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The role of sexuality in cervical cancer screening among Chinese women Woo, Jane Siu Tim 2008

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THE ROLE OF SEXUALITY IN CERVICAL CANCER SCREENING AMONG CHINESE WOMEN by JANE SIU TIM WOO B.A., The University of British Columbia, 2001 M.A., The University of British Columbia, 2002 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2008 © Jane Siu Tim Woo, 2008 11 Abstract Chinese women have significantly lower rates of Pap testing than Euro-Canadian women despite efforts to promote testing. Evidence suggests that Chinese women’s reluctance to undergo Pap testing may be related to culture-linked discomfort with sexuality. The purpose of this study was to explore the role of sexuality in the interaction between acculturation and Pap testing. Euro-Canadian (n = 213) and Chinese (n = 260) female university students completed a battery of questionnaires. Euro-Canadian women had significantly more accurate sexual knowledge, higher levels of sexual functioning, a broader repertoire of sexual activities and higher Pap testing rates. Chinese women were more likely to cite embarrassment as a barrier to Pap testing. Heritage acculturation, but not Mainstream acculturation, predicted Chinese women’s Pap testing behaviour. Mainstream acculturation was associated with more accurate sexual knowledge, greater sexual desire and satisfaction. The findings provide support for the hypothesis that low Pap testing rates in Chinese women are related to cultural attitudes towards sexuality and highlight the importance of taking into account sexuality in seeking to understand cervical cancer screening among cultural groups. 111 Table of Contents Abstract.ii Table of Contents iii List of Tables iv Acknowledgements V 1. Introduction 1 2. Methods 7 2.1. Participants 7 2.2. Measures 9 2.3. Procedure 10 2.4. DataAnalysis Plan 10 3. Results 11 3.1. Results for Inter-group Comparisons 11 3.2. Results for Chinese Women Only 18 4. General Discussion and Conclusions 20 4.1. Culture and Sexuality 20 4.2. Culture, Sexuality, and Cancer-Screening Practices 20 5. Limitations and Future Directions 24 References 26 Appendix A. Notes on Authorship 33 iv List of Tables Table 2.1. Demographic Variables in Chinese & Euro-Canadian Female University Students .. . .8 Table 3.1. Comparisons of Chinese to Euro-Canadian Female University Students on Relationship Length and Sexual Activity Among those Who Reported Being in a Current Relationship 12 Table 3.2. Comparisons of Chinese to Euro-Canadian Female University Students on Cervical Cancer Screening Behaviour and on their Primary Health Care Providers 15 Table 3.3. Odds of Ever Having had a Pap Test- Chinese & Euro-Canadian Women 17 Table 3.4. Odds of Ever Having had a Pap Test- Chinese Women Only 19 VAcknowledgements There are many people who I would like to thank for helping, guiding and cheerleading me through my Master’s degree. Firstly, I would like to thank all the subjects who gave of their time to participate in this study. I would also like to give a special thank you to Morag Yule for graciously helping me to collect data while I went away to spend time with my family, and for subsequently carrying a great many completed questionnaires to me by bus. I would like to thank Del Paulhus not only for all the time that he put into helping me think about my data from different perspectives, but also for his support throughout the process of writing my thesis. I am thankful to Cinnamon Stetler for giving me a chance to get involved in her research at a time when I had very little experience and for providing the first stepping stone for getting to where I am now. Words cannot express how much I am indebted to her. I am grateful to Scott Carlson for the opportunity to work in his lab, for his unwavering belief in me and for understanding when I needed to be understood. To my supervisors, Lori Brotto and Boris Gorzalka, I am so grateful for their constant encouragement, support and expertise. I am thankful for the time that they find for me in their busy schedules when I need it. Through their mentorship I have learned much about both research and life. To Marmses and Darses, none of this would have been possible without their steadfast support, love and patience. I am indebted to them for supporting my decision to return to school to pursue a dream when they thought that I was finally done with school. My husband Aaron has been my rock from the beginning. I am thankful to him for always making things better and for his willingness to play second fiddle to my work when he knows that is what I need. And to God, for gently leading even when I have been too stubborn to follow. 11. Introduction The Papanicolaou (Pap) test is a screening test for cervical cancer during which cells are removed from the cervix and then biopsied. Because the Pap test enables early detection of abnormal cells which can be treated before they develop into cancer, it is an invaluable tool in preventing cervical cancer if conducted regularly. Despite the usefulness of the Pap test in early cancer detection, research suggests it is underutilized by Chinese women (e.g. Hislop, Teh, Lai, Ralston, Shu, & Taylor, 2004; Kagawa-Singer & Pourat, 2000). There has been progress in research on the low Pap testing rates among Chinese women living in North America, but our understanding of the mechanisms through which culture impacts Pap testing remains incomplete. Moreover, there is evidence that culture-linked discomfort with sexuality may be related to reluctance to undergo screening of the reproductive organs, suggesting that sexuality should be a focus of study when researching health behaviours and culture (Kwok, Cant, & Sullivan, 2005). There is a great need to address this deficiency in our understanding because individuals of Chinese descent constitute one of the fastest growing minority groups in North America. Census data indicate that there are over 3.5 million Chinese individuals in North America (Statistics Canada, 2008; US Census Bureau, 2000). Furthermore, data indicate that although cervical cancer incidence is higher among Caucasian American women, mortality from cervical cancer is slightly higher among Asian American women (American Cancer Society, 2008). The growing Chinese population in North America, cervical cancer incidence and mortality rates indicate that research on the factors that impact Pap testing in Chinese women is urgently needed. Research on ethnicity and health behaviours indicates that Asians may be slower to seek medical attention compared to individuals of European descent, which results in inequities in morbidity and mortality rates (Gill, Shah, Le, Cook, & Yoshida, 2003; Zhang et al., 2006). This 2cultural difference in health seeking behaviours extends to preventive reproductive health behaviours as research has consistently found that Chinese women have lower participation rates in these preventive cancer screening services compared to Euro-Canadians. Among the preventive cancer screening measures in women’s reproductive health, it is well-documented that mammography and Pap testing rates are significantly lower among women of Chinese ancestry than those of European ancestry (Kagawa-Singer & Pourat, 2000; Taylor et al., 2002; Tu et al., 2005; Yu, Wu, & Mood, 2005). Current American guidelines recommend that all women have a Pap test at least once every 3 years beginning about 3 years after sexual debut but no later than age 21 (National Cancer Institute, 2008). Canadian guidelines on Pap testing frequency correspond to American guidelines but recommend commencement of testing once a woman becomes sexually active or reaches age 18 (Health Canada, 2008). In support of these recommendations, a study of women enrolled in a large prepaid health plan in San Francisco found that the majority of women diagnosed with cervical cancer had not had a Pap test in the 6- 36 months preceding their diagnoses (Sung, Kearney, Miller, Kinney, Sawaya, & Hiatt, 2000). The low rates of mammography and Pap testing in Asian women has led to the unfortunate finding that though breast cancer prevalence is lower in Asian American women compared with Caucasian American women, breast cancer mortality is much higher in Asian American women due to more advanced disease at diagnosis (American Cancer Society, 2005; Lin, Clarke, Prehn, Glaser, West, & O’Malley, 2002). Financial difficulty has been cited as a barrier to utilization of preventive reproductive health services in individuals from ethnic minority groups in North America (e.g. Tang, Solomon, Yeh, & Worden, 1999). However, research has found that even with the removal of financial barriers, Chinese women continue to have lower mammography screening rates (Tu, 3Taplin, Barlow, & Boyko, 1999). Furthermore, the province of British Columbia (BC) in Canada provides a large scale naturalistic observation that vividly illustrates the extent of Chinese women’s reticence in regard to monitoring their reproductive health. BC has had an organized cervical cancer screening program in place since 1955 in which Pap tests are accessible to women at all general medical practitioners at no cost. Cervical cancer morbidity has fallen by 85% and deaths have decreased by 75% since the 1950’s as a result of this program (British Columbia Cancer Agency (BCCA), 2005). Despite these dramatic reductions, cervical cancer continues to be a cause of illness and death among Chinese women in BC due to low Pap testing rates (Hislop et al., 2004). In a further effort to reduce barriers to Pap testing among Chinese women in a Canadian city with a large Asian population, the Asian Women’s Health Clinic was established in 1994, with female Chinese health care professionals providing reproductive health services and education. Between 1994 and 1997, the number of new patients presenting at this clinic annually doubled from about 170 to 350 (Sent, Ballem, Paluck, Yelland, & Vogel, 1998). Despite these encouraging findings, data indicate that Chinese women’s Pap testing rates remain below provincial rates (BCCA, 2007; Hislop et al., 2004). What could be restraining Chinese women’s motivation to submit to Pap testing? There is speculation that their low rate of Pap testing could be related to more conservative attitudes, beliefs and behaviours towards sexuality (Kwok, Cant, & Sullivan, 2005). Although some studies have alluded to the potential role of sexuality in cervical cancer screening (e.g. Fisher & Fisher, 1998; Tang et al., 1999), none have empirically tested this hypothesis. Chinese discomfort with intimate issues can be observed in numerous contexts. Talking about sex is taboo in traditional Chinese families, where older generations, having themselves received inadequate or no sex education, do not know how to bring up the topic with their 4children and thus prefer not to talk about it (Chang, 1997). Research has consistently found that Chinese individuals possess less sexual knowledge than North Americans (Brotto, Chik, Ryder, Gorzalka, & Seal, 2005; Chan, 1990; Meston, Trapnell, & Gorzalka, 1998). Studies of sexual behaviour have also routinely found Chinese individuals to be less sexually experienced than those of European descent (Durex, 2005; Family Planning Association of Hong Kong, 1994; Forrest & Singh, 1990; Weisberg, North, & Buxton, 1992). Although there have been significant socio-political and economic changes in China since the 1 980s, sexual knowledge among Chinese youth continues to be limited and attitudes toward sexuality continue to be conservative by Western standards as a clear tension between traditional Chinese views and Western attitudes towards sex persists (Gao et al., 2001; Higgins, Zheng, Liu, & Sun, 2002; Higgins & Sun, 2007). It is therefore apparent that there are significant cultural differences in sexual attitudes, knowledge and behaviour, with Chinese people demonstrating more conservative attitudes, less knowledge and less sexual experience compared with Euro-Canadians. However, although Chinese conservativeness across diverse domains of sexuality is well-documented in the sexuality literature and the persistently low occurrence of Pap testing among Chinese women is well-established in the literature on health behaviours, culture-linked sexual conservativeness has never been empirically studied as a potential barrier to engaging in cervical cancer screening. One way to study the influence of culture on behaviour is by making cross-cultural comparisons between people living in China and those living in North America. Cross-cultural studies, however, do not capture the changes that occur in the self-identity of individuals who move to a new culture. Another way of studying the role of culture that may be more relevant to healthcare practitioners and healthcare policy development in North America is by studying acculturation. When an individual moves to North America and attempts to integrate into the 5new culture, a process of acculturation occurs as values of the new culture are incorporated into one’s self-identity. Attention to acculturation is crucial given individual differences in the extent to which each person assimilates the new country’s values, as well as maintains affiliation with their culture of upbringing, and could provide valuable information to healthcare practitioners and policy makers that is missed by focusing exclusively on ethnic group membership. Ryder, Alden, and Paulhus (2000) define “heritage culture” as an individual’s culture of birth or upbringing and “mainstream culture” as the predominant culture in the new setting. In support of taking into account acculturation rather than merely examining ethnic group differences, research has found that Chinese Canadian students were more sexually experienced and knowledgeable than Chinese students in Hong Kong, but less experienced and knowledgeable than Euro-Canadian students (Chan, 1986; Meston, Trapnell, & Gorzalka, 1996; Meston et al., 1998). These findings would have been obscured if ethnic group had been the only measure of culture employed. Monumental changes have occurred over the past two decades or so with globalization and increasing openness of Chinese society to Western ideas. Consequently, more recent research has found that acculturating Asian students in North America have adopted more open attitudes towards sexuality, although they remain sexually conservative in relation to Western norms (Leiblum, Wiegel, & Brickle, 2003). The current study is unique in that a bidimensional measure of acculturation, the Vancouver Index of Acculturation (VIA; Ryder et al., 2000), is used. The VIA is a self-report instrument that measures mainstream and heritage acculturation independently. This study adopts the bidimensional approach to assess acculturation because it allows for the possibility that individuals may continue to maintain ties with the values, beliefs and behaviours of their heritage culture while adopting aspects of the mainstream culture, thereby providing more rich 6information than the unidimensional approach (Berry, 1980). The finding by Brotto et a!. (2005) that mainstream and heritage acculturation interact significantly in predicting sexual attitudes, with Westernization having little effect on sexual attitudes if a woman maintained strong heritage ties, is an example of a fascinating effect that would not have been detected with a unidimensional measure of acculturation. The primary aim of this study was to explore the role of sexuality and acculturation in Chinese women’s cervical cancer screening behaviours. While it makes intuitive sense that the reluctance of Chinese women to submit to Pap testing could be connected to discomfort with sexuality and embarrassment, and some studies have alluded to conservative sexuality as a potential barrier to screening, the current study seeks to test this hypothesis empirically with a view towards developing culturally-appropriate interventions to increase Pap testing rates in this group. Firstly, because studies have demonstrated a robust relationship between sexual attitudes and sexual function such that a more open attitude is strongly associated with greater sexual function (Athanasiou & Shaver, 1971; Schmidt, Sigusch, & Meyberg, 1969), we hypothesize that higher sexual function will be linked to greater likelihood of Pap testing. Secondly, among the Chinese women, we hypothesize that higher mainstream acculturation and lower heritage acculturation will be associated with higher likelihood of Pap testing. 72. Methods 2.1. Participants Female undergraduate students at a large Canadian university who were enrolled in Psychology courses offering extra credit for research participation were eligible to take part in this study. Out of 584 women who returned their questionnaire packages, 260 self-identified as Chinese and 213 self-identified as Euro-Canadian. Among the Chinese group, 40% were born in North America with the remainder born abroad. The remaining 111 women self-identified as other ethnic groups and were excluded from further analyses for the purposes of this paper. Some of the data on ethnic group differences in Pap testing rates have been published elsewhere (Brotto, Chou, Singh, & Woo, 2008); however, they will be analyzed further in the current paper. Demographic data are presented in Table 2.1. The Euro-Canadian subjects were significantly older (t[3 18] = -4.88, p < .001) and had significantly more years of education than the Chinese group (t[468] = -2.99,p < .01). 8Variable Mean Age in years (SD)*** Place of Birth (% of each group)*** Chinese (n = 260) 20.53 (2.62) Euro-Canadian (n213) 22.28 (4.65) Canada or US China/Hong Kong/Taiwan Southeast Asia Europe Other Education in years (SD)* * Marital status* * * 40.0% 55.4% 4.2% 0% 0.4% 87.8% 0% 0.5% 7.1% 4.6% Unmarried 97.7% 89.1% Married 1.2% 9.5% Divorced 0.4% 0.9% Table 2.1. Demographic Variables in Chinese & Euro-Canadian Female University Students Sign/icant group d(fferences at *p < .001 14.70 (1.46) 15.11 (1.45) 92.2. Measures Vancouver Index ofAcculturation (VIA). The VIA (Ryder et a!., 2000) was used to assess the mainstream and heritage dimensions of acculturation separately in keeping with a bidimensional model of acculturation. More Westernization is reflected by higher scores on the mainstream dimension and higher affiliation with one’s heritage culture is reflected by higher scores on the heritage dimension. The VIA consists of 20 items, with 10 domains. One heritage and one mainstream item is keyed to each domain: cultural traditions, marriage partner, social activities, comfort in professional relationships, entertainment, behaviour, maintenance or development of cultural practices, values, humour and social relationships. Both dimensions of the VIA were found to have good internal consistency in the Chinese validation sample (Cronbach’s a = .92 for heritage acculturation and .85 for mainstream acculturation). Sexual Beliefs and Information Questionnaire (SBIQ). The SBIQ (Adams, Dubbert, Chupurdia, Jones, Lofland, & Leermakers, 1996) is a 25-item inventory that assesses beliefs and knowledge about sexual functioning. Participants select “True”, “False”, or “Don’t Know” in response to each item. The total score is computed by summing the number of items that were answered correctly and reflects the accuracy of sexual knowledge. The SBIQ has good internal consistency (Cronbach’s a = .82) and satisfactory test-retest reliability (r = .82,p < .00 1). Female Sexual Function Index (FSFI). The FSFI (Rosen et a!., 2000) is a self-report measure of sexual function and consists of 6 domains: Desire, Arousal, Lubrication, Orgasm, Satisfaction and Pain. The total FSFI score is obtained by summing the scores from the individual domains. Test-retest reliability is high for each domain (r = .79 to .86) and internal consistency is high (Cronbach’s alpha values were 0.82 and higher). Women ‘s Health Questionnaire (WHQ) and Health Beliefs Questionnaire (HBQ). 10 The WHQ (Barroetavena, 2005) and HBQ (Woo, 2005) are unpublished questionnaires developed for this study to assess participants’ cancer screening practices, beliefs about cancer and barriers to cancer screening. At the time of this study, no published questionnaire assessing beliefs and behaviours relating to Pap testing was available. 2.3. Procedure The study was publicized using the university’s online research participation management system. Interested students collected a questionnaire package, completed it at home (90 minutes) and returned it to the research laboratory in a sealed envelope. All participants gave written informed consent and received course credit for their participation. All procedures were approved by the university’s Behavioural Research Ethics Board. 2.4. Data Analysis Plan The data were analyzed in two sequential steps- firstly, the Euro-Canadian women were compared to the Chinese women to examine the effect of ethnic group membership on sexuality variables such as sexual knowledge and sexual function and on cancer-screening variables such as Pap testing behaviours and knowledge. Next, the data for the Chinese women only were analyzed to examine the role of acculturation on these variables. 11 3. Results 3.1. Results for Inter-group Comparisons Effects ofSeif-IdentUled Ethnic Group (Euro-Canadian vs. Chinese) on Measures ofSexuality Data on relationships and sexual activity are presented in Table 3.1. There were significantly more Euro-Canadian women (65%) compared to Chinese women (52%) who reported being in a re1ationship,(1) = 8Al,p < .01, p -.13. Among the women who were in a relationship, relationship length was significantly longer in the Euro-Canadian (mean = 2.50 years) compared to the Chinese (mean 1.86 years) women, t(234) = -l.96,p = .05. 12 Variable Chinese (n = 134) Euro-Canadian (n = 138) % currently in a relationship* * 51.5% 64.7% Length of relationship in years (SD)* 1.86 (2.07) 2.50 (3.19) % who have recently engaged in 94.0% 99.3% hugging, kissing or holding hands* % who have recently engaged in touching 83.6% 97.1% with clothing removed* * * % who have recently touched their 78.4% 97.1% partner’s genitals* * * % who have recently performed oral sex 58.2% 89.9% on their partner* * * % who have recently had oral sex 46.3% 87.0% performed on them by their partner* * * % who have recently engaged in vaginal- 67.9% 92.0% penile intercourse* * * Table 3.1. Comparisons of Chinese to Euro-Canadian Female University Students on Relationship Length and Sexual Activity Among those Who Reported Being in a Current Relationship Significant group differences at *p <.05. **p <.01. ***p <.001. 13 In regard to the sexuality measures, the Euro-Canadian women scored significantly higher on the SBIQ (t[468] = -8.36, p < .00 1), indicating more accurate knowledge about sexuality. Scores on all subscales of the FSFI were significantly higher in the Euro-Canadian relative to the Chinese group: desire, (t[471] = -6.5O,p < .001); arousal (t[470] = -8.48,p < .001); lubrication (t[470] = -‘7.8O,p < .001); orgasm (t{464] = -7.63,p< .001); satisfaction, (t[396] = -3.63,p < .001); pain, (t[471] = -6.67,p < .001); and the FSFI total score, (t[382] = - 7.73, p < .001), indicating higher levels of sexual response in the Euro-Canadian women. On measures of types of sexual activities among the women who were in a relationship, the Euro-Canadian women were more likely to have ever engaged in kissing, hugging and holding hands,(l) = 5.85,p < .05, p = -.15; more likely to have ever touched with clothing removed,(1) = 14.3’7,p <.001, p = -.23; more likely to have evertouched apartner’s genitaIs,(1) = 22AO,p < .001, p = -.29; more likely to have ever performed oral sex on a partner,(1) = 35.62,p < .001, p = -.36; and more likely to have ever had oral sex performed upon them,‘2(l) = 5O.84,p < .001, p = -.43. In addition, the Euro-Canadian women were significantly more likely to have ever had penile-vaginal intercourse,X2(1) = 24.85, p < .001, p =-.30. Effects ofSelf-Identfled Ethnic Group (Euro-Canadian vs. Chinese) on Measures ofCancer Screening Beliefs and Behaviours Significantly more Euro-Canadian women than Chinese women reported ever having had a pelvic exam = 136.56,p < .001, p = -.54) and having had a Pap test in the past two years 2[1] = l52.41,p < .001, p = .57). Results reported by Brotto et al. (2008) indicate significant ethnic differences in Pap testing rates but no differences in time elapsed since last Pap test 14 among women who reported having had at least one Pap test. However, the Euro-Canadian women had significantly more Pap tests in the previous 5 years, t(3 02) = -13.09, p < .001. Euro-Canadian women and Chinese women did not differ on whether they had a regular family doctor, ([l] = 2.20,p> .05, ç = .05). However, Chinese women were significantly less likely to have a female primary care provider compared to the Euro-Canadian women (y2[2] = 27.9O,p < .001, Cramer’s V = .24) and significantly more Euro-Canadian women had ever been told by their doctors that they should have a Pap test done (y[1] = 100.39,p < .00 1, q .46). Data on cervical cancer screening behaviours and primary health care are presented in Table 3.2. 15 Variable Chinese Euro-Canadian (n—260) (n=213) % who have ever had a pelvic exam*** 18.8% 72.3% % who have had a Pap test in the previous 18.1% 74.6% 2 years*** % who have a regular primary care 80.8% 75.1% provider % who have a female primary care 39.1% 60.2% provider* * * % who have ever been told by their doctor 20.5% 66.2% to have a Pap test*** Table 3.2. Comparisons of Chinese to Euro-Canadian Female University Students on Cervical Cancer Screening Behaviour and on their Primary Health Care Providers Significant group differences at ***p < .001. There were no ethnic group differences in the proportion of women who correctly endorsed the statement “Pap tests can prevent cancer” 2[1] = .28, p> .05, p = .024). However, significantly fewer Chinese women correctly endorsed the statements “A woman needs to continue having Pap tests after menopause”(2{1] = 6.88,p < .01, ‘p = .12) and “Pap tests are necessary even if a woman has no symptoms” ([1] = l6.75,p < .001, ‘p = .19). Chinese women were also more likely to state that embarrassment(2[1] = 39.5O,p < .001, ‘p = -.29), concerns about pain or discomfort ({1] 57.38,p < .001, ‘p = -.35), and fear of finding cancer (y2[1] = 22.’72,p < 16 .001, q = -.22) were deterrents to Pap testing. The two groups did not differ in their belief that some cancers can be cured if they are detected early(2[2] = 2.87,p> .05, Cramer’s V = .08). Effects ofSelf-Identfled Ethnic Group (Euro-Canadian vs. Chinese) and Measures ofSexuality on Cancer-Screening Behaviours and Knowledge A logistic regression was conducted to assess whether ethnicity, sexual knowledge, sexual function and beliefs about cervical cancer screening could predict whether a woman had ever had a Pap test. The overall model was found to be significant (y2[10] = 32S.74,p < .001) and revealed that self-reported ethnicity and sexual activity were both significantly associated with ever having had a Pap test, such that Euro-Canadian women, and women who were sexually active were more likely to have ever had a Pap test. In addition, women for whom embarrassment was a barrier to Pap testing and women who had never been told by their doctors to get a Pap test were less likely to report ever having had a Pap test. Women who were concerned about pain were less likely to have ever had a Pap test. Notably, sexual knowledge was not predictive of ever having had a Pap test, and whether or not she believed that Pap tests were necessary in the absence of symptoms were not significantly associated with ever having had a Pap test. Gender of physician and fear of finding cancer were also not predictors of Pap testing behaviour. Results of the full model are presented in Table 3.3. 17 Variable Odds Ratio Self-reported Ethnic Group*** (Ref= Euro-Canadian) 4.92 Sexual Knowledge (SBIQ score) 1.05 Sexual Function (FSf’I score) 1.03 Gender of doctor (Ref = Male) 1.73 Has been told by their doctor to have a Pap test*** (Ref 14.84 Has not been told) Whether or not sexually active (Ref = Yes)* * * .15 Believes that Pap tests are necessary even when there are 2.65 no symptoms (Ref = Does not believe) Is prevented from getting a Pap test by embarrassment* * .19 (Ref = Not prevented) Is prevented from getting a Pap test by concerns about .42 pain* * (Ref = Not prevented) Is prevented from getting a Pap test by fear of finding .73 cancer (Ref = Not prevented) Table 3.3. Odds of Ever Having had a Pap Test- Chinese & Euro-Canadian Women Significant group differences at **p <.01, ***p <.001. 18 3.2. Results for Chinese Women Oniy Effects ofAcculturation and Measures ofSexuality on Cancer-Screening Behaviours (Chinese Women Only) Mainstream but not heritage acculturation was significantly correlated with SBIQ scores such that more Westernized women had more accurate sexual knowledge (r[260] = .18, p < .01). Mainstream acculturation was also significantly correlated with FSFI Desire (r[2851 .16, p < .05) such that women with higher mainstream acculturation reported greater sexual desire. A logistic regression was conducted to bring together acculturation, sexual knowledge, sexual function and cervical cancer-screening variables in the prediction of whether Chinese women had ever had a Pap test. The overall model was significant,(8) = l18.O’7,p <.001 and showed that among the Chinese women, doctor’s recommendation and being sexually active significantly predicted a higher likelihood of a woman’s ever having had a Pap test. Heritage acculturation trended towards significance (p = .07) such that lower Heritage acculturation was linked to higher odds of having ever had a Pap test. Results are presented in Table 3.4. 19 Variable Odds Ratio Heritage Acculturation 0.66 Mainstream Acculturation 1.35 Sexual Knowledge (SBIQ score) 1.01 Sexual Function (FSFI score) 1.05 Has been told by their doctor to have a Pap test*** (Ref 15.06 Has not been told) Gender of doctor (Ref = Male) 1.14 Whether or not sexually active (Ref = Yes)* * .12 Age 1.18 Table 3.4. Odds of Ever Having had a Pap Test- Chinese Women Only Significant group differences at **p < .05. ***p <.001. 20 4. General Discussion and Conclusions 4.1. Culture and Sexuality Chinese thought and culture have been most heavily influenced by the teachings of Confucius,who viewed sex as being good as long as it did not lead to social instability or damage interpersonal relationships. However, the Neo-Confucians of the Song Dynasty (960 to 1276 A.D.) gave the Confucian classics strict interpretations when Confucianism was declared the official state doctrine. From this time on, Confucianism became sexually suppressive; sexual behaviour was reserved for marriage and was viewed as serving a purely procreative role. This long history of sexual suppression appears to form the foundation for traditional Chinese attitudes towards sexuality (Ng & Lau, 1990). Against this backdrop of centuries of sexual repression in Chinese culture, it is not surprising that individuals of Chinese descent hold more conservative attitudes towards sex, possess less sexual knowledge and are less sexually experienced than their Euro-Canadian counterparts (Brotto et a!., 2005; Brotto, Woo, & Ryder, 2007; Meston et a!., 1998). Consistent with this, the current study found that Euro-Canadians had more accurate sexual knowledge and higher levels of sexual functioning. Among those who were in a relationship, the Euro-Canadian women also had a broader repertoire of sexual activities, with more of the Euro-Canadian women having engaged in kissing, hugging and holding hands, touching with clothing removed, touching a partner’s genitals, giving and receiving oral sex, and vaginal-penile intercourse. 4.2. Culture, Sexuality, and Cancer-Screening Practices In analyses of the Euro-Canadian and Chinese women together, sexual activity, ethnicity, concerns about pain, embarrassment and doctor’s advice regarding Pap testing were all 21 significant predictors of whether a woman had ever had a Pap test. In fact, doctor’s recommendation had the largest effect on Pap testing likelihood, a result that is consistent with prior research on health behaviours (e.g. Coughlin, Breslau, Thompson, & Benard, 2005; Ling, Klein, & Dang, 2006). Arguably, the variable that is most within the control of public health agencies and education programs is the recommendations that doctors make to their patients. Taken together with the finding that significantly more Euro-Canadian women than Chinese women had ever been told by their doctor to have a Pap test, education of doctors to broach the topic of reproductive health with all female patients may be a first step towards reducing the persistent disparity in Pap testing rates. Interestingly, among the Chinese women, heritage acculturation trended towards significance in predicting Pap testing likelihood such that those who continued to affiliate strongly with traditional Chinese culture were less likely to have ever had a Pap test. Although not quite reaching statistical significance, the odds ratio of .66 suggests that heritage acculturation may merit attention when seeking to understand Chinese women’s Pap testing behaviour. On the other hand, mainstream but not heritage acculturation was correlated with sexual knowledge and sexual function. It therefore appears that though acculturation may be implicated in both sexuality and Pap testing behaviours, different dimensions of acculturation are important to each, which was an unexpected finding. Why might mainstream acculturation only be associated with sexual knowledge and function whereas heritage acculturation is only linked to Pap testing behaviour? This may be due to different processes that occur during acculturation. Sexual knowledge may become more accurate as acculturating Chinese women come into contact with aspects of Western culture such as portrayals of sexuality in the media. In so doing, sexual openness may increase as suggested by the higher sexual response scores. However, at 22 this point, if a woman continues to adhere strongly to her heritage culture, Chinese cultural beliefs may hamper willingness to undergo Pap testing. Research suggests that in Chinese culture, gynaecological services are viewed as necessary only in relation to reproduction or when symptoms of illness become intolerable (Jackson et al., 2002; Lee, Lee, & Stewart, 1996). Pap tests are also seen as unnecessary prior to marriage as sexual activity supposedly does not occur outside marriage (National Asian Women’s Health Organization, 1995). Thus, unmarried Chinese women may be discouraged from accessing these health services for fear of social denunciation. Follow up research may be able to elucidate more clearly the factors that underlie these results. Another interesting finding relating to reproductive health knowledge is that although there were no ethnic differences in the proportion of women who had regular health care providers, the Chinese women were significantly more likely to have male primary care providers. In addition, the Chinese women were significantly less likely to report that they had been told by their doctor to have a Pap test. These findings are in accord with prior research (Hislop et a!., 2004). These data suggest a need for education of health care providers on the importance of providing information about cervical cancer risk factors to their patients. Our hypothesis that discomfort with sexuality and embarrassment with having one’s genitals examined play a central role in Chinese women’s reluctance to submit to Pap testing is supported by the present findings. Embarrassment was more likely to be a barrier to Pap testing for Chinese women than for Euro-Canadian women. Given conservative Chinese views of sex, and the incursion into areas of the body normally exposed only during sexual activity that is necessitated by a Pap test, it is understandable that asymptomatic Chinese women would be 23 disinclined to actively seek out and voluntarily submit to a Pap test even though the vast majority of them (89.2%) acknowledged that Pap tests are necessary even in the absence of symptoms. The findings of this study that Euro-Canadian women had had more Pap tests than Chinese women in the previous 5 years and that more Euro-Canadian women than Chinese women had ever had a pelvic exam, and had had a Pap test in the previous 2 years conform to the well-documented finding of low rates of Pap testing among Chinese women. However, it is interesting that Brotto et a!. (2008) found no significant ethnic difference in the time elapsed since a woman’s last Pap test amongst women who reported having ever had a Pap test. This indicates that among women who have overcome initial barriers to Pap testing, the two groups were comparable in terms of compliance with recommendations on Pap testing frequency (Health Canada, 2008; National Cancer Institute, 2008). This is an important finding because it suggests that once a Chinese woman can be convinced to have her first Pap test, she may be likely to undergo regular screening which greatly reduces her odds of developing and dying from cervical cancer. 24 5. Limitations and Future Directions This study has some limitations that must be addressed. Firstly, our university sample is significantly younger, more educated, more fluent in English and has higher socioeconomic status than would be presumably found among Chinese women in the general population. Hislop et al. (2000) found that these were all factors that predicted lower Pap testing rates among women in the community. Thus, the results of this study may not be generalizable to the general population. Furthermore, because our sample was relatively young, we are unable to ascertain whether the ethnic and acculturation differences in Pap testing behaviour become more pronounced as women age. To address these limitations, we are conducting a study of Chinese women in the community in which the measures used in this study are administered as a structured interview by female interviewers who are fluent in English, Cantonese and Mandarin so that subjects can complete the interview in the language of their choice. Another limitation of the current study is the use of unvalidated questionnaires (Barroetavena, 2005; Woo, 2005) to assess Pap testing behaviours and knowledge because no validated measures existed at the time of data collection. However, this limitation may be mitigated by considering that the WHQ (Barroetavena, 2005) has been used in prior studies of Pap testing behaviours in Chinese women (e.g. Hislop et a!., 2004; Tu et al., 2005). To conclude, the rapid growth in the Chinese population in Canada and the US has lent greater urgency to the search for sound theories that can account for the reluctance of women of this ethnic group to seek potentially life-saving preventive health services. The results of this study suggest that a certain degree of sexual openness may be beneficial in regard to regular cervical cancer screening, enabling early treatment and reducing morbidity and mortality from cervical cancer. Compared with Euro-Canadian women, Chinese women lag behind in terms of 25 knowledge about sexuality, risk factors for cervical cancer and general information on the importance of the Pap test. Chinese women are also more conservative in their sexual beliefs, attitudes and behaviours than Euro-Canadian women. 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Improved survival of Asians with corpus cancer compared with Whites. Obstetrics & Gynecology, 107, 329-335. 33 Appendix A. Notes on Authorship This thesis was a collaboration between my two co-supervisors, Dr. Boris Gorzalka and Dr. Lori Brotto, and myself. I co-designed the study as well as developed a questionnaire on the beliefs that women may hold about health behaviours as no such validated questionnaire was available when we began data collection. I also played a central role in all aspects of carrying out this research, from recruiting subjects and managing the database to analyzing the data and writing the manuscript for submission to a journal.

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