Barriers faced by Vietnamese immigrant women in Taiwan who do
not regularly undergo cervical screenings: a qualitative study Fang Hsin Lee, Hsiu Hung Wang, Yung Mei Yang & Hsiu Min Tsai Accepted for publication 6 April 2013 Corresponding to H.H. Wang: e-mail: hhwang@kmu.edu.tw Fang Hsin Lee MSN RN Lecturer, Doctoral student Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan and College of Nursing, Kaohsiung Medical University, Taiwan Hsiu Hung Wang PhD RN FAAN Professor and Dean College of Nursing, Kaohsiung Medical University, Taiwan Yung Mei Yang PhD RN Assistant Professor College of Nursing, Kaohsiung Medical University Kaohsiung, Taiwan Hsiu Min Tsai PhD RN Associate Professor Department of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan LEE F. H. , WANG H. H. , YANG Y. M. & TS AI H. M. ( 2014) Barriers faced by Vietnamese immigrant women in Taiwan who do not regularly undergo cervical screenings: a qualitative study. Journal of Advanced Nursing 70(1), 8796. doi: 10.1111/jan.12168 Abstract Aim. To assess and understand the barriers faced by Vietnamese marital immigrant women who do not regularly undergo cervical screenings in Southeast Taiwan. Background. Studies have shown a low uptake rate of preventive medical services among immigrants. As immigrant women may not be aware of the healthcare delivery system in their host country, their uptake of and access to healthcare services might be limited. Design. A qualitative, descriptive inquiry design was adopted. Methods. This qualitative study employed semi-structured, individual, in-depth interviews of 17 Vietnamese immigrant women. Data were collected from FebruaryJuly 2011 and analysed using content analysis. Findings. The barriers to receiving cervical screening were lack of health literacy, lack of female healthcare providers, negative perceptions of cervical screening and personal reasons. Conclusion. The results might serve as a reference for government entities and healthcare providers in Taiwan to improve cervical screening rates; this should help enhance the effectiveness of healthcare services for Vietnamese immigrant women. The ndings can also provide a reference for making appropriate healthcare policies for immigrant women in other countries. Keywords: barriers, cancer nurse, cervical cancer, cervical screening, immigrant women, qualitative method, Vietnamese Introduction International migration and marriage immigration are trending upward in many countries. Immigrants usually have poorer health and experience more barriers to the uptake of healthcare services than native populations (Shin et al. 2007, Noymer & Lee 2013). Immigrant women living in developed countries usually represent vulnerable popula- tions because of their patriarchal and subservient societal structures (Yang & Wang 2011). Therefore, immigrant health care is an important issue in developed countries throughout the world (Steele et al. 2002, Guerin et al. 2013 Blackwell Publishing Ltd 87 J AN JOURNAL OF ADVANCED NURSING 2005). Due to trends in international migration and Taiwans economic development, exchange between Taiwan and foreign countries has expanded in recent years. Under these circumstances, marriage immigration has become a common phenomenon in Taiwanese society. According to the Taiwan National Immigration Agency (2011), 131,992 Taiwanese people had foreign-born spouses from Southeast Asian countries with conrmed certicates of alien resi- dency. Among these foreign spouses, the largest group consisted of Vietnamese people (648%), followed by Indo- nesian (206%), Thai (60%) and Filipino (54%) (National Immigration Agency 2011). Research has suggested that immigrants tend to display low uptake rates of healthcare services, especially for preventive health care (Bruce & Amish 2006, Johnson et al. 2008, Lin et al. 2008). Viet- namese women are more likely than women of other eth- nicities to develop cervical cancer (Taylor et al. 2009). One study has suggested that immigrant women from Southeast Asian countries were more vulnerable to cervical cancer; however, lower cervical screening rates and lower treatment success rates were observed in this female sample (Love et al. 2009). It is important to understand whether immi- grant women are aware of and using health services (Gupta et al. 2002), because such trends can have dire conse- quences with regard to the increased risk of mortality due to cervical cancer. The perception of healthcare service uptake affects the rates of cancer screening and mainte- nance of good health practices. For these reasons, providers should pay attention to immigrant womens individual per- ceptions of healthcare service use (Gurequ et al. 2010). Background As the initial stage of cervical cancer is asymptomatic and symptoms are not revealed until the disease advances into invasive cervical cancer (Jane et al. 2009), cervical screen- ing plays a signicant role in decreasing the incidence and mortality rate of cervical cancer (Brink et al. 2005). It assists in identifying pre-cancerous lesions, thereby enabling treatment before the full development of cancer (Wong et al. 2009). Moreover, treatment success rates are higher if diagnosis and treatment are performed on carcinomas in situ (Lee-Lin et al. 2007, Wong et al. 2009). According to statistical surveys in Taiwan (Department of Health 2010), the cervical screening rate was 563% in 20082010. Cervical screening rates among Vietnamese women are lacking, because the database of the National Health Insurance (NHI) in Taiwan does not include the difference of nationality. Other studies, however, have indicated that only two-thirdsthree-quarters of Vietnamese American women have undergone cervical screening in the last 3 years (McPhee et al. 1997, Taylor et al. 2004a,b). However, there are many barriers to the administration of cervical screening, including lack of knowledge about cervi- cal screening, the time-consuming process involved, embar- rassment, the lack of female healthcare providers, busy schedules and beliefs that such tests are unnecessary (Weng 2006, Lin et al. 2007, Chen et al. 2008, Wong et al. 2009, Al-Naggar & Isa 2010, Hsu et al. 2011). Some of these barriers are particularly salient among immigrant women, especially the lack of knowledge of cervical screening, embarrassment, the lack of female doctors (which causes the inability to nd a female doctor), cultural beliefs, dis- comfort during the test and being accustomed to traditional medical approaches (Carrasquillo & Pati 2004, Taylor et al. 2004a, Chilton et al. 2005, Lee-Lin et al. 2007, Samuel et al. 2009). Thus, cultural and medical barriers to uptake need to be surmounted so that immigrant women can receive proper cervical health care. In Taiwan, women aged 30 years who are covered by the NHI program can receive a free cervical screening each year. Foreign residents are required to participate in Taiwans insurance system after receiving an alien resi- dency certicate and residing in Taiwan for more than 4 months; with enrolment in the system, they can also receive a free cervical screening each year. The women aged <30 years undergo cervical screening at their own expenses in Taiwan. The policy of cervical screening is the same for both Taiwanese women and Vietnamese women. However, previous qualitative studies regarding cervical screening among immigrant women in Taiwan have been limited. To ll this gap, we examine the barriers faced by Vietnamese immigrant women in receiving (or regularly receiving) cervical screenings through the use of a qualita- tive design. The study results might serve as guidelines for the development of culturally appropriate healthcare inter- ventions and policies for immigrant women in other coun- tries that have similar marriage immigration. In addition, our results could be useful in enhancing the effectiveness of healthcare services, improving the cervical screening rate and further decreasing the mortality rate due to cervical cancer among this population. The study Aim The aim of the study was to assess the barriers faced by Vietnamese marital immigrant women who do not regularly undergo cervical screenings in Southeast Taiwan. 88 2013 Blackwell Publishing Ltd F.H. Lee et al. Design This qualitative, descriptive study involved semi-structured, individual, in-depth interviews. Descriptive information was collected regarding the barriers faced by Vietnamese immigrant women in Taiwan who do not regularly undergo cervical screenings. Participants We used a snowball sampling method to recruit Vietnam- ese immigrant women living in southern Taiwan (speci- cally, women who were not receiving regular cervical screenings). A total of 17 women participated in this study; data were collected until data saturation was achieved. Data saturation was assured by the researchers during the analysis phase; it was achieved when no new signicant themes were identied (Higginbottom 2004). We included women who: (a) did not regularly (less than once per year) undergo cervical screening; (b) had national health insurance; (c) were at least 30 years old; (d) had not had a hysterectomy; and (e) were able to communi- cate verbally in Mandarin or Taiwanese. In Taiwan, women with cervical cancer diagnosis would have routine cervical screenings 12 times per year while receiving treatments. Compared with others, these women might be more concerned about their health and might not face the same barriers of undergoing cervical screenings. We excluded women who had already been diagnosed with cervical cancer. Data collection The researchers designed a semi-structured interview guide especially for the study. The questions were developed in consultation with obstetricians and experts in community nursing, womens health and sociology. Two Vietnamese immigrant women participated in a pre-test of the interview guide and it was revised on the bases of their opinions. Examples of the questions in the interview guide are: (a) When was the last time you underwent a cervical screening? (b) Describe how you underwent a cervical screening? and (c) For what reasons do you not regularly undergo cervical screenings? The rst author (a PhD candidate who was trained in qualitative research methods) performed the interviews. The formal interviews lasted an average of 40 minutes (range: 3065 minutes). Interviews were digi- tally recorded for subsequent coding. Non-verbal data were also collected during the interviews to provide researchers with reference data against which to analyse the data. All data were collected between FebruaryJuly 2011 and analy- sed using content analysis. Ethical considerations The institutional review board of a medical university hos- pital approved the study. During the study period, partici- pants maintained the right to terminate participation at any time. Condentiality was assured and no identifying data were released. Data analysis All interview data were transcribed verbatim and analysed using the content analysis approach described by Krippen- dorff (1980), which involves summarizing the data by iden- tifying themes. The researchers read the responses and made summary-like notes and comments. The unit of analy- sis was the response phrases related to a specic dimension. Thematic units of analysis were analysed by grouping simi- lar qualities or attributes, resulting in the reduction of data into clusters. The data were analysed by all four of the authors through panel discussions. Rigour The researchers adopted the following ve standards of rig- our for qualitative research: credibility, transferability, dependability, conformability and authenticity (Lincoln & Guba 1985, Guba & Lincoln 2005). Credibility was demon- strated through prolonged immersion in the data. The researchers conducted peer debrieng to discuss the analysis and thematic formation of the study; it was concluded that saturation had been achieved in the identied themes. Reec- tions triggered by the text readings were documented in jour- nal entries, which allowed the themes to emerge from the text. This helped avoid subjective bias. Increased credibility was also achieved by having the semi-structured interview guide pre-tested. However, the credibility of the results may have decreased as a result of using only one interviewer. To ensure transferability, the researchers continually re-thought and re-examined the relationships among the transcriptions to ensure the comprehensiveness, completeness and broadness of the situational information. To establish dependability and conformability, the interviews were digi- tally voice-recorded and transcribed verbatim. The study ndings were established by maintaining an audit trail of all procedural steps and methodological decisions. The researchers used peer debrieng and an external auditor with expertise in Krippendorffs thematic clustering technique. To 2013 Blackwell Publishing Ltd 89 JAN: ORIGINAL RESEARCH Pap test of Vietnamese immigrant women archive authenticity and fairness, quotes from all partici- pants have been included in the results section. Results The characteristics of the participants are shown in Table 1. In total, 17 women participated in this study. The participants ranged in age from 3256 years (mean = 348 years). Their length of residence in Taiwan was between 1517 years (mean = 94 years). All partici- pants had children and their average number of children was 17. All participants were married. On the basis of the analysis, the barriers for participants who do not regularly undergo cervical screenings were categorized into four themes: lack of health literacy, lack of female healthcare providers, negative perceptions of cervical screening and personal reasons (Table 2). Lack of health literacy Health literacy refers to the capacity for reading, writing and calculating health-related materials and activities (Speros 2005). Lack of health literacy indicates that the women had no knowledge of cervical cancer or cervical screening. Ten participants were not aware that the NHI program in Taiwan offers a free annual cervical screening to women aged 30 years and twelve did not understand the purpose of cervical screening, as exemplied by the fol- lowing statements: Can I get the test? (K); How much does it cost? (O); and I dont know what cervical screen- ing is for (A). Some of the participants reported not know- ing where they could obtain a cervical screening: One time, I brought my child to the health center for vaccination. The staff asked if I would like a cervical screening and only then did I become aware that they provide this service (F). Most of the participants assumed that healthcare services in Viet- nam were expensive and that regular people could not afford private insurance, as exemplied by the following statements: It is expensive to see a doctor and buy insur- ance in Vietnam (D); If the condition is not serious, we choose not to go to a doctor (K); and When feeling uncom- fortable, we go to drug stores to buy medicine. We only go to the doctor if we cannot bear the symptoms of the illness (C). Most of the participants had never heard of the provi- sion of cervical screening in Vietnam: I used to live in the countryside and I never heard about cervical screening (G). Lack of female healthcare providers The participants reported being unable to nd female healthcare workers to provide cervical screening, as exem- plied by the following statements: Once, I went to do a postpartum checkup. I had a cervical screening immediately Table 1 Sample characteristics (N = 17). Participant Age, years Stay in Taiwan, years Educational level Number of children Marital status A 43 14 Primary school 2 Married B 56 17 Junior high school 2 Married C 32 15 University 1 Married D 32 11 Senior high school 2 Married E 33 5 Primary school 2 Married F 33 11 Junior high school 2 Married G 33 6 Primary school 2 Married H 34 2 Junior high school 1 Married I 34 10 Primary school 2 Married J 35 4 Junior high school 1 Married K 35 125 Primary school 2 Married L 36 14 Senior high school 2 Married M 36 11 Senior high school 1 Married N 36 10 Senior high school 2 Married O 42 6 Primary school 1 Married P 38 13 Junior high school 2 Married Q 39 11 Primary school 2 Married Table 2 Barriers to undergoing cervical screening. Themes Sub-themes Lack of health literacy 1. Unaware of policy and the purposes of cervical screening 2. Unaware of where the service is provided 3. Lack of the concept of preventive care 4. Belief that a cervical screening is not required when there are no symptoms Lack of female healthcare providers 1. Having a female physician/female nurse perform the cervical screening 2. Being unable to nd a female physician Negative perceptions of cervical screening 1. Lack of a reminder system in health centres and clinics 2. Insufcient explanation about the test 3. Uncomfortable feelings (pain, cold speculum) Personal reasons 1. Lack of a role model 2. Being busy; forgetting to have the test 3. Being embarrassed 4. Being worried about the test results 90 2013 Blackwell Publishing Ltd F.H. Lee et al. on the physicians recommendation. There was no opportu- nity to choose a female physician (P). Most participants stated that if they had the choice, they would prefer that a female physician or nurse deliver the cervical screening. Their reasons were as follows: Having a female physician makes me feel less embarrassed (H); and A female physi- cian brings a sense of security. Female physicians under- stand me better than male physicians do (B). Negative perceptions of cervical screening This section identies the participants negative perceptions during cervical screening service. Eleven participants stated that they had never received a phone call or postal remin- der regarding cervical screening from health centres or the obstetrics and gynaecology clinics they had visited. One participant mentioned: I have never received a phone call from the staff of the health center that asked me to take the cervical screening (L). Only three participants stated that the physicians had clearly explained the testing proce- dure. Most of the participants reported that they did not receive sufcient information about the test: The physi- cian did not tell me anything but simply asked me to take it easy and not feel nervous during the procedure (Q); The physician did not talk with me during the process; only a nurse told me when I could get the results (A) and If the physician explained (the test) more, I might not have been so nervous (O). Some of the participants felt uncomfortable during the test: The speculum was cold and the insertion was uncomfortable and a little bit painful (N); and The room was cold; my legs felt uncomfortable (M). Personal reasons This section discusses the personal reasons/obstacles that prevented women from receiving cervical screening (either once or regularly). The barriers included being busy, forget- ting to schedule the test, being worried about the test results, feeling embarrassed and lacking a role model. Most of the participants had to work during the daytime and were busy with household chores during the evening: I work during the day and have to take care of my children. When do I have time to take the test? (L). Even if the par- ticipants were aware of the need to have cervical screening, the burdens of their multiple roles left them no time to schedule an appointment: I did not have cervical screening every year, because I was busy and usually forgot to do it (J). Some participants were worried that if the test results conrmed cervical cancer, it would have a negative impact on the individual and her whole family: I did not want to take the test, as I was afraid of undesirable results (M). Most of the participants found cervical screening embar- rassing: Taking my clothes off in front of others is pretty embarrassing (E); and It is a terrible and embarrassing sit- uation when I take the test (A). Female relatives and friends also affected the participants behaviour regarding the test, as shown by the following examples: My mother does not take the test (C); My mother-in-law has never taken the test. She has never told me about the test and I never asked her about it (I); and In Vietnam, only those who are sick go to a doctor (F). Discussion Lack of health literacy Most participants had limited knowledge of cervical cancer and cervical screening. For example, they were not aware that women aged 30 years could receive a free cervical screening every year by using the NHI in Taiwan. Some did not understand the relationship between cervical screening and cervical cancer and did not know where a screening could be obtained. Our ndings are consistent with those of other studies, which have revealed that 25% of Vietnamese women have never heard of cervical screening (Nguyen et al. 2002) and that a large proportion of Vietnamese Americans are unfamiliar with cervical screening (Gregg et al. 2011). Jenkins et al. (1999) discovered that Vietnam- ese women were not aware of the importance of preventive care; therefore, women were less likely to receive preventive medical services. In Vietnam, traditional beliefs about health and the lack of preventive care policies hinder the implementation of healthcare services (Hoang & Erickson 1982). Traditional and cultural beliefs in Vietnam suggest that the human body is private. Vietnamese people believe that diseases occur because of external factors. They believe that diseases are not preventable, regardless of how much effort goes into prevention. Therefore, they visit a doctor only after contracting a disease (Nguyen et al. 2007). Moreover, pre- marital sexual behaviour is stigmatized in Vietnam; physi- cians believe that unmarried women should not engage in sexual behaviour and hence that young, unmarried women have no need for cervical screening (McPhee 2002). Women from minority ethnic groups have poorer levels of health literacy and are less likely to receive a cervical screening (Lindau et al. 2001). Poor literacy creates barriers to the implementation of useful behaviours for the preven- tion of cervical cancer (Garbers & Chiasson 2004, Lindau 2013 Blackwell Publishing Ltd 91 JAN: ORIGINAL RESEARCH Pap test of Vietnamese immigrant women et al. 2006). Improving health literacy could positively inuence the adoption of health behaviours (Lindau et al. 2001, Schillinger et al. 2002, von Wagner et al. 2007). Lack of female healthcare providers The participants preferred to have female physicians or nurses perform their cervical screenings, in accordance with the ndings of previous studies (Chen et al. 2008, Samuel et al. 2009, Al-Naggar & Isa 2010). Physical examinations conducted by male physicians can cause greater embarrass- ment and anxiety among women than those performed by female physicians (Holroyd et al. 2004, Sutton & Ruther- ford 2005). Further, the major barrier to Vietnamese immi- grant women in obtaining cervical screening is the lack of female physicians available to perform the test (Donnelly 2006a,b). The cervical screening rate among Vietnamese women increased when female physicians became able to perform the test (Nguyen et al. 2002, Al Saira & Mohamed 2009). Negative perceptions of cervical screening Negative perceptions might provide another reason for women to resist receiving cervical screening. In Taiwan, cervical cancer prevention is promoted by health centres and these centres primary strategy for encouraging cervical screening uptake is to give phone calls and postal remind- ers. However, these strategies might not be appropriate for immigrant women: language barriers could hinder them from receiving cervical screenings (Samuel et al. 2009). Therefore, healthcare providers should offer detailed expla- nations during the testing process in addition to sufcient healthcare resources (i.e. postcards written in Vietnamese). In traditional Asian societies, women easily feel pressured when interacting with healthcare providers (Holroyd et al. 2001). Healthcare providers should not simply focus on the medical process, but should pay attention to the feel- ings and concerns of their female patients. Personal reasons Personal reasons for not undergoing cervical screening included the lack of a role model, being busy, forgetting to have the test, feeling embarrassed and being worried about the test results. Our ndings provide evidence to support previous studies showing that fear, uncertainty and scheduling issues affect whether women receive cervi- cal screenings (Hislop et al. 2003, Ackerson & Perston 2009). Most participants lived with their mothers-in-law, but seldom discussed the procedure with them, even though women usually need a role model to engage in positive health behaviours (Tang et al. 1999, Mattila et al. 2000). Moreover, in Taiwanese culture, women are held accountable for traditional responsibilities, including bear- ing a son to carry on the family name and taking care of the children and elder members of the family (Liao & Chan 2005). Most of our participants either had young children and usually stayed at home taking care of their families or worked to help provide family income. Consequently, they were unable to (or did not) receive regular cervical screenings. In Vietnamese culture, women follow traditional patriar- chal beliefs that emphasize the subordinate role of women in the family and the larger society (Morash et al. 2007). Therefore, family structure may affect individual healthcare decisions (Nguyen 1985). In this study, Vietnamese women may not undergo cervical screenings because their families are involved in healthcare decisions; however, whether this is the case remains to be investigated. Limitations The current study had some limitations. First, we recruited only participants who could communicate in Mandarin or Taiwanese. This might affect the generalizability of our results to the larger population of Vietnamese immigrants living in Taiwan. Participants who are unable to communi- cate in either Mandarin or Taiwanese should be considered in future studies. In Taiwan, women who are covered by the NHI program and aged 30 years can receive a free cervical screening each year. However, women aged <30 years were not included in this study. Future studies might consider including participants from all age groups who are (or have been) sexually active. Implications for practice Education for cervical cancer prevention should meet the needs of special populations and overcome their lack of health literacy (Rogers & Cantu 2009). In Taiwan, when educating Vietnamese immigrant women about cervical cancer prevention, the inuence of health literacy should be taken into account. Healthcare providers should assess the recipients ability to learn and acquire sufcient health information. If necessary, bilingual written documents should be provided and the presence of professional inter- preters might facilitate communication between Vietnamese immigrants and Taiwanese healthcare providers. This will 92 2013 Blackwell Publishing Ltd F.H. Lee et al. assist in the establishment of a health education model for women with low health literacy. In clinical practice, female patients should be provided with recommendations and information about cervical screening when receiving medical services. If necessary, patients could be referred to female physicians or female nurses for the test. Nurses are allowed to perform cervical screening in many countries (Hilton et al. 2003, de Villiers et al. 2004, Castellsague et al. 2006), but according to Tai- wans health policy, nurses are forbidden from performing the procedure (Law & Regulations database of The Repub- lic of China 2012). The results of this study might serve as a reference for the government to consider the legitimacy of allowing nurses to perform cervical screening, which not only helps to reduce embarrassment among patients (as nurses are often women themselves) but also encourages autonomy among nursing professionals regarding cervical cancer prevention. Female volunteers from Vietnam could be recruited to help with phone reminders to Vietnamese immigrant women to help increase the adoption rate of cer- vical screening. Furthermore, a mobile service could be pro- vided for women who cannot regularly schedule cervical screenings because of work or family duties. This might help to enhance the accessibility and availability of cervical screening services for immigrant women. Conclusion The current study showed that the barriers preventing Viet- namese immigrant women from receiving regular cervical screenings could be categorized into four themes: lack of health literacy, lack of female healthcare providers, negative perceptions of cervical screening and personal reasons. Although the NHI program in Taiwan offers free cervical screenings, our ndings suggest that the uptake of this service among Vietnamese immigrant women was still affected by personal and healthcare-delivery system-related factors. These themes might serve as references for the government and healthcare providers in Taiwan to improve the cervical screening rate and enhance the effectiveness of healthcare ser- vices for Vietnamese immigrant women. Future research should employ a larger-scale survey to provide an overall pic- ture of cervical screening among immigrant women. Acknowledgements We are grateful to the participants in the interview. Funding The authors would like to express their appreciation to the National Science Council of Taiwan for funding this study (NSC 100-2314-B-037-008). Conict of interest No conict of interest has been declared by the authors. Author Contributions FHL, HHW, YMY and HMT were responsible for the study conception and design. FHL performed the data collection. FHL, HHW, YMY and HMT performed the data analysis. FHL and HHW were responsible for the drafting of the man- uscript. FHL, HHW, YMY and HMT made critical revisions to the paper for important intellectual content. FHL and HHW obtained funding. HHW supervised the study. All authors have agreed on the nal version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]: What is already known about this topic
Cervical screening has been reported to decrease the
mortality rate of cervical cancer.
Cervical screening rates are lower among immigrant
women, because immigrant women often face lan- guage and cultural barriers and have difculty access- ing the unfamiliar healthcare system. What this paper adds
The barriers faced by Vietnamese immigrant women in
the implementation of cervical screening were catego- rized as lack of health literacy, lack of female health- care providers, negative perceptions of cervical screening and personal reasons.
The perceptions of cervical screenings among immi-
grant women in Taiwan have been explored and may be the reference of policy making. Implications for practice and/or policy
These ndings could enable the provision of effective
healthcare services to improve the cervical screening rate of Vietnamese immigrant women.
These ndings can serve as guidelines for the develop-
ment of culturally appropriate healthcare interventions and policies for immigrant women in other countries with similar marriage immigration practices. 2013 Blackwell Publishing Ltd 93 JAN: ORIGINAL RESEARCH Pap test of Vietnamese immigrant women
substantial contributions to conception and design, acqui-
sition of data, or analysis and interpretation of data;
drafting the article or revising it critically for important
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