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Affective and Cognitive Attitudes on Cervical Health Behaviors Among Asian American Women

Lee, Jongwon, PhD, RN; Carvallo, Mauricio, PhD; Lee, Eunice, PhD, RN, FAAN; Chung, Jane, PhD, RN; Shin, Chanam, PhD, RN

doi: 10.1097/FCH.0000000000000216
Original Articles

Cervical cancer is a major cause of death for Vietnamese and Korean American women, yet their screening rates remain low. This study explored factors influencing cervical health behaviors of these populations, using a 2-dimensional model (ie, affect and cognition) of attitude structure approach. Semistructured interviews were conducted with 33 participants. A semantic content analysis was used to identify major codes and themes across the transcripts. Multiple aspects of both negative and positive affect and cognition, which led to 3 different cervical health behaviors (avoidance, ambivalence, and acceptance), emerged from the interviews. The clinical implications of these findings are discussed.

College of Nursing, The University of New Mexico, Albuquerque (Dr J. Lee); Department of Psychology, University of Oklahoma, Norman (Dr Carvallo); UCLA School of Nursing (Dr E. Lee); Virginia Commonwealth University School of Nursing, Richmond (Dr Chung); and Arizona State University College of Nursing and Health Innovation, Phoenix (Dr Shin).

Correspondence: Jongwon Lee, PhD, RN, College of Nursing, The University of New Mexico, MSC 07 4380, Box 9, 1 University of New Mexico, Albuquerque, NM 87131 (

The authors have no conflicts of interest to declare.

INCIDENCE AND MORTALITY rates of cervical cancer have dramatically decreased across all 4 major racial/ethnic groups in the United States, including Asians.1 However, the latest estimates suggest that cervical cancer still represents a significant health risk for some Asian American subgroups, in particular, Vietnamese American women (VAW) and Korean American women (KAW). For example, the cervical cancer incidence rate for VAW (9.0-9.5/100 000) ranks as one of the highest in the nation.2,3 This incidence rate is much higher than that for non-Hispanic whites (6.8-7.5/100 000) and similar to that for African and Hispanic Americans (8.6-9.4/100 000) in the United States1,2,4 Similarly, the cervical cancer incidence rate for KAW ranks as the third highest (7.2-7.5/100 000) among major Asian American subgroups.2,3 This incidence rate remains higher than the average rate for Asian American women as a whole (6.0-6.5/100 000) and similar to that of non-Hispanic whites (6.8-7.5/100 000).1–3 Moreover, the high incidence rates for cervical cancer in these 2 groups are similar to the latest trends reported in their homeland (10.6/100 000 and 9.1/100 000, respectively). When taking into account that the vast majority of Vietnamese and Korean populations in the United States are foreign-born (83.7% and 78.5%, respectively), we could consider that their migration to the United States might, in part, contribute to such high prevalence of cervical cancer.5–8

Despite these relatively high incidence rates, both VAW and KAW consistently report lower rates of cervical cancer screening (70%-81% and 68%-79%, respectively) compared with other major Asian American subgroups (72%-89%) and non-Hispanic whites (84%-88%).9–13 More importantly, despite evidence showing that human papillomavirus (HPV), one of the major etiologic agents causing cervical cancer, can be easily prevented by vaccines for girls and women aged 11 to 26 years,14–16 both groups report the lowest rates of HPV vaccine completion (9%-33%) across all major racial/ethnic groups (45%-78%) in the United States.17–19 In addition, research shows that VAW and KAW report low awareness of the fact that HPV is a major cause of cervical cancer and that a series of vaccines are readily available to protect against HPV infection and the development of precancerous and cancerous lesions surrounding the cervix.19–22

An extensive body of research has highlighted the importance of exploring attitudes as key determinants of health-related behaviors.23–26 Accordingly, a number of studies have explored such psychological aspects of women's health behaviors, including those related to cervical cancer.27–30 Most importantly, researchers not only have focused on general attitudes toward a specific attitudinal object but also have recognized the importance of distinguishing between 2 different components of attitudes: affective and cognitive. The affective component of attitudes refers to the magnitude or direction of affect related to an attitudinal object (desires, feelings, drives, emotions, etc).31,32 The cognitive component of attitudes refers to one's perceptual responses or verbal statements of beliefs, judgments, thoughts, or expectations toward an attitudinal object.31,32 These 2 distinctive yet interrelated bidimensional components of attitudes have been widely used in an attempt to explain or predict an individual's behavior in the area of social and behavioral science.

For example, in a study on how these bidimensional attitudes are associated with disease detection behaviors versus health promotion behaviors,33 the researchers demonstrated that affective responses play a more important role in behaviors of disease detection (eg, cholesterol-level check, skin cancer check), whereas cognitive responses play a more relevant role in behaviors of health promotion (eg, low-fat diets, sunscreen use). Another similar study indicated that the influence of affective attitudes may be stronger for types of health behaviors that are viewed as having a more immediate impact on people's psychological state (eg, smoking, drinking alcohol, dieting, and exercise) and weaker for behaviors deemed to have a less immediate impact, such self-examination or screening.34 Research also shows that affective attitudes are more accessible in memory than cognition-based attitudes.35 Thus, they are more likely to influence health-related behaviors.

The aforementioned findings suggest that an individual's behaviors are not always based on the cognitive aspects of attitudes, such as reasoned judgments, perceptions, beliefs, or values one may have about an attitudinal object (eg, risks, benefits, costs). Rather, the behavior may be driven solely by automatic affective responses or in combination with cognitive evaluations of an attitudinal object.31,32,34 More importantly, these findings support the view of a bidimensional, affective-cognitive structure of attitudes and emphasize the importance of distinguishing between these 2 components and exploring them separately.31,32,34,36,37 These views on attitudinal entities are extremely important, especially in studies exploring complex human behavior, such as that related to cervical cancer and health, because they could guide health care researchers to develop intervention messages that are more persuasive based on appeals that target either the affective or cognitive components of attitude, or both.

To our knowledge, there is no single empirical study exploring an affect-cognition model of attitudes toward cervical cancer and health behaviors. To address this research gap, the current study explored cervical cancer health behaviors and underlying factors affecting such behaviors within the 2-dimensional structures of attitudes among VAW and KAW living in New Mexico. The findings from this study can help enhance health care researchers' understanding of how these 2 separate components of attitudes (affective and cognitive) are interrelated and may predict subsequent cervical health–related behaviors. Ultimately, they could facilitate the development of more efficient and responsive interventions that promote changes in cervical health behaviors.

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A descriptive, qualitative research approach was used to explore affective and cognitive aspects of attitudes toward cervical health behaviors and factors underlying cervical cancer screening among VAW and KAW in New Mexico. Approval to conduct this study was obtained from the University of New Mexico Human Research Review Committee.

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Sample and settings

A total of 33 VAW (n = 16) and KAW (n = 17) were conveniently sampled from ethnic beauty salons that were operated by Vietnamese or Korean female cosmetologists in Albuquerque, New Mexico, and served predominantly Vietnamese or Korean women, respectively. Data saturation was used as a guiding principle to determine the sample size necessary for this study. On the basis of this approach, a sample of 33 participants was determined to be appropriate for uncovering most or all of the themes and categories that were important in the analyses conducted. Inclusion criteria for this study required participants to self-identify as Vietnamese or Korean, be 18 years or older, and be able to speak and understand their own native language.

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Data collection procedures

Fifteen ethnic beauty salon owners were approached by the principal investigator (PI) and 2 research coordinators fluent in both English and the Vietnamese or Korean language. Among them, 12 salon owners (5 Korean; 7 Vietnamese) granted permission to use their beauty salon as a place to recruit participants (customers and employees). The research coordinators, along with the PI's assistance, visited the salons run by their same ethnic cosmetologist and approached each of the potential participants in the salons to identify whether they were eligible and interested in participating in the study. Once a participant was identified as eligible and interested in the study, the coordinator and the PI guided her to a private room in the salon and explained the study purpose, the approximate time needed for completion of the study, and her rights as a study participant. Signed consent forms were collected after providing sufficient time to ask any questions the participant might have about the study. For those working at the beauty salons who expressed interest but could not participate because of their busy work schedule, date, time, and place outside their regular working hours that were most convenient (eg, before or after work or on weekends, at the PI's home) was arranged.

A qualitative interview guide with 4 open-ended questions was developed by the PI and another coinvestigator. The semistructured individual interview was conducted by the coordinators, along with the PI's assistance and guidance. The interview lasted approximately 40 to 60 minutes. All interviews were conducted in the participant's primary language, audiotaped, and transcribed verbatim in Vietnamese or Korean by transcriptionists fluent in those languages. The transcripts were then further translated into English by professional translators for analysis.

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Data analysis

ATLAS.ti (version 7; ATLAS.ti Scientific Software Development, Berlin, Germany), a qualitative data analysis software program, was used for analysis. A content analytic approach was used to analyze each of the transcripts line by line and to identify codes, categories, themes, and patterns within and across the transcripts.38,39 Before the analysis, a coding scheme was developed to ensure the consistency of coding among the investigators. A codebook that included codes and their corresponding definitions and example quotes was also developed. An audit trail was used to trace and make transparent logics and key decisions by the investigators throughout the analytic process. The PI and the other investigators conducted an initial analysis of the transcripts independently and collectively and identified the broad themes and codes that emerged from the data. Categories and subcategories were then constructed and labeled by grouping and merging substantive themes and codes with similar meanings and were compared for their patterns.

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Multiple perspectives on cervical health behaviors and their underlying factors emerged from interviews of 33 VAW and KAW (Table). Importantly, these perspectives were similar in both VAW and KAW despite the difference of ethnicity and country of origin, suggesting that perceived cultural similarities in the concept of cancer and health exist in both groups, which originated from 2 neighboring subregions of Asia (ie, Southeast and East Asia). The majority of the women interviewed expressed their views on cervical cancer and health behaviors in both negative and positive forms within the 2-dimensional structure of attitudes. Both negative and positive forms of affective and cognitive attitudes appeared to be, in part, influenced by external (eg, age, socioeconomic status [SES]) or internal (eg, health history, personality) attributes that may or may not be malleable by means of cancer prevention programs. Most importantly, both negative and positive attitudes were intertwined as a whole; that is, negative aspects of affective (eg, fear) and/or cognitive (eg, lack of knowledge) attitudes did not necessarily lead to negative intentions and behaviors (eg, no screening), and vice versa (Figure). The findings were organized on the basis of both negative and positive forms of responses to the affective and cognitive structures of attitudes.





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Affective attitudes

Negative responses

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.

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Positive responses

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.

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Cognitive attitudes

Negative responses

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.

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Positive responses

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.

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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).

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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.

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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.

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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.

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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.

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affect; Asian American; attitudes; cervical cancer; cognition

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