a hysterectomy and five (three considered to be ‘at risk’ and two not) were visiting the GP for a smear that day. The most common reason for attendance was ‘tiredness’ (n=30,29%) and influenza or head cold (n=19, 18%). While 37 women (36%) had seen no other health professional in the previous six months, a further 36 (35%) had seen another GP; 30 (29%) a specialist; three (3%) hospital casualty; and three (3%) a women’s health nurse. - -- __ Marital status Single Married Widowed/divorced Education 4 2 years 12 years >12 years Years of residency in Australia 4 0 years 10 years plus Acculturation Low ( ~ 8 ) Moderate (8-10) Hiqh (r10) Is this your regular GP? Yes 100 No 12 __ Number of times seen GP in past 6 months None 5 Once 16 2-5 times 61 6-10 times 27 More than 10 times 5 General health status Very good Good Fair Poor Current health status Very good Good Fair Poor Note: *Total number varies where data are missing with item. Knowledge, prevalence and predictors of participation in cervical screening Of all women, 98 (83%) knew what a pap smear was, but there was a significant difference between single (58%) and ever married women (85%) in their knowledge @=0.024, x2=5.08). Of 86 women considered ‘at risk’, only 56 (65%) were considered adequately screened (Table 2).Thirteen ‘at risk’ women (1 5%) said they did not know what a pap smear was. Table 2: Cervical screening status for 86 Vietnamese women ‘at risk’.8*b Last smear 52 vears aao Age 18-39 N Yo Age 40-69 N % Total 53 3 6 ~ _ 5 18 % 62 3 7 _ 6 21 Coming for smear today . >2 years ago 2 3 8 df=4, &=I .4i p o . 8 4 3 -_ - Can’t remember Never __________~ ~~ _ _ _ _ _ ~ Note (a) ‘At risk’excludes women never married and women reporting a hysterectomy (b) Where responses were missing, columns will not add to 100% AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 2 Cervical screening among immigrant Vietnamese women seen in general practice Table 3: Odds ratio of having had a cervical smear within the past two years among at riskVietnamese women who knew what a smear was (n=73). Screening interval <2 years (%) ORa ORb 95%CIc Age 18-39 40-69 40 33 32 41 69 55 24 0.20,1.07 Education 212 years c12 years 0.09,3.10 1.06,2.55 1.01,1.45 -~ ___~~..~_ Acculturation Residence in Australia Health status Good Fair Visits to QP >2 in past 6 months 52 in past 6 months 57 16 68 88 Notes: (a) Unadjusted odds ratio. (b)Adjusted for fhe other variables listed. (c) Confidence inrerval for adjusted odds ratio. Of the 30 unscreened women ‘at risk’, 22 (73%) reported visiting a GP at least twice in the past six months and a further four (l3%), at least six times. Unscreened women were significantly more likely to have made at least 2-5 visits to the GP in the past six months than screened women (73% v 46%) (p=0.048, d p 4 , xz=9.58) After adjustment for variables significantly associated with screening in univariate analyses above, acculturation and years of residency were shown to be significant independent predictors of screening status (Table 3). Women who were most acculturated or had resided longest inAustralia were more likely to be screened @=0.0272, adjusted odds ratio 1.64 andp=0.0373, adjusted odds ratio 1.2 1 respectively). Age did not predict screening status. called an opportunistic discussion about cervical screening. None of these eight women recalled being advised to have a pap smear or make an appointment. Potential recruitment strategies Five of the 49 women (10%) returning the follow-up questionnaire declined to answer the optional section about preferences for recruitment strategies. Table 4 summarises ratings by the remainder in decreasing order. For 11 of the 13 strategies listed, eight or fewer women indicated it already happened. The most popular strategy was access to a female doctor. Discussion Women’s recall of an opportunistic discussion about cervical screening From 94 women (80%) who consented to being sent the follow-up questionnaire, we received 49 replies (52%). Women who returned the questionnaire were more acculturated than those who didn’t (mean score 12.34 vs. 9.46,p<0.05). However, neither the mean period of residence in Australia (nine years) nor age mean (mean 44 vs. 41 years) were significantly different. Screening status of those women ‘at risk’ was not associated with likelihood of returning the follow-up questionnaire (p=O. 109). Forty-five women (92%) said that their GP should discuss pap smears with them and 43 (88%) thought that a women of their age should have a pap smear. After excluding three women who had returned the follow-up questionnaire and who had also attended for a cervical smear, we examined replies from the remaining 46 to assess opportunistic approaches to cervical screening. Twenty-one of these 46 (46%) recalled that their GP had initiated a discussion about cervical smears. However, of eight women who were ‘at risk’ and unscreened at the time of the consultation, only three (38%) re1999 VOL. 23 NO.2 While there has been increasing attention focused on participation by immigrant Vietnamese women in population-based cervical screening,*’ no studies published to date have employed replicable sampling strategies and quantified participation by women ‘at risk’ in cervical screening and elicited ranked preferences for recruitment strategies. We recognise the potential limitation for community representativeness of our method which surveyed women seen in general practice, but balance this against the representativeness of GPbased surveys for the English-speaking majority,26the feasibility of data collection and the socio-demographic characteristics of participating women. Our waiting room survey resulted in bias towards older women, typically an under-screened group, while the follow-up questionnaire was more likely completed by acculturated women. Using self-administered questionnaires, our study confirms low rates of participation in cervical screening by immigrant Vietnamese women, even acknowledging the biases of self-report among non-Engli~h-speakers.*~ General practice-based studies typically find self-reported AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Lejak, Hua and Ward Table 4: Respondents' ratings of 13 potential recruitment strategies (n=44). Would help a lot Strategy Could see a female doctor for the smear ____ - __ -Medicare paid for smear - .. _ _ ~ _ _ - - . More information about pap smears in Vietnamese An interpreter was available with a female doctor Pap smear provider spoke Vietnamese Would help a little Make no difference ~~- Already happens __ -- I had a reminder from the Pap Test Registry There was a special clinic at the practice GP reminded me even if saw GP for something else Go to a special Women's Health Clinic ___ ~- My GP wasn't so busy ~~ My regular GP had a female nurse who did pap smears . .~ Could see a female nurse for the smear There was a clinic at work participation in biennial cervical screening as high as 85%.28Using cytology registry data, however, the rate for NSW was only 57.3'10 for the biennial period ending July 31, 1998, and 55% for Central Sydney.2' This suggests our data are valid. We also believe ours is a timely Australian study to demonstrate independent predictors of Vietnamese women's screening status, permitting more efficient targeting. Vietnam has no organised cervical screening program.30Our findings suggest that public health efforts in Australia must focus on Vietnamese women who have recently immigrated and those least acculturated. Increasing age appears to be less useful as an association of under-screening in this ethnic community. While the rate of opportunistic recruitment by Vietnamese-speaking GPs for cervical screening as estimated in our study appears to be low, it is comparable with other Australian GP research.28 To realise the full population benefit from cervical screening, recruitment remains the greatest challenge.3i As in other aspects of ethnic health research,I2there has been insufficient research to identify culturally appropriate ways to promote cervical screening among ethnic minority groups. It is exceptional to find rigorous evaluation of specific initiatives using objective measures of participation in screening, such as data collected by cytology registers and controlled designs.33In Queensland, personalised .~~ letters in Vietnamese have been shown to be i n e f f e ~ t i v e Recruitment initiatives reported to date with Vietnamese communities in NSW have added little to our knowledge of effective strategies. One" involved community education and anotheri2used a media campaign in combination with education and referral to special cervical screening clinics staffed by nurses at various health centres. Neither involved GPs directly. One promising recruitment initiative in South Australia is targeting Vietnamese women by involving six male Vietnamesespeaking GPs in medical record audit, establishment of recall systems and, more recently, collaboration with avietnamese community nurse who offers pap smear clinics at their surgeries.35 Preferences of women surveyed in our study suggest such a com172 bination of strategies will likely succeed. Preferences of unscreened women for female providers,36 as also suggested by our findings, ought to be tested empirically in interventional research. In addition to evaluating ways to improve access to female providers and promote bulk-billing, those responsible for recruitment programs also might consider the high level of interest for more information about cervical screening in Vietnamese. Given the level of acculturation among the key target group and their low rates of English literacy,j7 culturally sensitive resources which address specific health beliefs among the non-acculturated will be necessary. GPs are an important source of health information for Vietnamese women.12,i3,38 recommend further collaboraWe tion with Vietnamese GPs in the design and conduct of interventional trials, especially to evaluate opportunistic recruitment when prompted by distribution of such culturally specific material by GPs during routine health visits. Acknowledgments We thank the general practitioners, their receptionists and patients for their participation: Professor Michael Mira and Associate Professor Lindsay Thompson for the support of the two GP Divisions; and Qiming Zhong for the Chinese translation. The Royal Prince Alfred Hospital Ethics Committee approved the protocol in December 1997. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Cervical screening among immigrant Vietnamese women seen in general practice: current rates, predictors and potential recruitment strategies

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Publisher
Wiley
Copyright
Copyright © 1999 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1999.tb01229.x
Publisher site
See Article on Publisher Site

Abstract

Margaret Lesjak Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales rates among Vietnamese women attending Vietnamese-speaking general practitioners (GPs) in Sydney, their recall of opportunistic recruitment by these GPs and their preferences for strategies to encourage screening. Method:Women born in Vietnam aged 1869 years were recruited through the waiting room of their GP and completed questionnaires in either Vietnamese or Chinese before and after their consultation. Results: Of 355 women seen during the survey period, 170 were ineligible. Of those eligible, 118 women (64% response rate) completed waiting room questionnaires. O 86 women ‘at risk, 56 f (65%) reported having a cervical smear within two years or due on that day; 26 (86%)of those 30 women overdue for screening reported visiting a GP at least twice in the past six months. After adjustment for age and education, women who were more acculturated or had resided in Australia for the most years remained significantly more likely to be screened (p0.027 and ~ 0 . 0 3 7 respectively).In the follow-up questionnaire, returned by 49 women (52%) who agreed to receive it, recall of opportunistic advice from the GP was low. Female GPs, free screening and more information in Vietnamese were the three most popular recruitment strategies. Conclusion: Study confirms low participation rates in cervical screening by Vietnamese women using self-report. Recent immigrants and the least acculturated are least likely to be screened. Implications: A community-based strategy involving Vietnamese-speaking GPs shows promise, inviting behavioural evaluation. (AustNZJPubfic Hea/th 1999;23: 168-173) Myna Hua Health Promotion Unit, Central Sydney Area Health Service, New South Wales Jeanette Ward Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, New South Wales heVietnamese inAustralia are a relatively young immigrant community, arriving after the fall of South Vietnam in 1975. Vietnamese-born people are now the fourth-largest non-English speaking migrant group in Austra1ia.l In NSW, women born in Vietnam have the highest incidence of cervical cancer (agestandardised incidence rate 173; 95% CI 118-244) of the four overseas-born migrant groups who have a higher age-standardised incidence than the Australia born.2 Cervical cancer is also common among Vietnamese women resident in the United States and their participation in screening by Papanicolaou (pap) smear has been shown to be I O W . ~ . ~ What little information is available about Vietnamese immigrant women in Australia also suggests low rates of participation in cervical screening. Data based on self-report from the 1989-90 National Health Survey demonstrated that only 57% of ‘women born in Asia’ ever had had a pap smear.6 Sharan,’ Adamson and Taylor,s and Krasovitsky and Munir’ produced the earliest reports showing that Vietnamese women were the least likely of women from non-English speaking backgrounds to have ever had a pap smear. While not always employing replicable methods, subsequent projects have consistently shown that Vietnamese women are not participating to any great extent in cervical screening.I0-’* Although little is known of the use of general practice by Vietnamese immigrants for general health care, general practitioners (GPs) remain the main providers of cervical screening for Vietnamese women who have ever had a smear. io-’3 The region defined by the geographic boundaries of the Central Sydney Area Health Service (referred to here as Central Sydney) is ideal for ethnic health research because of its high proportion of residents who are overseas-born and speak languages other than English at home.19 The Vietnamese community is the fifthlargest of such groups in Central Sydney, speaking either Vietnamese or Chinese (mostly Cantonese).lg There are some 157,518 women aged 20-69 years in Central Sydney of whom an estimated 3,614 (2%) areVietnam born.19Therate of cervical cancer in Central Sydney is high compared to NSW as a whole.20 Vietnamese-born women represent a key group for recruitment to cervical screening.? We conducted this study to determine prevalence and predictors of cancer screening among Vietnamese women seen in general practice in Central Sydney. We enhanced earlier study designs2?by also assessing the rate of opportunistic re- Submitted: June 1998 Revision requested: October 1998 Accepted: January 1999 Correspondence to: Assoc. Prof. Jeanette Ward, Director, Needs Assessment & Health Outcomes Unit, Locked Bag 8, Newtown, NSW 2042. Fax: +61 2 9515 3334; e-mail: jward@nah.rpa.cs.nsw.gov.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 2 Cervical screening among immigrant Vietnamese women seen in general practice cruitment by Vietnamese-speaking general practitioners (VSGPs) of women overdue for cervical screening. Given the high incidence of cervical cancer,* we included additional questions to assess Vietntlmese women’s preferences for strategies to encourage their attendance for screening. Survey administration All GPs in Central Sydney offering consultations in Vietnamese were approached about the study involving self-administered surveys in Vietnamese or Chinese of consecutive female Vietnamese patients aged between 18 and 69 years attending their surgeries. If agreed, ML briefed their receptionists about the study requirements. For a specified period, receptionists approached all Vietnamese women to participate in a women’s health study. Receptionists were required to keep tally sheets of ineligible and non-consenting women for this time period. Women were considered ineligible if they were not literate enough in either Chinese or Vietnamese to complete the questionnaire, were too sick or had refused or competed a questionnaire previously. Having completed the questionnaire, consenting women were also asked to provide their name and address for a follow-up questionnaire lo be sent to them within a week of attending the surgery. The follow-up questionnaire was mailed with a reply-paid envelope to enhance return. One follow-up call, by MH, was made to women who had agreed to being sent the second questionnaire but who had not returned it after four weeks. Remaining nonrespondents were sent a second copy of the mailed questionnaire with an accompanying written note of encouragement in Vietnamese by MH to return it. Recruitment of eligible women by receptionists was monitored by ML through personal visits and telephone contact. GP about cervical screening by asking, ‘To the best you can remember, did this doctor ask you when you had your last pap smear?’(‘Yes’ ‘No’ ‘Can’t remember’) then ‘Advise you to have a pap smear?’ (same response sets) and ‘Advise you to make another appointment for a pap smear‘?’ (same response sets). Women were asked to indicate their opinion about two attitudinal statements as follows: ‘Do you think a GP should talk to women about pap smears?’, as well as ‘Do you think your GP should talk to you about pap smears?’. A separate optional section listed 13 potential cervical screening recruitment strategies. Women could respond as follows: ‘Would help a lot’, ‘Would help a little’, ‘Would make no difference’, ‘Already happens’. Using a recognised method,24questionnaires were translated and back-translated into Chinese andVietnamese by independent bilingual professionals and pilot tested outside the study area. Copies in English, Chinese or Vietnamese are available on request. Statistical analysis Demographic characteristics of the sample were compared to the 1996 Census data.” National policy is that all women aged 18 to 70 years who have ever been sexually active have a pap smear every two years.*5 Pap smears may cease for women over 70 if they have had two normal smears in the past five years. After excluding women who reported having had a hysterectomy or were single (a proxy for ever having had sexual intercourse with a male partner in ethnic health research),22those remaining women were defined as ‘at risk’ for cervical cancer. For those women ‘at risk’, we assessed knowledge and calculated selfreported participation in cervical screening. We used logistic regression to determine predictors of a pap smear within two years among those women ‘at risk’ and who knew what a pap smear was. For univariate analysis, we used age (<40 vs. 240 years), education (<I2 years vs. 212 years), years of residence (continuous), health status (good vs. faidpoor), acculturation (continuous) and the number of visits to a GP in the past six months (categorised into < 2 vs. 22 on the basis of cell sizes). The independent variables (age, education, acculturation and years of residence) used for multiple logistic regression were selected on the basis of a review of the literature and/or significance after univariate analysis. Crude and adjusted odds ratios and 95% confidence intervals were calculated from logistic regression analysis using SAS. Questionnairecontent The waiting-room questionnaire commenced with asking nine standard socio-demographic questions, three introductory health questions (not reported here) and two health status questions as follows: ‘In general, would you say your health is excellent, very good, good, fair or poor?’ and ‘At this moment, how would you rate your health?’ (same response sets given). Women were also asked to indicate their reason(s) for attendance from a list of 15 fixed responses. We included a validated eight-item acculturation scale which ‘medium’ categoriscs respondents into three levels: ‘low’ ( 4 ) , (8-10) and ‘high’(>10).23Four questions were asked about cervical scteening, as follows ‘Do you know what a pap smear is?’, ‘When was your last pap smear?’, ‘Who took your last pap smear?’ and ‘Have you had a hysterectomy?’. Results Of the 11 Vietnamese-speaking GPs in Central Sydney, three were excluded, as less than 50% of their patients were Vietnamese. However, all three practised outside the suburb where the majority ofVietnamese in Central Sydney reside. Of the remaining eight, six agreed to participate (75%). The two refusing GPs were both male. Of the six participating GPs, four were male and, except for one with a part-time partner, all were in solo practice. Their ages ranged from 32 to 57 years, with a mean of 44 years Mailed follow-up questionnaire The follow-up questionnaire examined women’s views of opportunistic health discussions by her VSGP. For women known from the waiting room questionnaire to be unscreened and at risk, we assessed their recall of an opportunistic discussion by the 1999 VOL. 23 NO. 2 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Leiak. Hua and Ward Table 1 : Socio-demographic characteristics of 118 Vietnamese women in the sample.” 1996 CensuslBAge 20-39 40-69 Sample Age 20-39 40-69 2,363 1.351 60 48 12 76 19 68 23 21 51 38 31 32 38 and they had practised as a GP for 1-21 years (mean 11 years). Data were collected in December 1997 before the Christmas holiday period and resumed for the first three weeks of January 1998. From tally sheets completed by receptionists, we calculated that 355 women attended during the survey period. Of these, 170 were ineligible (47 were notvietnamese, 37 were outside the age rangt., 30 had refused previously, 26 were accompanying patients, 15 were too sick/forgot glasses, 14 had literacy difficulties and three had already completed a questionnaire) Of 185 eligible women, 118 participated (64% consent ratc) There was no significant difference between the mean age of consenters (41 years) and non-consenters (39 years). The questionnaire was completed by 113 (96%) in Vietnamese and five (4%) in Chinese. Compared to the available Census data, women in the 20-39 age group were under-represented @=0.0089) and women aged 40-69 years were over-represented (p=0.0097) (Table I ) . Among the most commonly cited main reasons for migrating, 52 (46%) respondents had migrated primarily because they were refugees; 42 (37%) migrated to reunite with their families and 1 1 (10%) migrated with their spouse. Family reunion was significantly associated with being a resident of Australia for less than 10 years (family reunion) @=O.OOl, x2 = 16.3,df-I), while refugee status was significantly associated with more than 10 years’ residence in Australia @=O.OOl, xz = 26.4, d p l ) . Six (5%) women had had a hysterectomy and five (three considered to be ‘at risk’ and two not) were visiting the GP for a smear that day. The most common reason for attendance was ‘tiredness’ (n=30,29%) and influenza or head cold (n=19, 18%). While 37 women (36%) had seen no other health professional in the previous six months, a further 36 (35%) had seen another GP; 30 (29%) a specialist; three (3%) hospital casualty; and three (3%) a women’s health nurse. - -- __ Marital status Single Married Widowed/divorced Education 4 2 years 12 years >12 years Years of residency in Australia 4 0 years 10 years plus Acculturation Low ( ~ 8 ) Moderate (8-10) Hiqh (r10) Is this your regular GP? Yes 100 No 12 __ Number of times seen GP in past 6 months None 5 Once 16 2-5 times 61 6-10 times 27 More than 10 times 5 General health status Very good Good Fair Poor Current health status Very good Good Fair Poor Note: *Total number varies where data are missing with item. Knowledge, prevalence and predictors of participation in cervical screening Of all women, 98 (83%) knew what a pap smear was, but there was a significant difference between single (58%) and ever married women (85%) in their knowledge @=0.024, x2=5.08). Of 86 women considered ‘at risk’, only 56 (65%) were considered adequately screened (Table 2).Thirteen ‘at risk’ women (1 5%) said they did not know what a pap smear was. Table 2: Cervical screening status for 86 Vietnamese women ‘at risk’.8*b Last smear 52 vears aao Age 18-39 N Yo Age 40-69 N % Total 53 3 6 ~ _ 5 18 % 62 3 7 _ 6 21 Coming for smear today . >2 years ago 2 3 8 df=4, &=I .4i p o . 8 4 3 -_ - Can’t remember Never __________~ ~~ _ _ _ _ _ ~ Note (a) ‘At risk’excludes women never married and women reporting a hysterectomy (b) Where responses were missing, columns will not add to 100% AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 2 Cervical screening among immigrant Vietnamese women seen in general practice Table 3: Odds ratio of having had a cervical smear within the past two years among at riskVietnamese women who knew what a smear was (n=73). Screening interval <2 years (%) ORa ORb 95%CIc Age 18-39 40-69 40 33 32 41 69 55 24 0.20,1.07 Education 212 years c12 years 0.09,3.10 1.06,2.55 1.01,1.45 -~ ___~~..~_ Acculturation Residence in Australia Health status Good Fair Visits to QP >2 in past 6 months 52 in past 6 months 57 16 68 88 Notes: (a) Unadjusted odds ratio. (b)Adjusted for fhe other variables listed. (c) Confidence inrerval for adjusted odds ratio. Of the 30 unscreened women ‘at risk’, 22 (73%) reported visiting a GP at least twice in the past six months and a further four (l3%), at least six times. Unscreened women were significantly more likely to have made at least 2-5 visits to the GP in the past six months than screened women (73% v 46%) (p=0.048, d p 4 , xz=9.58) After adjustment for variables significantly associated with screening in univariate analyses above, acculturation and years of residency were shown to be significant independent predictors of screening status (Table 3). Women who were most acculturated or had resided longest inAustralia were more likely to be screened @=0.0272, adjusted odds ratio 1.64 andp=0.0373, adjusted odds ratio 1.2 1 respectively). Age did not predict screening status. called an opportunistic discussion about cervical screening. None of these eight women recalled being advised to have a pap smear or make an appointment. Potential recruitment strategies Five of the 49 women (10%) returning the follow-up questionnaire declined to answer the optional section about preferences for recruitment strategies. Table 4 summarises ratings by the remainder in decreasing order. For 11 of the 13 strategies listed, eight or fewer women indicated it already happened. The most popular strategy was access to a female doctor. Discussion Women’s recall of an opportunistic discussion about cervical screening From 94 women (80%) who consented to being sent the follow-up questionnaire, we received 49 replies (52%). Women who returned the questionnaire were more acculturated than those who didn’t (mean score 12.34 vs. 9.46,p<0.05). However, neither the mean period of residence in Australia (nine years) nor age mean (mean 44 vs. 41 years) were significantly different. Screening status of those women ‘at risk’ was not associated with likelihood of returning the follow-up questionnaire (p=O. 109). Forty-five women (92%) said that their GP should discuss pap smears with them and 43 (88%) thought that a women of their age should have a pap smear. After excluding three women who had returned the follow-up questionnaire and who had also attended for a cervical smear, we examined replies from the remaining 46 to assess opportunistic approaches to cervical screening. Twenty-one of these 46 (46%) recalled that their GP had initiated a discussion about cervical smears. However, of eight women who were ‘at risk’ and unscreened at the time of the consultation, only three (38%) re1999 VOL. 23 NO.2 While there has been increasing attention focused on participation by immigrant Vietnamese women in population-based cervical screening,*’ no studies published to date have employed replicable sampling strategies and quantified participation by women ‘at risk’ in cervical screening and elicited ranked preferences for recruitment strategies. We recognise the potential limitation for community representativeness of our method which surveyed women seen in general practice, but balance this against the representativeness of GPbased surveys for the English-speaking majority,26the feasibility of data collection and the socio-demographic characteristics of participating women. Our waiting room survey resulted in bias towards older women, typically an under-screened group, while the follow-up questionnaire was more likely completed by acculturated women. Using self-administered questionnaires, our study confirms low rates of participation in cervical screening by immigrant Vietnamese women, even acknowledging the biases of self-report among non-Engli~h-speakers.*~ General practice-based studies typically find self-reported AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Lejak, Hua and Ward Table 4: Respondents' ratings of 13 potential recruitment strategies (n=44). Would help a lot Strategy Could see a female doctor for the smear ____ - __ -Medicare paid for smear - .. _ _ ~ _ _ - - . More information about pap smears in Vietnamese An interpreter was available with a female doctor Pap smear provider spoke Vietnamese Would help a little Make no difference ~~- Already happens __ -- I had a reminder from the Pap Test Registry There was a special clinic at the practice GP reminded me even if saw GP for something else Go to a special Women's Health Clinic ___ ~- My GP wasn't so busy ~~ My regular GP had a female nurse who did pap smears . .~ Could see a female nurse for the smear There was a clinic at work participation in biennial cervical screening as high as 85%.28Using cytology registry data, however, the rate for NSW was only 57.3'10 for the biennial period ending July 31, 1998, and 55% for Central Sydney.2' This suggests our data are valid. We also believe ours is a timely Australian study to demonstrate independent predictors of Vietnamese women's screening status, permitting more efficient targeting. Vietnam has no organised cervical screening program.30Our findings suggest that public health efforts in Australia must focus on Vietnamese women who have recently immigrated and those least acculturated. Increasing age appears to be less useful as an association of under-screening in this ethnic community. While the rate of opportunistic recruitment by Vietnamese-speaking GPs for cervical screening as estimated in our study appears to be low, it is comparable with other Australian GP research.28 To realise the full population benefit from cervical screening, recruitment remains the greatest challenge.3i As in other aspects of ethnic health research,I2there has been insufficient research to identify culturally appropriate ways to promote cervical screening among ethnic minority groups. It is exceptional to find rigorous evaluation of specific initiatives using objective measures of participation in screening, such as data collected by cytology registers and controlled designs.33In Queensland, personalised .~~ letters in Vietnamese have been shown to be i n e f f e ~ t i v e Recruitment initiatives reported to date with Vietnamese communities in NSW have added little to our knowledge of effective strategies. One" involved community education and anotheri2used a media campaign in combination with education and referral to special cervical screening clinics staffed by nurses at various health centres. Neither involved GPs directly. One promising recruitment initiative in South Australia is targeting Vietnamese women by involving six male Vietnamesespeaking GPs in medical record audit, establishment of recall systems and, more recently, collaboration with avietnamese community nurse who offers pap smear clinics at their surgeries.35 Preferences of women surveyed in our study suggest such a com172 bination of strategies will likely succeed. Preferences of unscreened women for female providers,36 as also suggested by our findings, ought to be tested empirically in interventional research. In addition to evaluating ways to improve access to female providers and promote bulk-billing, those responsible for recruitment programs also might consider the high level of interest for more information about cervical screening in Vietnamese. Given the level of acculturation among the key target group and their low rates of English literacy,j7 culturally sensitive resources which address specific health beliefs among the non-acculturated will be necessary. GPs are an important source of health information for Vietnamese women.12,i3,38 recommend further collaboraWe tion with Vietnamese GPs in the design and conduct of interventional trials, especially to evaluate opportunistic recruitment when prompted by distribution of such culturally specific material by GPs during routine health visits. Acknowledgments We thank the general practitioners, their receptionists and patients for their participation: Professor Michael Mira and Associate Professor Lindsay Thompson for the support of the two GP Divisions; and Qiming Zhong for the Chinese translation. The Royal Prince Alfred Hospital Ethics Committee approved the protocol in December 1997.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Apr 1, 1999

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