Physicians and Pap Testing in the Chinese and Vietnamese Communities in Toronto

Brief communication 489 PHYSICIANS AND PAP TESTING IN THE CHINESE AND VIETNAMESE COMMUNITIES IN TORONTO There has been a dramatic decline in the incidence of invasive cervical cancer in Canada during the past 30 years, a decline largely attributable to early detection efforts.1,2 However, not all women in Canada benefit equally from early diagnosis and treatment. According to data from the 1996-97 National Population Health Survey (NPHS), approximately 22.3 percent of recent immigrant women and 12 percent of long-term immigrant women never had a Papanicolaou (Pap) test compared with 5.3 percent of Canadianborn women. Immigrant women born in Asian countries were more likely to have never had a Pap test compared with immigrants born in Western Europe or elsewhere.3 Other studies attest to the fact that Chinese and Vietnamese immigrant women in North America are less likely to be screened for breast and cervical cancer compared with the general population.4"6 Physician recommendation has consistently been shown to be a critical determinant of screening behavior;7"11 it is unlikely that this finding is unique to the majority population.12 According to data from the 1996-97 NPHS, the proportion of immigrant women from Asian countries who reported that they had a regular physician (91.4 percent) was similar to that of the Canadianborn population (96.6 percent).3 Findings from the Chinese Health Survey suggested that this figure reached 90 percent in the Chinese community in Toronto.13 This study investigates why, despite the fact that Chinese and Vietnamese women have extensive contact with physicians, the practice of cancer screening remains relatively uncommon in this group. Although there are no Canadian national statistics on the incidence of cancer by ethnicity, an earlier study found that cervical cancer incidence among Chinese women aged 40 to 54 and 55 years and older in the province of British Columbia was two to four times higher, respectively, than among white women in the same age-groups.14 In the United States, rates of cervical cancer were observed to be four to five times as high among Vietnamese women15,16 compared with white women but similar among Chinese women and white women.17 Because of such facts, Chinese and Vietnamese women in Canada are considered to be high-risk groups. The specific objectives of the study are to determine physician and practice characteristics associated with cervical cancer screening and to identify Received February 13, 2002; revised November 26, 2002; accepted February 7, 2003. Journal of Health Care for the Poor and Underserved · Vol. 14, No. 4 · 2003 490 Physicians and Pap Testing barriers to cervical cancer screening among the Chinese and Vietnamese family physicians who serve these communities in Toronto, the largest and most diverse urban center in Canada. According to the Canadian population census , in 1996, there were 401,190 people of Chinese and Vietnamese ethnic origin living in Toronto, constituting 9.5 percent of the total population. Approximately one-fifth of all recent (resident fewer than five years) immigrants to Toronto were from Hong Kong (11 percent), China (8 percent), or Vietnam (2.8 percent).18 The Ontario Cervical Cancer Screening Program (OCSP) recommends that women of all ages who are, or ever have been, sexually active be screened and that after three normal Pap tests, screening should be continued every two years to age 70.19 The Canadian Task Force on Preventive Health Care recommended Pap screening every three years after two normal tests for women.2 Method The study population consisted of family physicians who were members of the Ontario Branch of the Chinese-Canadian Medical Society (CCMS) (207 physicians) and the Association of Vietnamese Physicians in Toronto (34 physicians ), which together are estimated to enroll 60 to 70 percent of all Chinese and Vietnamese physicians in Toronto (R. Chu, personal communication, April 1999). This sampling frame was chosen because it is believed that the majority of Chinese and Vietnamese residents in Toronto consult an Asian physician for health problems (W. Kwong, personal communication, April 1999). Gray and Stoddard report that patients of a minority culture are more likely than patients of a majority culture to have a minority physician as their...

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