Fear, scariness, danger. Most women interviewed expressed feelings of fear, scariness, and danger as their initial emotions when they thought of cervical cancer. They were afraid of it because they knew they could possibly die if not detected early and treated in a timely manner. Two of the women stated, “It's [getting cancer] dangerous to life” and “It is scary ... to hear about people dying from cancer.”
Empathy, sadness, guilt. Some women expressed empathy toward people going through the cancer management process or sadness because they felt they were not able to provide any support for them. In addition, some of them expressed guilty feelings toward women who were sick or diagnosed with cancer because it would be a burden to their family members and they would not be able to take care of them. Several women stated, “I get emotional ... when I think about cancer; I feel sad for those people having it [cervical cancer] because I am not being able to help them, support them, and comfort them,” “I usually place myself in their shoes,” “In case you get sick, then it's just a burden for your husband and children,” and “I feel guilty about not being able to take care of my kids when needed.”
Anxiety, worry, nervousness. Most women expressed that they were nervous and worried about undergoing screening because they did not know what to expect during the physical examination. In addition, they worried about the results of the screening tests. In particular, young women who had never been exposed to screening in the past indicated that they felt nervous about being screened and receiving abnormal results. A young woman noted, “I would be scared to go [and get screened] for the first time because I have never gone for before.... I would be very concerned about finding it out that there is a problem.”
Embarrassment, shyness, discomfort. The majority of the women interviewed expressed feelings of embarrassment, shyness, or discomfort about getting screened. These kinds of feelings and emotions, in part, result from their lack of exposure to and information about screening, culture, or individual personality traits (eg, introversion). For instance, many women, especially young women, indicated that they would feel embarrassed, shy, or extremely uncomfortable if they were to go through the screening procedure. They were particularly concerned about displaying their reproductive areas to a physician as part of the procedure, a behavior contrary to norms that dictate that reproductive organs should be kept private and exposed only to a sexual partner. Several women said, “They [Vietnamese women] are embarrassed and shy. One reason is that they are young and did grow up there [in Vietnam]. Girls are told that down there ... [in their] private parts. That's something to be kept in private” and “That's the most [source] of embarrassment, that is why I still have not done it [screening] yet.”
While most women identified culture as a major factor influencing their feelings of embarrassment, discomfort, or shyness, some women (especially younger women who had never been screened for cervical cancer) were likely to perceive an introverted personality as a prime factor, not culture. Women noted, “It's related to my personality.... I don't talk much. I don't talk about health. That's just me,” “I'd like to keep it [reproductive area] personal and private. I'm that kind of a person.” Some of these women also expressed that the physician's gender matters, and they would feel uncomfortable and anxious about having a male doctor examine their reproductive areas. One woman noted, “I don't know of any women who would want to go into [a doctor's] office and drop their pants! It's not really something normal.” Another woman stated, “It is totally discomfort. I mean ... it's weird for a male doctor to look at the bottom. I always prefer to have a female doctor.” This kind of discomfort and physician preference was apparent even among young women who were born and raised in the United States and thus were familiar with the mainstream American culture. This is, in part, because they were raised by parents who were first-generation immigrants, especially by mothers who held traditional cultures and norms. This ultimately influences their perceptions on health and actual behaviors regarding cervical cancer screening. Importantly, most of these young women perceived themselves as possessing 2 sets of cultures (eg, mainstream and ethnic of origin) that were equally influential in their everyday lives.
Appreciation, satisfaction. Although many negative aspects of affective attitudes emerged from the interviews, some positive attitudes regarding cervical health were also revealed. For instance, several women, especially older women, expressed that when they thought about cervical cancer, they felt blessed for not having it and being healthy and appreciated the fact that cervical cancer had not touched their lives. They were very satisfied about the screening procedures they had gone through in the past because the procedures had been thorough and performed by friendly doctors at clean facilities.
Comfort, familiarity, openness. Although the majority of women expressed discomfort related to screening, some stated that there had been changes in their levels of discomfort due to recurrent exposure to screening; thus, they were becoming more familiar and comfortable with the screening procedure. In particular, older women who were married and had experienced childbirths indicated that they were less nervous and less sensitive about showing their private reproductive areas to doctors, even to male doctors. This ultimately led women to feel comfortable undergoing screening procedures. Some women expressed feelings similar to this participant's statement: “I was scared when I went to the clinic for the first time to get screened, but after some time, I got used to it. It didn't feel bad at all. You just change clothes and let the doctor examine you.” These women also stated that they were likely to accept routine screening and were open to talking about reproductive health issues they considered to be private with their friends and primary doctors. As one participant said, “Cervical cancer screening isn't a big deal. I just tell myself it's just once a year that I have to get a check-up. I accepted it.... I opened up more to my doctors,”
Peace, calmness, assurance. Although some women indicated that waiting for the results of screening created feelings of anxiety and nervousness, they also stated that once they found out that the results were normal, they experienced peace, calmness, reassurance, and security knowing that they would not have to worry about cervical cancer until the next check-up.
Lack of susceptibility. Not having any signs or symptoms of sickness and illness caused many VAW and KAW to take it for granted that they were healthy and had no need for routine screening. One participant said, “If I don't have any symptoms or there is nothing wrong with my body, I don't go [to the clinic] and just don't have to deal with it.” Another said, “I don't need to get it [a Papanicolaou (Pap) smear]. It's not necessary, but if something is wrong below [reproductive areas], then I go and check it.” Some of these women also tended to perceive that they were not at risk for cervical cancer because there was no history of cervical cancer in their families or among close relatives. They also expressed that they would never expect to get cervical cancer because they ate a healthy diet and exercised regularly.
Misbeliefs and disbeliefs. The majority of women also held common misbeliefs in terms of causes and risk factors concerning cervical cancer. Women, especially young women, tended to believe that they did not need to get screened because they were single. A young woman said, “Because I'm a single, I don't care about it [getting screened].” These women shared the common misbelief that virginity prevented them from acquiring cervical cancer; that is, they equated sexual inactivity with no need for screening of cervical cancer. Some of these women also stated that having multiple sexual partners and sexual promiscuity could lead to cervical cancer, as one participant said, “I heard it's easier for those who have had lots of sexual partners to get it.” This kind of misbeliefs was apparent even among women raised and educated in the United States.
In terms of treatment of cervical cancer, some women were likely to believe that cervical cancer would be easier to treat and cure than other types of cancer. Such beliefs are, in part, rooted in their perceptions that cervical cancer is localized only in the uterus and thus if the entire uterus is removed, the cancer would be cured. One woman noted, “I'm under the impression that everything will be okay if we just get our wombs removed.” Another common misbelief prevalent in VAW and KAW was that just talking about cancer could actually lead to getting cancer. Accordingly, VAW and KAW are discouraged from talking about this topic. Moreover, for some women, talking about cancer is considered taboo. Ultimately, this leads them to have few opportunities to bring into conversation cancer-related topics in their daily lives and to learn about prevention and early detection of cervical cancer. In addition, some women do not believe in Western medicine and tend to rely on traditional remedies or herbal medicines of their homeland as a form of therapy when they get sick. Such mistrust in Western medicine prevents them from seeking health care services in the United States even when they experience abnormal signs and symptoms in their reproductive areas.
Limited knowledge and awareness. Lack of knowledge and awareness of cervical cancer and screening was deep and prevalent in Vietnamese and Korean participants' social networks. Many women indicated that they did not know what cervical cancer was, what caused it, and what the best way to prevent it or detect it early was. One participant noted, “I can't really say much about cervical cancer because I don't know anything about it.” Moreover, they did not know what Pap smears were (eg, purpose, procedures) and why they were important to their health. For instance, some women indicated that they were not even aware that a Pap smear was being performed when they went for a routine gynecologic checkup, suggesting that they did not fully understand the purpose and procedures of a cervical examination. Both VAW and KAW commonly stated that acid-base imbalances of their body, stress, lack of exercise, unhealthy diets and foods, environmental pollutions, and lack of sanitation in their perineal areas could cause cervical cancer. Most importantly, some of these women often expressed that “not knowing” or “avoiding thinking” about illnesses, cancer in particular, was the best way to manage their health or maintain a healthy life.
Perceived empowerment. Although most women often had misperceptions about cervical health and were minimally aware of the importance of routine screening, some perceived themselves as strong enough to stand up for their health. This perception, in part, was based on their current job status or previous illnesses they had gone through. For example, some Vietnamese women stated that they had income and benefits from a job that could pay for their own health care costs; thus, if they had health problems, they could seek health care services, regardless of their husband's or partner's financial support. These women also held the view that controlling their own sexual relationships was another way to exercise empowerment and to protect their health from illnesses, including cervical cancer. In particular, they emphasized that if they were to be able to have control over their own health care and ask questions to obtain more information about the procedures they were receiving from their provider, they could make more informed decisions about their health (eg, screening). Ultimately, this would lead them to perceive they had the power to control their own health.
Perceived autonomy. Women who were older or had previously recovered from critical medical conditions tended to consider their health a priority. This propelled them to put effort into maintaining and checking their health, including screening for cervical cancer. One woman stated, “I didn't really care about it [health] a lot, but now it's all about being healthy ... living in that way is the most beautiful thing in the world. In order to do that.... I put an effort. I push myself into action [related to screening].” These women also believed that God did not provide cures for them; thus, it was critical to seek out treatment from health professionals if they had health problems. Older women, in particular, were more inclined to think about their health as a priority because they were at increased risk for illnesses. They felt compelled to seek preventive screening practices and often sought health-related information by questioning pharmacists, relatives, and friends who were in health care fields or by searching the Internet. One woman noted, “Even though no one tells me to do it [a Pap smear], that's something that I do on my own. I think it's something I need to do.” Another woman stated, “I was told that I had to get it [a Pap smear] done, so I went and got it. That's the only way I would feel safe ... because people get older, there's a risk of getting things especially like cancer. So, I went and got it because I felt more compelled, especially now, to pay more attention to it [cervical cancer].' Another participant said, “I think we should be aggressive about it [prevention].”
Perceived self-care. Some women felt that they had to take care of their own health and could protect it if they got old and sick; if they were not able to do so, they would rather die than place a burden on their family. They perceived healthy aging as a prime issue, and this ultimately influenced them to put tangible efforts into seeking a healthy lifestyle (eg, healthy diets, exercise) and regular checkups for cervical cancer. If they were ill, they often used traditional remedies based on their own past experiences or suggestions of their relatives or peers who had recovered from similar or the same health problems. In addition, when their health problem was serious and needed to be evaluated, they self-referred to a doctor.
Cervical cancer health behaviors
On the basis of the aforementioned affective emotions, feelings, and/or cognitive evaluations, or judgments, VAW and KAW conveyed 3 major types of cervical health behaviors, which are avoidance, ambivalence, and acceptance (3As).
Most VAW and KAW preferred not to openly talk about cervical cancer with their family members, peers, or relatives or to seek relevant information and recommended routine screenings. Such behavior, in part, was based on common misperceptions that (1) if they were to talk about cancer, they would ultimately get it (ie, words become seeds), and (2) if they were to try to learn more about cervical cancer, they would find more cervical health–related problems. The avoidance of saying words such as “cancer” was also, in part, due to fearful feelings about death associated with cancer. Most of the women were aware of the potential risks of getting cancer as they got older and recognized the possibility that they might die if they were to get it; yet, they consciously tried to minimize such feelings and avoided bringing cancer-related topics into conversations. These women often indicated that “not knowing” the facts about cancer was a way to live without emotional stress and worry and to remain healthy and at peace. They tended to perceive that health was not an imminent issue and that it would be unlikely that they would ever get cancer. This ultimately led them to separate themselves from the concept of cancer prevention in their everyday lives and not to take any action for early detection of cervical cancer.
Some women indicated that they were well aware of the importance of being screened yet were not ready to take action. They experienced emotional pressure to undergo screening, yet this did not transfer to the tangible action of actually doing it. They expressed a great deal of emotional hesitance or feelings of uncertainty about whether to undergo cervical cancer screening procedures. This ultimately led them to delay initiating a first-time screening or to be less likely to be compliant with the recommended routine screenings in a timely manner.
Although most VAW and KAW practiced negative or ambivalent behaviors with regard to cervical cancer and screening, some of the women acknowledged that health was of utmost importance in their lives. Accordingly, they vigorously sought health advice and information from peers and doctors and complied with routine health checkups as recommended. In particular, older women who had critical illnesses in the past perceived themselves as strong warriors who could fight and stand up for their health. They were very aggressive about their own health care and prevention and developed strategies to balance their time and effort for their families and themselves (eg, setting up a “get away from family” time, building a socializing venue for monthly peer gatherings). They talked about a positive self-image and felt proud of themselves, given that they had a job that enabled them take care of their own health without a partner's or spouse's support. They said that they had to value their health not only for themselves but also for their families and ensure that their health was taken care of as needed.
This study explored the affective and cognitive aspects of attitudes toward cervical cancer and health behaviors (and their underlying factors) among VAW and KAW living in New Mexico. The findings shed light on where these bidimensional aspects of attitudes are rooted and how each of them influenced, independently or in combination with the other components, actual cervical cancer screening–seeking behaviors (including searching for health-related information) in these populations. The results support the view that intervention strategies to maximize screening and early detection of cervical cancer in VAW and KAW must be tailored not only to attitudinal attributes (affect and cognition) but also to different types of behaviors (avoidance, ambivalence, and acceptance) that are uniquely manifested among these women.
More specifically, for women who hold positive attitudes toward cervical cancer health and vigorously seek screening and medical advice, continuous reinforcement of their efforts and encouragement for maintaining their health care prevention practices might be an appropriate strategy. In contrast, for those who have never obtained cervical cancer screening or do not want to talk about cancer-related topics, initial exposure to general health and wellness programs through health fairs, for example, or by presenting “health talks” at venues such as the Asian community center might be a realistic approach. This could ultimately motivate these women to start thinking about the issue of cancer and to gradually discuss the topic without experiencing unpleasant emotions. Finally, for women who are well aware of the importance of obtaining cervical cancer screening but have never received it, provocative intervention strategies (eg, peer pressure; direct, hands-on assistance with appointment scheduling and transportation, peer-escort clinic visits) that could change their awareness and resolutions into tangible action might be influential and appropriate. This underscores the fact that simply acquiring knowledge about the relationship between cervical cancer screening and health or being aware of the importance of cancer screening does not automatically translate into overt actions that lead to getting screened. To transform knowledge into actions, it is important to develop intervention strategies that are tailored to individual needs and levels of readiness to take action. The use of such strategies should increase uptake of screening practices among racial and ethnic minority women.40,41
The study findings also suggest that attitudes and subsequent cervical health behaviors of VAW and KAW appear to be, in part, rooted in preexisting external (eg, SES, country of origin, resources) and/or internal (eg, personality, illness exposure) attributes that may or may not be malleable as a result of cancer intervention programs (Figure). Some of these external and/or internal attributes reported in this study are consistent with findings revealed in previous studies,42–44 whereas others are not.10,45
For example, consistent with previous findings,42–44 the current study shows that factors such as marital status, age (or aging), and cultural norms are important determinants of attitudes and/or behaviors toward cervical health in VAW and KAW; that is, women who are older, married, or less attached to their own ethnic traditional norms tend to hold more positive attitudes toward cervical cancer prevention and engage in more proactive health behaviors. This suggests that intervention strategies should not only take into account culture-specific concerns but also maximize the effectiveness of these interventions in changing cervical health behaviors and perceptions in these populations they should be designed to target young and single women.
Some of the findings derived from this study, to some degree, are not consistent with the results of previous studies.10,45 For instance, some studies have reported that immigration, education, and/or insurance status are major determinants of cervical health perceptions and/or behaviors.10,45 Contrary to these findings, the results of this study show that cervical health–related perceptions, attitudes, and behaviors of VAW and KAW vary, regardless of levels of education, insurance, and/or immigration status; that is, some women had never been screened for cervical cancer despite the fact that they were covered by health insurance, highly educated, and aware of the importance of cervical cancer screenings. In particular, young women who were born and raised in the United States and thus were familiar with mainstream American culture expressed great levels of reluctance, discomfort, and anxiety about visiting health clinics for the purpose of obtaining cervical cancer screening.
Moreover, most of these young women held a dual cultural identity (ie, mainstream and ethnicity of origin culture) that easily wavered between one culture and the other, depending on the group of people they interacted with and the circumstances they found themselves in. For instance, if they interacted with people from the mainstream culture, they would be more likely to endorse norms and values that were consistent with the American culture whereas if they interacted with members of their same ethnicity community, they were more likely to view themselves as part of the ethnic group and tried to comply with the corresponding cultural norms and values.
Most importantly, when it comes to engaging in decision-making processes related to health-related issues (eg, cancer screening), these young women tended to heavily rely on the ethnic cultural norms held by their parents (who were first-generation immigrants). That is, these young women's perceptions about health and health care–seeking behaviors differed on the basis of the values and perceptions of the concept of health that their parents endorsed (especially their mothers). This parental influence on cervical health behaviors among these populations, to our knowledge, corresponds to a unique finding not previously reported before. This finding suggests that when developing intervention programs targeting young VAW and KAW, family dynamics and the value systems of their parents must be systemically explored and incorporated into the intervention programs.
Another important and unique finding from this study is that among VAW and KAW, ethnic culture is not always a prime factor affecting attitudes and behaviors related to seeking cervical health services. Although most of the VAW and KAW reported that traditional culture and norms may constitute a major barrier preventing seeking cervical health services, some women, especially those who were young and/or had never been screened for cervical cancer, claimed that their own personal traits (eg, introversion, stubbornness, shyness) were the most important factors underlying their reluctance to seek cervical cancer screening. In fact, culture and personal traits are not explicitly independent concepts; rather, they are, to some degree, interrelated. Culture influences the way people live, learn, and behave and, ultimately, shapes some aspects of their personality traits.46 Nonetheless, it is important to note the finding that some VAW and KAW view personal characteristics within the individual self as qualities that transcend culture and norms embedded in their ethnic community. This finding supports the view that although interventions tailored to their unique culture are necessary, they are not sufficient to maximize the effects on changes in attitudes and behaviors related to cervical health in these populations. Therefore, developing interventions that target some elements of personal traits is also necessary.
Finally, although the current study constitutes the first attempt, to our knowledge, to assess the bidimensional aspects of attitudes and their subsequent effects on behaviors related to cervical health, the qualitative nature of the study limits the generalization of the findings to other racial and ethnic groups living in different regions of the United States. Importantly, the nature of this study prevented us from arriving at a conclusion about whether different types of cervical health behaviors among VAW and KAW are based more on affective than cognitive components, or vice versa, or that both are equally influential. To determine the relative importance of each of these 2 components in explaining cervical health–related behaviors, quantitative research should be conducted. Such research would provide in-depth insight into whether cervical cancer intervention programs should emphasize messages that promote changes based on affective or cognitive components of attitudes, or both. In other words, if VAW's and KAW's attitudes toward cervical health behaviors were to be more cognitive based, then interventions that aim to change their attitudes with logical arguments and explanations would be more appropriate; however, if attitudes were more affective based, interventions that use emotional appeals would be more successful.
2. Jin H, Pinheiro PS, Xu J, Amei A. Cancer incidence among Asian American
populations in the United States, 2009-2011. Int J Cancer. 2016;138(9):2136–2145.
3. Torre LA, Sauer AM, Chen MS Jr, Kagawa-Singer M, Jermal A, Siegel RL. Cancer statistics for Asian Americans, Native Hawaiians, and Pacific Islanders, 2016: converging incidence in males and females. CA Cancer J Clin. 2016;66(3):182–202.
4. Centers for Disease Control and Prevention. United States cancer statistics: data visualizations. http://www.cdc.gov/cancer/dataviz
. Published 2018. Accessed July 5, 2018.
6. Seol HJ, Ki KD, Lee JM. Epidemiologic characteristics of cervical cancer
in Korean women. J Gynecol Oncol. 2014;25(1):70–74.
7. Kweon SS. Updates on cancer epidemiology in Korea, 2018. Chonnam Med J. 2018;54(2):90–100.
9. Chawla N, Breen N, Liu B, Lee R, Kagawa-Singer M. Asian American
women in California: a pooled analysis of predictors for breast and cervical cancer
screening. Am J Public Health. 2015;105(2):e98–e109.
10. Do M. Predictors of cervical cancer
screening among Vietnamese American women. J Immigr Minor Health. 2015;17(3):756–764.
11. Lee HY, Ju E, Vang PD, Lundquist M. Breast and cervical cancer
screening among Asian American
women and Latinas: does race/ethnicity matter? J Womens Health. 2010;19(10):1877–1884.
12. Pourat N, Kagawa-Singer M, Breen N, Sripipatana A. Access versus acculturation: identifying modifiable factors to promote cancer screening among Asian American
women. Med Care. 2010;48(12):1088–1096.
13. White A, Thompson TD, White MC, et al Cancer screening test use—United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):201–206.
14. Burger EA, Lee K, Saraiya M, et al Racial and ethnic disparities in human papillomavirus (HPV)-associated cancer burden with first- and second-generation HPV vaccines. Cancer. 2016;122(13):2057–2066.
15. Garland SM, Pitisuttithum P, Ngan HYS, et al Efficacy, immunogenicity, and safety of a 9-valent human papillomavirus vaccine: subgroup analysis of participants from Asian countries. J Infect Dis. 2018;218(1):95–108.
16. Naud PS, Roteli-Martins CM, De Carvalho NS, et al Sustained efficacy, immunogenicity, and safety of the HPV-16/18 AS04-adjuvanted vaccine: final analysis of a long-term follow-up study up to 9.4 years post-vaccination. Hum Vaccin Immunother. 2014;10(8):2147–2162.
17. Kim B, Kim J, Kim S, Kim D. What is the awareness, perception, and rate of HPV vaccination and Pap screening amongst Korean American women? Obstet Gynecol. 2016;127(suppl 1):56S.
18. Okafor C, Hu X, Cook RL. Racial/ethnic disparities in HPV vaccine uptake among a sample of college women. J Racial Ethn Health Disparities. 2015;2(3):311–316.
19. Yi JK, Anderson KO, Le YC, Escobar-Chaves SL, Reyes-Gibby CC. English proficiency, knowledge, and receipt of HPV vaccine in Vietnamese-American women. J Community Health. 2013;38(5):805–811.
20. Kim K, Kim B, Choi E, Song Y, Han HR. Knowledge, perceptions, and decision making about human papillomavirus vaccination among Korean American women: a focus group study. Womens Health Issues. 2015;25(2):112–119.
21. Lee HY, Choi YJ, Yoon YJ, Oh JJ. HPV literacy in Korean American women: does English proficiency matter? Poster presented at: SSWR Society for Social Work and Research 2018 Annual Conference; January 10-14, 2018; Washington, DC.
22. Yi J, Lackey S, Zahn M, Castaneda J, Hwang J. Human papillomavirus knowledge and awareness among Vietnamese mothers. J Community Health. 2013;38(6):1003–1009.
23. Early J, Armstrong SN, Burke S, Thompson DL. US female college students' breast health knowledge, attitudes
, and determinants of screening practices: new implications for health education. J Am Coll Health. 2011;59(7):640–647.
24. Hofmann W, Rauch W, Gawronski B. And deplete us not into temptation: automatic attitudes
, dietary restraint, and self-regulatory resources as determinants of eating behavior. J Exp Soc Psychol. 2007;43(3):497–504.
25. Liu X, Erasmus V, Sun X, Cai R, Shi Y, Richardus JH. Preventing HIV transmission in Chinese internal migrants: a behavioral approach. Sci World J. 2014;2014:319629.
26. Sheeran P, Maki A, Montanaro E, et al The impact of changing attitudes
, norms, and self-efficacy on health-related intentions and behavior: a meta-analysis. Health Psychol. 2016;35(11):1178–1188.
27. Miyagi E, Sukegawa A, Motoki Y, et al Attitudes
toward cervical cancer
screening among women receiving human papillomavirus vaccination in a university-hospital-based community: interim 2-year follow-up results. J Obstet Gynaecol Res. 2014;40(4):1105–1113.
28. Ogbonna FS. Knowledge, attitude, and experience of cervical cancer
and screening among sub-Saharan African female students in a UK University. Ann Afr Med. 2017;16(1):18–23.
29. Penaranda E, Molokwu J, Flores S, Byrd T, Brown L, Shokar N. Women's attitudes
towards cervicovaginal self-sampling for high-risk HPV infection on the US-Mexico Border. J Low Genit Tract Dis. 2015;19(4):323–328.
30. Rahman H, Kar S. Knowledge, attitudes
and practice toward cervical cancer
screening among Sikkimese nursing staff in India. Indian J Med Paediatr Oncol. 2015;36(2):105–110.
31. Farley SD, Stasson ME. Relative influences of affect
on behavior: are feelings or beliefs more related to blood donation intentions? Exp Psychol. 2003;50(1):55–62.
32. Sánchez-García M, Batista-Foguet JM. Congruency of the cognitive and affective components of the attitudes
as a moderator on intention of condom use predictors. Soc Indicators Res. 2008;87(1):139–155.
33. Millar MG, Millar KU. Affective and cognitive responses to disease detection and health promotion behaviors. J Behav Med. 1993;16(1):1–23.
34. Lawton R, Conner M, McEachan R. Desire or reason: predicting health behaviors from affective and cognitive attitudes
. Health Psychol. 2009;28(1):56–65.
35. Verplanken B, Hofstee G, Janssen HJW. Accessibility of affective versus cognitive components of attitudes
. Eur J Soc Psychol. 1998;28(1):23–35.
36. De Wit R, Victoir A, den Bergh OV. “My mind's made up by the way that I feel”: affect
and intention in the structure of attitudes
toward condom use. Health Educ Res. 1997;12(1):15–24.
37. Richardson JG, Trafimow D, Madson L. Future health-related behavioral intention formation: the role of affect
. J Soc Psychol. 2012;152(6):775–779.
38. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288.
39. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Thousand Oaks, CA: Sage; 1994.
40. Tetroe JM, Graham ID, Scott V. What does it mean to transform knowledge into action in falls prevention research? Perspectives from the Canadian Institutes of Health Research. J Safety Res. 2011;42(6):423–426.
41. World Health Organization. Comprehensive Cervical Cancer
Control: A Guide to Essential Practice. 2nd ed. Switzerland, Geneva: World Health Organization; 2014.
42. Hanske J, Meyer CP, Sammon JD, et al The influence of marital status on the use of breast, cervical, and colorectal cancer screening. Prev Med. 2016;89:140–145.
43. Lee EE, Eun Y, Lee SY, Nandy K. Age-related differences in health beliefs regarding cervical cancer
screening among Korean American women. J Transcult Nurs. 2012;23(3):237–245.
44. Lee HY, Yang PN, Lee D, Ghebre R. Cervical cancer
screening behavior among Hmong-American immigrant women. Am J Health Behav. 2015;39(3):301–317.
45. Shi L, Lebrun LA, Zhu J, Tsai J. Cancer screening among racial/ethnic and insurance groups in the United States: a comparison of disparities in 2000 and 2008. J Health Care Poor Underserved. 2011;22(3):945–961.
46. Benet-Martínez V, Oishi S. Culture and personality. In: John OP, Robins RW, Pervin LA, eds. Handbook of Personality: Theory and Research. 3rd ed. New York, NY: The Guilford Press; 2010: 542–567.
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved
affect; Asian American; attitudes; cervical cancer; cognition