Cambodian American Women

Factors That May Lead to Being Screened Rarely or Never

Knowledge, Attitude, and Belief Barriers

• Language: little to no English proficiency^{1 2 3}
• Low literacy in Khmer, official language of Cambodia^{1 2 3}
• Lack of familiarity with preventive health concepts⁴
• Having a traditional Cambodian orientation to health⁴
• Shyness of Pap smear test procedures⁵
• Belief in karma or fate^{6 7}
• Perception that Cambodian women do not get cancer (particularly if traditional postpartum practices have been observed)⁶
• Belief that only symptomatic, premenopausal, sexually active women are at risk for disease⁶
• Fear of
• Having cancer^{1 6 7}
• Technical equipment⁵
• Large medical center⁵
• Individual appointments⁵
• Lack of knowledge about the American system^{3 4}

External and Other Barriers

Access to health care

• No health insurance^{3 4}
• No regular health care provider^{3 4}
• Lack of female physicians⁵

Logistical issues^{5 6}

• Problems with appointment scheduling
• Lack of transportation
• Lack of childcare
• Lack of medical interpreters

Lack of culturally appropriate health education materials⁶

Factors That May Lead to Increased Screening

Knowledge, Attitudes, and Beliefs

• Perceiving the severity of cervical cancer^{6 8}
• Understanding that a Pap test can prolong life so family obligations may be fulfilled^{6 8}

External and Other Factors

• Access to health care
• Having a female health provider^{6 8}
• Receiving a physician referral or recommendation^{6 8}
• Support of family⁶
• Use of interpreter²
• Preceding any formal presentation or education group with an informal time for social interactions and refreshment⁵
• A warm, friendly environment⁵
• Screening framed as a social engagement to spread the word⁵

Current Research on Outreach/Intervention Strategies

Social Events

• In Olmstead County, Minnesota, screenings were framed as a social event for Cambodian women aged 50 years and older and were based on the premise of building familiarity and trust. In comparison with screening rates identified in the baseline reviews of the medical records, almost a fivefold increase (from 16% to 74%) was noted in the number of women who underwent clinical breast examinations, mammography, or Pap tests after the intervention.
  
  The intervention included seven community informational meetings held in private homes or churches and six screening clinic sessions, all held within a period of six months. On the day of each clinic appointment, a Cambodian project staff member transported the women to their appointment as a group. A medical interpreter was available if further translations were needed. Tea and egg rolls were served during the waiting period, and a health education videotape, specifically designed for the intervention, was shown. As a consequence of the dispersion of the information, several women younger than 50 years of age attended the educational meetings and requested to have clinical breast examinations and cervical tests.⁵



• In another successful intervention using this method, the social engagement was time-consuming but was considered by staff as essential in sustaining the recruitment. The experiences in the screening clinics quickly spread by word of mouth throughout the community, increasing the number of women who access screening. Providing a culturally appropriate institutional setting was also instrumental to the success of the project. Results of this study suggest that those who plan health care services need to change institutional practices that are barriers for the target cultural group.⁵
  
  The importance of creating a welcoming, comfortable social ambiance during interactions, as part of the intervention for this population, cannot be overemphasized. Cambodians prefer a warm, friendly relationship at a gathering before addressing formal topics.⁵

Video

• One intervention created a culturally appropriate video based on a qualitative survey of barriers. According to the authors, "Video is increasingly being used as a medium for health education. Unlike other communication channels, it ensures a uniform, consistent transmission of health-promotion messages. Videotapes also allow presentations of biomedical concepts that are difficult to explain in print. Furthermore, video is a particularly useful medium for interventions targeting Cambodian American populations because of their low average literacy and high rates of VCR ownership." Because many Cambodian women believe traditional postpartum practices protect women from cervical disease, the video depicts a community leader explaining how women's health can be improved by adding American biomedical procedures, such as the Pap test, to traditional Cambodian methods. The video also includes several clinic scenes where physicians stress the importance of Pap testing.^{6 9}

Logistics

• One intervention used lay bicultural health outreach workers and included home visits, presentations at small group meetings, barrier-specific counseling, use of a Khmer-language video, and tailored logistic assistance (e.g., transportation and medical interpretation). All contacts occurred in home or neighborhood settings. Targeted women were contacted on multiple occasions (i.e., through home visits, small group meetings, and telephone contacts) and exposed to health messages in multiple ways (i.e., via a video, one-to-one interactions with outreach workers, and educational presentations). Finally, the outreach workers provided transportation, childcare assistance, and medical interpretation to facilitate Pap testing.^{4 6}

Beliefs/Culture

• Related tenets of Buddhism (once adequately understood) could be adapted to disease prevention efforts. For example, programs could introduce a shift of focus from past karma expressing itself in the present to improving future karma through "right action" and "making merit" in the present by caring for the self in the interest of children and grandchildren.⁸

Other Suggested Interventions

• Research suggests that programs aimed at increasing the use of Pap testing by Cambodian immigrants might usefully stress that all women should be regularly screened, even if they are postmenopausal and/or not sexually active. Further, special outreach efforts should be conducted to educate women who are illiterate in both Khmer and English.^{3 8}



• Efforts can also target physicians by creating medical office systems that remind physicians to perform interval Pap testing.⁸

Works Cited

1. Phipps E, Cohen MH, Sorn R, Braitman LE. A pilot study of cancer knowledge and screening behaviors of Vietnamese and Cambodian women. Health Care for Women International 20:195-207, 1999.



2. Taylor VM, Jackson JC, Yasui Y, Schwartz SM, Kuniyuki A, Fischer M, Tu S-P. Pap testing stages of adoption among Cambodian immigrants. Asian and Pacific Islander Journal of Health 8(1):58-68, 2000.



3. Yi JK. Factors affecting cervical cancer screening behavior among Cambodian women in Houston, Texas. Family and Community Health 18(4):49-57, 1996.



4. Jackson JC, Taylor VM, Chitnarong K, Mahloch J, Fischer M, Sam R, Seng P. Development of a cervical cancer control intervention for Cambodian American women. Journal of Community Health 25(5):359-375, 2000.



5. Kelly AW, Chacori MDMF, Wollan PC, Trapp MA, Weaver AL, Barrier PA, Walter BF, Kottke TE. A program to increase breast and cervical cancer screening for Cambodian women in a midwestern community. Mayo Clinic Proceedings 71(5):437-444, 1996.



6. Taylor VM, Jackson JC, Schwartz SM, Yasui Y, Tu S-P, Thompson B. Cervical cancer control in a Cambodian American population. Asian and Pacific Islander Journal of Health 6(2):368-377, 1998.



7. Taylor VM, Jackson JC, Tu S-P. Cancer control research among Cambodian Americans in Washington. Asian and Pacific Islander Journal of Health 8(1):32-38, 2000.



8. Taylor VM, Schwartz SM, Jackson JC, Kuniyuki A, Fischer M, Yasui Y, Tu S-P, Thompson B. Cervical cancer screening among Cambodian-American women. Cancer Epidemiology, Biomarkers & Prevention 8(6):541-546, 1999.



9. Mahloch J, Jackson C, Chitnarong K, Sam R, Sieng Ngo L, Taylor VM. Bridging cultures through the development of a cervical cancer screening video for Cambodian women in the United States. Journal of Cancer Education 14(2):109-114, 1999.