Background: Cervical cancer is still the most common cancer among women worldwide and the leading cancer cause of death in many countries, in particular developing countries. The lifetime experience, social-economic status, sexual behaviour, environmental factors and ethnic or racial origin of women have been recognised as major risk determinants of cervical cancer. Vietnamese women who migrate to Western countries experience an incidence of cancer higher than that of the host country but at a level consistent with cervical cancer incidence in the South of Vietnam today. Yet Vietnamese-born women are less likely to attend for Pap smear screening.
Objective: This study investigated the patterns of exposure to risk of women at different stages of their lives in Vietnam, during migration, and in Australia. Their knowledge, perceptions and attitudes to cervical cancer screening were studied and related to their past exposure to risk factors.
Methods: During the study period (January 1996 to November 2000), a total of 300 Vietnamese women resident in the South Western Sydney area were interviewed. A personal interview, lasting an average of 1 hour was conducted with each participant to obtain detailed information on demographic, migratory, reproductive, sexual, contraceptive, medical and dietary histories. Women were focused to discuss various issues in relation to the effects of social change and problems of adaptation. How they were exposed to risk over their lives, and factors influencing their attitudes, perceptions and knowledge of cervical cancer and screening.
Results: The majority of Vietnamese women born in Vietnam came from remote areas, others had been forced to leave cities and lived under conditions of hardship. More than half of the women reported gynaecological symptoms and married before departure. Some women were married at a very young age (<15 years). Most women spent between one to two years in the refugee camp before they were accepted to live in Australia. Living conditions were described as poor or very poor in all camps. The women experienced sickness that they attributed to their very poor diet and very poor genital and menstrual hygiene. About half of the women experienced gynaecological symptom; hygiene was poor in the camps. The frequency of symptoms associated with duration of the journey and the length of stay in the refugee camps. Miscarriage occurred in some women during their stay in the refugee camp.
Although issues related to HPV infection were not explored within the sample in this study, social and cultural factors associated with the transmission of HPV infection were explored comprehensively and in-depth. Sexual behaviour and practice among Vietnamese women and men have been explored largely in relation to gender, sexual orientation, and in different social, economic, environmental and political contexts. The strongest identified risks, relating to cultural influence and social norms within Vietnamese communities, are the normalisation of extra marital sexual relationships for men, restricted access to knowledge about sexually transmitted disease and inadequate safe sex practices for preventing HPV infection.
Pap smear screening in Australia: in relation to conditions in Vietnam, Vietnamese born women who were unlikely to be screened were poorly educated, unemployed, living in rural area, poorly living in Vietnam, poor genital hygiene, poor water sanitation hygiene. In relation to conditions in Australia, unscreened Vietnamese women were poor English comprehension, lack of education, unemployed, and also living in poor conditions. The majority of Vietnamese women believed that they were too healthy to have a Pap smear, or it was too costly to have a Pap smear, or else felt too embarrassed to have a Pap smear.
Conclusions: This study's findings provide a significant contribution to public health research and implications for national and international women's health policy development and practice. A profile of Vietnamese-born women who have experienced a physically and psychologically stressful life course and who are extremely vulnerable to cervical cancer risks has been presented in this research.
A limitation in this study relates to HPV which is regarded as the main factor in the development of cervical cancer. HPV status was not explored in this sample. However, striking factors which were identified in this study related to social risks, such as continuous social network disruption and poverty experienced in Vietnam. Also identified were inadequate safe sex practices for preventing infection and the acceptance of the women of their husbands' extra marital sexual partners.
The identified factors have significant inter-related impacts on Vietnamese women. Firstly, their biological responses to health risks and the impact of their early life course experience, such as social disruption, placed them at high risk of exposure to cervical cancer. Secondly, as a result of social disruption, women also experienced poverty and poor living and working conditions and poor social cohesion, leading to isolation which has compounded their unfamiliarity with Australia's health care system.
Thirdly, cultural impacts have been found to be of great influence on the sexual health behaviours of Vietnamese women. Submission and acceptance of husbands' or partners' extramarital sexual relationship place women at high risk of developing cervical cancer. Women who came to Australia at an older age (>40 years) were found to be at a higher risk due to their early age at first sexual experience. Fourthly, environmental impacts have been identified as strong predictors for risk of developing cervical cancer such as poor environment (inadequate nutrition and sanitation) and poor facilities, which contributed to poor menstrual hygiene. Water and soil pollution due to Agent Orange, and other chemicals used by the US army, caused miscarriages, birth defects and agricultural and environmental destruction.
Strategies to increase the participation of Vietnamese women in cervical cancer screening programs in Australia have been identified and, an innovative model has been developed for implementation in Vietnamese communities in south western Sydney and Australia. That is, how must Australia's health system respond to increase the choices and opportunities for Vietnamese women to seek Pap tests and cervical cancer information.