Cervical Cancer Screening Experiences Among Chinese American Immigrant Women in the United States

Abstract

Objective

To understand the experiences and perceptions of having cervical cancer screening tests and to explore the extant barriers to having the tests among first-generation Chinese American women in the United States.

Design

Qualitative, descriptive, phenomenological research.

Setting

Los Angeles, California.

Participants

Snowball and purposive sampling of 12 Chinese American immigrant women ages 20 to 65 years.

Methods

Individual face-to-face, in-depth, semistructured interviews in which participants were asked about their experiences and perceptions about cervical cancer screening. Interviews were audiotaped, transcribed, and translated into English. Data analysis included comparing and distinguishing, collecting and counting, and presupposing and inferring.

Results

Through the analysis process, we identified four major themes that reflected the experiences, perceptions, and barriers to having cervical cancer screening among Chinese American women: Belief in a Healthy Lifestyle, Maintaining Privacy for Female Health Problems, Fear of Losing Control, and Feeling Vulnerable in an Unfamiliar Health Care System. These themes indicated that Chinese immigrant women in the United States face challenges to their cultural health beliefs and practices with regard to decision-making and health-seeking behaviors related to cervical cancer screening. They felt more vulnerable as immigrants because of systematic barriers to navigation of the unfamiliar health care system and limited resources.

Conclusion

Women’s health care providers should be aware of and give consideration to cultural differences through the provision of more educational information and comfort to Chinese immigrant women who seek cervical cancer screening. Ultimately, the development of culturally appropriate and affordable cancer prevention programs with effective strategies is important to ease Chinese American women’s senses of vulnerability.

Cervical cancer was the most common cause of cancer death for women in the United States in the 1950s and now accounts for only 0.7% of all cancer deaths among women (National Cancer Institute, 2017). Human papillomavirus (HPV) infection has been established as the leading cause of cervical cancer (Bao, Li, Smith, & Qiao, 2008). High-quality screening with cytology (Papanicolaou [Pap] testing), which is used to detect premalignant and malignant cells within the cervix before abnormal cells progress to invasive carcinoma, is a standard test for cervical cancer and has dramatically reduced the incidence of death from cervical cancer (Centers for Disease Control and Prevention [CDC], 2014). In addition, the detection of the most common HPV types in cervical cancer has made it possible to develop new HPV screening methods and vaccines (Bao et al., 2008). The U.S. Preventive Services Task Force (2012) and the American Cancer Society (2016) released similar guidelines recently for cervical cancer screening. A routine Pap test is recommended every 3 years for all women ages 21 to 65 years, and the screening interval can be extended to every 5 years when combined with HPV testing for women ages 30 to 65 years. More intensive screening is recommended for women with a greater risk of cervical cancer (Saslow et al., 2012; U.S. Preventive Services Task Force, 2012). Although there have been significant decreases in rates of cervical cancer diagnosis and mortality, screening rates vary greatly among ethnic populations in the United States (Moyer, 2012).

For several decades, Asian American women have consistently reported the lowest cervical screening rates among all ethnic groups in the United States (CDC, 2015). In 2013, this rate among Asian women 18 years and older was 66.9%, compared with 73.8% to 77.4% for non-Asian women in the United States (CDC, 2015). In 2007, the California Health Interview Survey showed that the cervical screening rates within 3 years among Asians and Chinese Americans were 77.5% and 80.8%, respectively (Chawla, Breen, Liu, Lee, & Kagawa-Singer, 2015). This was far less than the Healthy People 2020 goal of 93% for Pap testing among women within the past 3 years (Office of Disease Prevention and Health Promotion, 2017). Low rates of cervical cancer screening within this group are cause for concern because Asian Americans compose one of the fastest-growing ethnic groups in the country. The estimated number of Asian Americans in 2014 was 20.3 million, which represented 6.2% of the total population, and Chinese Americans were the largest ethnic group among them at 4.5 million (U.S. Census Bureau, 2016). Low rates of cervical cancer screening among Chinese American women were reported in Rhode Island (Robison et al., 2014); New Jersey and New York (Ma, Wang, et al., 2013); and Portland, Oregon (Lee-Lin et al., 2007). Without routine screening, there is no opportunity for early detection, which contributes to the greater incidence of and mortality from cervical cancer among Chinese American women than in the general U.S. population (Taylor et al., 2002).

For several decades, Asian American women have consistently reported the lowest cervical cancer screening rates among all ethnic and racial groups in the United States.

Literature Review

Researchers have tried to identify barriers and facilitators to cervical cancer screening among Asian Americans in a number of studies (Chawla et al., 2015; Fang, Ma, & Tan, 2011; Pourat, Kagawa-Singer, Breen, & Sripipatana, 2010). Multiple factors such as age, education, socioeconomic status, marital status, sexual behavior, and gender of the health care providers affected participation in cervical cancer screening of Chinese American women (Ji, Chen, Sun, & Liang, 2010; Menvielle, Richard, Ringa, Dray-Spira, & Beck, 2014). Chinese American women who were older, had less education, or were from lower socioeconomic groups participated least in cervical cancer screening (Ma, Gao, et al., 2013). Cheung, Li, and Tang (2011) also found that Chinese Australian women with limited English language abilities who were unemployed and had short immigration histories were less likely to have had a recent Pap test. Cultural factors, such as embarrassment and modesty, were considered as barriers to having a Pap test among Chinese Canadian women (Redwood-Campbell, Fowler, & Laryea, 2011).

Knowledge and education about cervical cancer screening were potential factors that influenced the likelihood of screening among a sample of 472 Chinese American women (Ralston et al., 2003). The lack of knowledge about risk factors including the role of HPV infection in the development of cervical cancer and a misunderstanding of the purpose of screening were negatively associated with the likelihood of being screened (Wang, Lam, Wu, & Fielding, 2014). Because HPV vaccines were not available in mainland China until 2016 (Zhao, 2017), Chinese women usually did not have the opportunity to be vaccinated before immigration. In a cross-sectional study conducted in Pennsylvania, researchers reported that only about 19% of Chinese American women had ever heard of HPV and HPV vaccines (Nguyen, Chen, & Chan, 2012). Chinese American women also reported lack of knowledge about current cervical cancer screening guidelines (Ji et al., 2010). In a survey of Chinese immigrants in Rhode Island, more than 25% of participants never had Pap tests or did not know if they had ever had the test (Robison et al., 2014). Because of limited awareness of HPV and knowledge about the necessity of cervical cancer screening, education and an invitation from a health care provider were the most effective ways to increase cervical cancer screening (Everett et al., 2011; Seo, Bae, & Dickerson, 2016; Yoo, Le, Vong, Lagman, & Lam, 2011).

The health problems of Asian Americans and their use of health services are understudied (Seo et al., 2016). Furthermore, knowledge of how to use health services in the United States requires understanding of the complexities. Even though Asian women in the United States share some commonalities, researchers consistently report great diversity in demographic and socioeconomic characteristics of Asian immigrants and clear ethnic differences with regard to their use of health services (Hsiao et al., 2006; Kim & Keefe, 2010; Yoo et al., 2011). More importantly, examination of survey questionnaires or extant numeric data may not be enough to capture the complexities of the health determinants and disparities experienced by marginalized ethnic minorities in the United States. Therefore, understanding the unique experiences related to perceptions of and obstacles to cervical cancer screening for Chinese immigrant women may inform strategies to improve the rate of cervical cancer screening and ultimately facilitate the early detection and treatment of cervical cancer among Chinese American women. The purpose of our study was to understand the experiences and perceptions related to cervical cancer screening and to explore perceived barriers to being screened in first-generation Chinese American women in the United States.

Methods

We designed our study to be consistent with the philosophical underpinnings of Husserl’s ideas and concepts, which led to the descriptive phenomenological approach to inquiry (Lopez & Willis, 2004). Phenomenology focuses on the activities of consciousness and how objects appear to consciousness (Giorgi, 2012). In addition, phenomenology is used to investigate the relationship between consciousness and world (Giorgi, 2012). Husserl’s philosophic approach is described as descriptive to articulate “the intentional objects of experience” and how human consciousness relates to a specific human world (Giorgi, 2012, p. 6). We attempted to describe Chinese immigrant women’s perceptions about cervical cancer screening through a phenomenological lens (Bernard, 2006).

Setting and Sample

We used snowball and purposive sampling to recruit a sample of Chinese American women in Los Angeles, California. The inclusion criteria for this study were as follows: ages 20 to 65 years, spoke English or Mandarin, and had no personal history of gynecologic cancer or hysterectomy. Recruitment was started after we obtained approval from the California State University, Northridge Institutional Review Board. Flyers with information about the study and a request for participants were posted in Chinese American churches and clubs in Los Angeles. Interested potential participants were given detailed information about the study and were guided through the informed consent process. All participants received information about their right to withdraw at any time without suffering any disadvantages. They were reassured that the information they provided in the interview would remain confidential and that their identities would not be linked to their comments (Rosedale & Fu, 2010). Pseudonyms were used to report the study findings.

Consented participants were encouraged to refer other women who might be interested in participation. Saturation of the data is reached when similar data emerge or participants repeat each other in their descriptions of their feelings and experiences (Fu & Rosedale, 2009). Strong similarities in our data emerged after the 10th interview. Two extra participants were recruited and interviewed to ensure that any additional information was not missed. No new information was gathered in the interviews of these two participants.

Data Collection and Analysis

One author conducted individual face-to-face, in-depth, semistructured interviews with the 12 participants. Each participant chose the site for the interview, which was the participant’s home or the research team’s office; only the participant and the interviewer were present during the interview. After the informed consent process, participants were asked to complete demographic questionnaires with queries about their age, education, income, immigration time, histories of Pap and HPV tests, and whether they had cervical cancer screening tests regularly. The interview guide with open-ended questions was used to assess the participants’ beliefs and feelings on previous cervical cancer screening experiences and cultural influences on their decisions regarding cervical cancer screening (see Table 1). Each interview lasted 40 to 60 minutes and was recorded with a digital recorder. All the interviews were transcribed and checked for accuracy by research team members. Among the 12 participants, 11 preferred to be interviewed in English, but they often used Chinese words for cultural or medical terminology during the interviews. One participant mixed Mandarin sentences with English throughout the interview. Mandarin sentences in the interview were translated by a bilingual Chinese researcher and verified by a bilingual female Chinese nursing student.

Table 1.

Interview Questions

1	What is your perception of health?
2	What do you do to protect your health?
	How do you protect yourself from disease?
3	Do you have an annual physical exam?
	When was the last time you went to see a doctor?
	How about women’s health care?
4	Do you know anything about cervical cancer?
	Do you know any risk factors for cervical cancer?
	What do you know about HPV?
5	Do you have regular Pap smears?
	When did you begin to have Pap smears?
	What do you know about Pap smears?
6	Could you share with me your experiences when you have had Pap smears?
	What do you feel during the Pap smear?

Note. exam = examination; Pap smear = Papanicolaou test.

Phenomenological reduction (Giorgi, 2012) and strategies of comparing and distinguishing, collecting and counting, presupposing and inferring (Fu & Rosedale, 2009) were used for analysis. An important concept of Husserl’s phenomenology is that researchers must suspend all prior personal knowledge and bias to grasp the essential lived experiences of the participants (Giorgi, 2012; Lopez & Willis, 2004). Throughout the study, we carefully assessed and neutralized biases and preassumptions before data collection and conducted the literature review after the data were analyzed, consistent with a phenomenological approach. During analysis, we tried to avoid the effects of ourselves on the interpretation of the data (Giorgi, 2012; Reiners, 2012). We examined the data in every transcript carefully, identified intentions of actions and perceptions, compared codes, developed themes inductively, and obtained a fuller description through the discovery of recurring themes. Specific analysis procedures were as follows: reading the transcripts repeatedly to gain a broad understanding of the interview, identifying key quotations and discussing key codes with the research team, combining the coded quotations and checking the accuracy of the codes and quotations, identifying major themes by combining key codes into broader categories, reviewing major themes and engaging in discussion to settle any discrepancies, and reviewing the transcripts and validating the structure of themes alongside interview data.

Trustworthiness

Lincoln and Guba (1985) suggested credibility, transferability, dependability, and confirmability as the four principles to ensure trustworthiness of qualitative research. To ensure the credibility of our findings, the interviewer engaged in dialog with each participant, we transcribed audio records verbatim, and we debriefed with other research team members who were experienced in women’s health care. We differentiated, compared, and summarized the essence of each participant’s perception and experience and selected the most representative quotations. Then, we integrated relevant literature for discussion of the findings. Transferability was achieved by presenting the findings clearly to apply to a wider population of Chinese American women. Dependability was achieved by detailed description of the research process, methodology, and findings so that other researchers can repeat the work. As to conformability, we acknowledged bias, maintained neutrality, and presented methods objectively. To ensure cultural relevance and appropriate translation, an additional Chinese researcher was involved in the analysis to confirm cultural meanings between Chinese and English. Chinese sentences in the transcripts were translated to English by emphasizing meaning-based translations rather than word-for-word translations (Larkin, Dierckx de Casterlé, & Schotsmans, 2007).

Results

Our study sample comprised 12 Chinese American women (see Table 2). Participants were all first-generation immigrants to the United States and were 34 to 64 years old with a mean age of 52 years. All participants had at least college degrees; seven had annual incomes of $50,000 or more. Eight of the 12 participants came to the United States 10 or more years ago; five of them were employed. Five participants met current cervical cancer screening guidelines (with or without an HPV test), four participants had Pap tests once about 3 to 5 years ago without HPV tests, and three participants never had a Pap or HPV test (see Table 3). No participants reported abnormal results for past Pap or HPV tests. None of the participants received HPV vaccinations. Through the analysis process, four themes reflecting Chinese American women’s experiences and perceptions of taking a Pap test emerged from the interview text: Belief in a Healthy Lifestyle, Maintaining Privacy for Female Health Problems, Fear of Losing Control, and Feeling Vulnerable in an Unfamiliar Health Care System.

Table 2.

Demographics of Participants (N = 12)

Characteristic	n
Age range of women, years
31–45	3
46–55	4
56–65	5
Education level
College	9
Graduate	3
Annual income
<$50,000	3
$50,000–80,000	5
>$80,000	4
Occupation
Unemployed	4
Working part-time	4
Working full-time	2
Retired	2
Time in the United States
<10 years	4
≥10 years	8

Table 3.

Participants Summary (N = 12)

Pseudonym	Age in Years	Occupation	Pap Test History	HPV Test History
Chen	57	Company manager	Every 3 years	Never
Min	40	Waitress	Never	Never
Liu	64	Retired	Annually	Never
Lin	47	Housewife	Annually	Do not remember
Cheng	62	Retired	Never	Never
Zhang	42	Housewife	Once, 3–5 years ago	Never
Wang	53	Housewife	Once, 3–5 years ago	Never
Feng	58	Church secretary	Once, 3–5 years ago	Never
Ma	34	Housewife	Every 3 years	Never
Hai	53	Software engineer	Once, 3–5 years ago	Never
Cai	51	Physician	Every 3–5 years	Once, 3–5 years ago
Sun	58	Landlady	Never	Never

Note. HPV = human papillomavirus; Pap = Papanicolaou.

Belief in a Healthy Lifestyle

Even though they were not regularly screened, 9 of the 12 participants had Pap tests in the last 5 years. However, only one participant had an HPV test with a Pap test. Many participants were not aware of HPV and did not remember if they were tested for HPV. Most of them believed that a healthy lifestyle prevented them from getting any form of cancer, including cervical cancer. They also believed that Pap test screening was unnecessary because they lived healthy lives and did not have any risks for cervical cancer. A number of participants were not aware of the purpose of the cervical cancer screening, including a Pap test and HPV test, and they misunderstood the risk factors that were associated with cervical cancer. Participants thought that the risk factors for cervical cancer were mostly related to an unhealthy lifestyle, such as smoking, drinking, unhealthy diet, and unsafe sexual practices. Some participants believed that HPV infection was related to poor hygiene, use of public toilets, or heredity. One participant, a 57-year-old manager of a private company, described her belief in a healthy lifestyle:

Most people from Asia still keep Asian lifestyles. They eat more fresh food, fish, and probably more easy life, less of stress, and have less cancer; they don’t get some kinds of disease as the people grew up here. In China, people do not know about Pap test, and they are fine. Our Chinese live a healthy life.

These participants perceived their risks and vulnerabilities for cervical cancer to be lower than those of other American women because they maintained healthy lifestyles even after immigration. This perception was primarily the result of low health literacy and lack of knowledge about risk factors for cervical cancer:

I don’t think I am vulnerable to cervical cancer. Because I don’t drink, I don’t smoke, and I kind of watch what I eat. And I do a lot of exercise; I am a very active person. I think cervical cancer may be from more liberal lifestyle.

A participant who worked at a Chinese restaurant in Chinatown echoed, “I am very conservative, really I never really, you know, I don’t have a promiscuous lifestyle and really my husband is the only person [to have a sexual relationship with]. So I don’t have the risk factors.”

Some participants believed that living in the United States was beneficial to them in the prevention of cervical cancer because of better public hygiene. A 42-year-old participant who immigrated to the United States 4 years ago said that hygiene was very important to prevent disease and that squatting toilets (less hygienic) were more common in public places in China:

When we go to the public restroom, we are very careful. You know, I always take some toilet paper with me wherever I go out. But some women don’t care, they sit on the toilet directly and get sick when they come back home. I think keep good hygiene can help preventing this disease.

Another participant mentioned the importance of cleanliness to prevent female diseases after using a public restroom: “I always carried a hand sanitizer with me, so does my sisters.”

Maintaining Privacy for Female Health Problems

Ten out of 12 participants did not have their own gynecologists, even though several had family physicians. Most participants avoided any gynecologic checkups because they felt ashamed of discussing gynecologic diseases with other people, even physicians. Participants found it more difficult to discuss female health problems with male physicians. Most participants realized that their perceptions of shame originated from their childhood educations and cultural norms. They mentioned that Chinese people tended to keep health problems or health-related concerns within the family, and sometimes they discussed these problems with no one, especially if the problem was associated with sexuality or sexual organs. A computer technician in a local library recalled:

I was told since I was a little kid that if you have a feminine problem, don’t share. You don’t know how other people think of you. Some people may think that you did something bad or wrong, now you are paying for it. We like to share the good news, not the bad news; besides, they could not help, why bother tell them.

This public perception negatively influenced the participants’ attitudes about seeking regular gynecologic screening tests, and it delayed them from initiating care for women’s health issues. A 47-year-old housewife expressed a negative attitude toward talking about female diseases with others:

You know most Chinese don’t want to talk about female disease with other people, we don’t want to spread it around; it’s very private, especially female disease. I know one of my friends had cervical cancer, but she didn’t want to talk about it, neither did I ask.

In addition, she told us that she never had a Pap test until she went for her first childbirth at age 27 years. Another participant noted, “The doctor did the cervix test after I had the baby, it was normal. Only once . but it was a long time age.”

Some participants expressed that comfort with talking about female diseases varied greatly depending on an individual’s cultural background and time since immigration. For example, one participant said:

I think American people talk more openly about it. Or even Chinese American who was born in the United States, or several generations already, they are more open about it. For us, immigrants, you know, it’s still a difficult topic so we don’t want to talk about it.

Fear of Losing Control

Chinese women stated that having a Pap test caused them to have feelings such as “cannot control,” “vulnerable,” “uncomfortable,” “difficult to relax,” and “embarrassed” and that they could do nothing but wait until the examination was finished. Six of the participants who experienced pelvic examinations said that these examinations were uncomfortable and caused them to feel embarrassed. Additionally, they disliked the insertion of the speculum into the vagina, and they found it difficult to relax, which may have increased their pain: “I just cannot relax during the exam. I guess maybe for that reason, I feel much pain because my legs cannot open widely enough to make the procedure easier. It feels like something I cannot control.” Participants expressed how they felt vulnerable:

I just hate the idea of lying down on the bed like that; I could not see what the doctor was seeing and doing over there, which I really want to know. I have to keep looking at the ceiling and try not to think about it. It lasts only a couple of minutes, but to me, such a long time.

They also stated that physicians did not explain the examination well enough to them and that most physicians assumed that the women were already familiar with the procedure: “The doctor is too busy, they don’t have time to give a nice explanation to you. They give you a book, you read it yourself.” Another participant elaborated: “I feel like a piece of meat on the butcher table when I am being examined.” This expression was often used by participants in Chinese to describe their feelings of being out of control and vulnerable. The same participant also recalled her last experience with a Pap test:

It depends on the doctor and the things what they use. Because Asian, the body is smaller, right? I remember last time, they just pick one the size for American women, and it hurt. So I kind of, “Oh I hurt,” so they change to smaller size.

Feeling Vulnerable in an Unfamiliar Health Care System

Some participants expressed their feelings of vulnerability in dealing with an unfamiliar health care system, having limited health insurance, and adjusting to the expense of health services in the United States:

I really do not understand the health care system here. It is quite different. You need to make an appointment ahead of time, sometimes even a month. Who knows if you are going to have time a month later? If you don’t go, they will schedule you to the following month. It is not convenient at all. It is part of the reason that I do not want to do it. Also, I think cervical cancer screening is not that important, I don’t want to spend much time and energy on it. So I take it out of my schedule.

Another participant expressed her frustration in dealing with health care insurance:

The health care insurance in the U.S. is very expensive. Not all employers pay it for their employees. Like me, my employer does not cover my health insurance, and I cannot afford a good insurance plan. Many restrictions may apply to my plan. Usually, I only see a doctor at an emergency situation. I am not going to die if I don’t do the Pap smear. But if I do it, the bill will kill me.

Participants felt more vulnerable because of their lack of knowledge and health literacy and because of the language barrier. Most participants lacked knowledge of cervical cancer screening, including the Pap test and HPV test, and they needed more information from their health care professionals, especially their physicians. Participants also expressed their trust and belief in their physicians. That is, the acceptance of routine cervical cancer screening was not based on any recognition of the role of Pap test tests in cancer screening; it was based on the belief that the physician would make the best health care recommendations. Only 2 of the 12 participants had annual gynecologic checkups with regular Pap tests. But even though one of them had a regular gynecologic checkup, she did not know the reason for the Pap and HPV tests:

I probably had Pap smear every year since I see my gynecologist regularly. I did whatever tests my doctor thinks I should do even I don’t know what those tests are.. I don’t remember that my doctor mentioned about HPV to me before.

When she was asked why she did not ask her physician what those tests were about, she answered:

My doctor seems very busy during my visit. I did ask questions. She gave me very brief answers, sometime used some words I did not understand, you know, English is not my primary language. So I do not ask. But I think I should do what she recommends, that is for my health.

Of the 10 remaining participants who did not have annual gynecologic checkups, 3 had never had a Pap test, and 4 had only had one Pap test in the United States. Most participants were not aware of the need for cervical cancer screening, and they did not know exactly what a Pap test or HPV test was. One participant believed that the HPV test was done by blood testing: “I might be wrong. I have no knowledge about HPV. I think my doctor tested my blood, but I don’t know the exact test.” Another said, “The doctors assume that you already know; they didn’t explain too much.” Lack of knowledge prevented them from pursuing routine cervical cancer screening. Additionally, the language barrier and the assumptions of health care providers made it difficult for Chinese immigrant women to obtain necessary health information for decision making about the Pap test. When they were asked why they did not have Pap tests more often, they expressed their needs for more information from health care professionals:

Everyone who had it before knows it is not a pleasant experience. My doctor did ask me to do it again. I said no and she let me. But if she could explain to me that it is for cervical cancer screening and it is important for me, I would do it. I wish she gave me more information. But I think my doctor had no time for me. She always has patients waiting.

Discussion

Cancer is the leading cause of death among Asian American women (Chawla et al., 2015; Torre et al., 2016). However, cancer screening rates for Asian Americans are the lowest of any other ethnic group in the United States. Asian immigrants are more likely to receive diagnoses in the advanced stages of the disease because of their reluctance to be screened regularly (Chawla et al., 2015). Low rates of cancer screening are related closely to the negative attitudes held by Asians about engagement in preventive care (Han, Kang, Kim, Ryu, & Kim, 2007; Lee et al., 2010). Nevertheless, the specific health beliefs and practices of immigrant populations in the United States pose challenges to the development of cancer prevention programs that are effective and culturally appropriate. In this study, we sought to understand the perceptions of Chinese American women related to cervical cancer screening. We identified four major themes as cultural and systematic barriers to cervical cancer screening among this population.

The decision to have cervical cancer screening was influenced profoundly by Chinese cultural beliefs and practices, negative feelings during procedures, and health care encounters of poor quality.

Our findings indicate the considerable influence of Chinese culture on participants’ decisions about whether to be screened for cervical cancer. The participants believed that a healthy lifestyle would prevent them from developing cervical cancer. Belief in a Healthy Lifestyle to keep people free of disease is very common in traditional Chinese culture, and this belief is passed from generation to generation (Kwok & Sullivan, 2007). With this cultural belief, people are less interested in actively seeking information on risk factors for certain diseases and pursuing behaviors that promote health. Our findings indicate that members of this group of highly educated Chinese American women (i.e., nine had college educations, and three had graduate educations) had limited knowledge about cervical cancer screening; most participants did not recognize the risk factors for cervical cancer including HPV infection, and they did not have screenings regularly. Belief in the value of the Pap test to detect cancer and general knowledge about the test increased the likelihood that women would be screened (Robison et al., 2014). The belief that one is not at risk may result in health care being sought only for illness or symptomatic conditions.

Knowledge and perceptions of cervical cancer can influence the preventive behaviors women use to protect their reproductive health. Women were less likely to obtain screening tests because they believed that Pap and HPV tests were necessary only for sexually active women and those with unhealthy lifestyles (Fletcher et al., 2014). We found that Chinese immigrant women maintained traditional cultural health beliefs, and these beliefs negatively influenced their likelihood of participating in cervical cancer screening. Similar patterns existed among Chinese immigrants in Australia, Canada, and the United States for breast and cervical cancer screening (Hulme et al., 2016; Kwok & Sullivan, 2007; Lee-Lin, Menon, Nail, & Lutz, 2012).

To increase cancer screening rates and adherence among Chinese American women, health care providers should address their unique health care needs and identify barriers to health care access.

Another culturally relevant theme in our study was Maintaining Privacy for Female Health Problems. Our findings indicated that Chinese American women refrained from discussing health issues that were associated with the reproductive system. Many of these women were influenced profoundly by the older generation of Chinese women. They were reluctant to have open discussions about female diseases with their physicians and with their close friends. Therefore, the incorporation of strategies to enhance women’s health education through the use of public education programs and community involvement could help address the tendency to be secretive about these issues (Lee-Lin et al., 2012). Health care providers should be aware of the cultural differences of Chinese American women and ask specific questions to obtain concrete information about reproductive health. We found that sufficient information and recommendations on cervical cancer screening from health care professionals may promote participation.

We found that recommendations from physicians influenced the likelihood that participants would obtain cancer screening, regardless of whether the recommendation was delivered in person, by mail, or with a phone call. Similar findings have been reported for other Asian immigrants generally (Lee-Lin et al., 2012; Seo et al., 2016; Sequist, Zaslavsky, Marshall, Fletcher, & Ayanian, 2009). In Chinese culture, physicians are respected authority figures who can influence the decision-making and health-seeking behaviors of their patients (Kwok & Sullivan, 2007). Thus, a physician’s recommendation for cancer screening is more likely to be followed. Ultimately, interactions between women and their providers need to be improved so that open discussions about culturally sensitive topics can be initiated in Chinese immigrant women (Lee-Lin et al., 2012).

When they recalled their experiences of cervical cancer screening, six participants expressed negative experiences of embarrassment, vulnerability, procedural pain/discomfort, and trauma. Participants also felt unsafe during the screening process, and they described poorquality encounters with health care providers and the Fear of Losing Control. For these participants, a Pap test was something significant and out of the ordinary. Given that sexuality is considered a very private matter and Chinese by and large refrain from openly discussing health issues associated with reproductive organs, it is very likely that a vaginal examination may further expose Chinese immigrant women to feelings of vulnerability and loss of control. However, health professionals treated a Pap test as a routine procedure with little emotional significance, which resulted in mistrust by the women (Armstrong, James, & Dixon-Woods, 2012).

As first-generation immigrants, our participants experienced difficulties and differences in dealing with the U.S. health care system. Among our participants, delayed and inconvenient access to health care had negative effects on the frequency of its use. Participants expressed their frustrations with long waiting times to see providers or to have Pap tests. Making an appointment to see a doctor is not a common practice in China. Most Chinese hospitals allow walk-in service without an appointment. Frustration with the differences between the two systems was a major barrier for participants, as was the lack of affordable health insurance and limited health insurance that restricted access to gynecologic health care. Asian immigrant women were more likely to report lack of health insurance and a regular provider than were non-Hispanic White women in the United States (Chang, Chan, & Han, 2015; Clough, Lee, & Chae, 2013).

The inconvenience of making an appointment and the lack of affordable health care insurance are barriers in the U.S. health care system for other vulnerable immigrant populations as well. Immigrants often experience significant language barriers and limited health literacy that are further exacerbated by cultural barriers (Hulme et al., 2016; Kreps & Sparks, 2008). Participants in our study found it difficult to navigate an unfamiliar health care system for available resources and necessary health services. It is not an easy task for U.S. health care policymakers to change the entire system. However, addressing the unique health care needs and barriers to care among immigrant populations is essential to increase cancer screening rates and adherence to screening recommendations. Affordable, community-based cancer screening programs with outreach for specific ethnic groups can prevent a large number of people from developing advanced cancer and dying from cancer because of late detection (Hulme et al., 2016).

Limitations

Consistent with phenomenological studies, we recruited a small convenience sample of Chinese immigrant women who lived in Los Angeles, California, and had high levels of education. Participants varied in age, occupation, and length of time spent in the United States. Our qualitative findings must be understood within the sample or the context of the informants in this study. Therefore, participants’ experiences may be different from other Chinese American women with different socioeconomic backgrounds.

Conclusions

We attempted to understand experiences and perceptions related to cervical cancer screening and to explore existing barriers to uptake of cervical cancer screening among first-generation Chinese American women in the United States. The Pap test, which is a highly effective cervical cancer screening tool, was not used regularly by the study participants. Also, the participants were not aware of the relationship of HPV to cervical cancer. A decision to not have a cervical cancer screening test was influenced profoundly by Chinese culture. Each ethnic group may have an individual cultural model that explains their decision-making and health-seeking behaviors about cervical cancer screening. Therefore, health care providers should be aware of and give consideration to these cultural differences in health care planning. Women’s health care providers must offer more education and comfort to Chinese American women to encourage cervical cancer screening. Specific strategies should include careful explanations of the process and purpose of any examination with a focus on easing immigrant women’s discomfort and sense of vulnerability during health care encounters.