HEALTH BELIEFS AND EARLY DETECTION AMONG CHINESE WOMEN

     Little is known about the knowledge and practices regarding early
     detection of cancer for Chinese women either living in their homelands
     or worldwide. The purpose of this exploratory study is to describe how
     cultural beliefs and understandings may influence participation in
     early detection programs for the increasing numbers of Chinese women
     who live in the United States. The Health Belief Model (HBM) emerged
     as a useful framework for categorizing data obtained in Mandarin from
     a qualitative study of married, educated Chinese women (n = 23; mean
     age 30.4 years) who attended a university clinic. Cultural beliefs
     about modesty, husband's involvement, self-care relationship between
     health and body functions, and use of preventive health behaviors in
     the absence of illness influenced women's participation and supported
     the HBM. Early detection was not a clear concept for these women: 80%
     believed performing monthly breast self-examinations and 70% believed
     receiving annual Papanicolaou smears would prevent cancer

Breast cancer is the most common type of cancer diagnosed for all women
(MO, 1992) and is the second cause of cancer death for women in the United
States (Baird, 1991). Although Chinese women residing in the United States
have a lower incidence of breast cancer compared to Caucasian women living
in the United States (54.0 vs. 86.5 per 100,000) (Baquet, Ringen, &
Pollack, 1986), their incidence is higher than for Chinese women living in
Asia (Yu, Harris, Gai, Gao, & Wydner, 1991). Ziegler et al. (1993) found
that Asian American women born in the West have a 60% greater risk of
breast cancer than Asian American women born in the East; the rate
continues to rise in subsequent generations of women following immigration
to the United States.

Cure rates for both breast and cervical cancer have improved for women who
use early detection strategies for breast and cervical cancer and who also
choose interventions and treatment promptly for problems (Baird, 1991;
Ferrans, 1994; Otto, 1991). Despite the increased probability for cure,
many women have not embraced those health services labeled as preventive
practices. For Chinese women in the United States, key beliefs about health
and illness may become misaligned with "beliefs of the dominant Western
culture" (Louie, 1985, p. 18), a situation am provokes misunderstandings.
Numbering 1,645,472, Chinese persons comprise the largest Asian population
in the United States (MO, 1992).

                     MULTIPLE BARRIERS TO PARTICIPATION

Known barriers to women's use of early detection services, namely breast
self-examinations (BSE) and Papanicolaou smears (PAP), include limited
access to health care, economic constraints, and lack of knowledge with
regard to risk factors and screening procedures (Gold, Bassett, & Fox,
1987; Otto, 1991). Champion (1988) cited knowledge and skill deficits as
other reasons why women do not practice BSE routinely.

The cues that motivate women to practice early detection behaviors continue
to elude health providers. Certainly, many barriers m participation are
embedded in the ways providers of health services plan and implement
programs for prevention, early detection, and health education. These
services tend to be system driven and designed for but not with women, who
are the consumers. Many inhibitors result from cultural insensitivity
wherein relevant sociocultural factors or elements of diverse beliefs and
practices are omitted from program operations or simply are unapparent to
health care providers.

For Chinese women living in the United States, health system barriers are
compounded by language barriers and sociocultural values concerning health
and sexuality (Mo, 1992) as well as by Chinese women's lack of trust in
Western health care (Olsen & Frank-Stromberg, 1993). The Chinese model for
health is structured primarily to attain wellness or to offset illness by
methods, usually prescriptive, to maintain balances among the body humors,
a model that is not readily comparable to Western ideas about either
prevention or cure. For instance, Chinese women find it unusual to seek
health services without receiving a prescription or remedy, perhaps an
herbal preparation, as part of the consultation. They may not perceive the
value or identify the purposes in obtaining screening services. Value-laden
beliefs become obstacles when they predispose women to underuse health
screening and early detection practices. Thus Chinese women living in the
United States are among those at risk for undetected cervical and breast
cancers and subsequently are untreated during the early and most curable
stages of the disease (Lovejoy, Jenkins, Wu, Shankland, & Wilson, 1989).

A woman's survival from breast cancer is related to the stage at which the
disease is diagnosed (Baird, 1991). The 5-year survival rates for localized
disease and breast cancer in situ are 93% and "approaching" 100%,
respectively (American Cancer Society [ACS], 1993). In comparison, the
5-year survival rate for Stage IV carcinoma of the breast is 10% (Otto,
1991). Young, Ries, and Pollock (1984) found that despite a lower
incidence, the 5-year survival rate for Chinese women was not significantly
better than for Caucasian women, all living in the United States. Mo (1992)
cites late-stage diagnosis related to cultural and institutional barriers
as a major reason for this disproportionate mortality rate.

Carcinoma of the cervix is the third most common gynecological malignancy
in the United States, following endometrial and ovarian cancer (Baird,
1991). A concurrent rise in the incidence of cervical hyperplasia and
cervical carcinoma in situ has been documented (Flannery, 1992). The 5-year
survival rate for carcinoma in situ is "virtually" 100% (ACS, 1993) as
opposed to diagnosis at Stage III in which 5-year survival is 30%
(Flannery, 1992).

Berman, Bastani, Nisenbaum, Henneman, and Marcus (1994) cited lack of
cervical cancer screening as a key explanatory factor accounting for
differences in morbidity and mortality related to cervical cancer within a
sample from a low-income, multiethnic population of women. Otto (1991)
states that "the vast majority of deaths resulting from cervical cancer can
be prevented if women practice routine screening with cervical cytology"
(p. 132). The incidence of invasive cervical cancer has declined 50% in the
United States since PAPs were instituted routinely in gynecology practices.
However, from 1977 to 1983 (ACS, cited in Olsen & Frank-Stromberg, 1993),
the incidence of cervical cancer in Chinese American women was 10.3 per
100,000, compared with 8.7 in Caucasian Americans.

                                  PURPOSE

This exploratory study was conducted for the purpose of describing how the
knowledge and beliefs with regard to early detection behaviors (i.e., for
BSE and PAP) held by a group of educated, married Chinese women influence
their participation in preventive health activities for early detection of
cancer.

                     DEFINITIONS AND RESEARCH QUESTIONS

Preventive health behaviors were defined as health education, performing
BSEs, and obtaining annual gynecological check-ups, including a PAP.
Although these behaviors are related to early detection strategies, the
term preventive is used widely by health providers and became relevant in
the research findings. On the other hand, mammography was not included as a
health behavior because the women in the sample were under the age
recommended for annual mammography examinations.

The variations of subjective health perceptions among women of various
cultural and ethnic groups have not been examined thoroughly (McAllister &
Farquhar, 1992). To this end, research questions included the following:
What is the meaning of preventive health behavior to married Chinese women
residing in an Eastern university community in the United States? What are
the modifying factors that influence the likelihood of this group of women
in taking recommended preventive health action, including PAPs and BSEs?
What are the perceived benefits and barriers for these women in partaking
of preventive health actions, including BSEs and PAPs?

                               HEALTH BELIEFS

Initially, the researchers generated research questions based on the
literature and their professional experiences. Then, during data analysis,
the researchers working independently recognized that their data categories
corresponded with several components of the Health Belief Model (HBM).
Lancaster (1992) states,

     The [Health Belief] model is useful in looking at health-protecting or
     disease-preventive behavior. It is useful in organizing information
     about clients' view of their state of health and what factors would
     influence them to change their behavior. Health education can be
     developed based on the data gathered from the use of the Health Belief
     Model as an organizing framework for looking at client status. (p.
     187)

Originated in the late 1960s and subsequently modified by Becker
(Cockerham, 1992; Woods, 1989), the Health Belief Model, which has a
phenomenological orientation, was developed to explain individual decision
making with regard to health behaviors (Mikhail, 1981). The framework of
the model includes individual perceptions, modifying factors, and variables
affecting the likelihood of taking actions. The model can be used to
illustrate how a person's perceived susceptibility and perceived severity
of a disease combine to form individual perceptions that are linked to a
perceived threat of encountering the disease. Modifying factors, including
demographic variables (age, sex, ethnicity), sociopsychological variables
(social class, reference group), and structural variables (previous
experiences with and knowledge of the disease), influence individual
perceptions and the perceived threat. External cues to action influence
perceived threat and may include information from the mass media, advice
from others, mailed reminders from providers, or illness of a family member
or friend.

One outcome of the model is the likelihood of an individual deciding to
take recommended preventive health action. This likelihood is subjective,
influenced by the perceived threat and the perceived benefits weighed
against perceived barriers to preventive action.

                                   SAMPLE

A convenience sample consisted of 23 married Chinese women who lived on or
adjacent to the campus of a large Eastern university in the United States.
The principal investigator, a Chinese graduate nursing student, initially
secured potential subjects' names through listings in the directory of the
Chinese Student Association. Additional subjects were recruited through
network sampling.

Ten women were from the People's Republic of China, and 13 were from
Taiwan, The Republic of China. The mean age of the women was 30.4 years (SD
= 3.1). Ninety-one percent of the subjects had at least a baccalaureate
degree, with more than half having completed post-baccalaureate degrees.
The mean number of years subjects had resided in the United States was 3.2
(SD = 1.5; range = 3 months to 5.5 years). Of the 17 subjects who had
children, 88% had only one child. Children's ages ranged from newborn to 9
years.

Sixty-one percent of the subjects cited no religious preference, whereas
21.7% cited Buddhism, 8.7% cited Catholicism, and 8.7% reported
Christianity as their religious preference. All subjects listed Mandarin as
their primary language, and most intended to return home within 5 years.
The majority were spouses of graduate students, with all but one receiving
some type of family financial assistance; 83% had some health insurance
coverage, usually a university-sponsored insurance plan that designates
university health services to be the service point of entry.

                                   METHOD

The three-part questionnaire used for the study was developed by the
investigators and translated into Mandarin by one research investigator.
The women were asked to respond to 8 demographic questions, then to 20
questions to ascertain each woman's knowledge and beliefs concerning
performance of procedures for BSEs and PAPs. These questions were based on
information from findings reported in women's health literature and the
researcher's own knowledge of the culture. The final section consisted of 6
open-ended questions with preset probes that were used to guide a
semistructured interview, also conducted in Mandarin, on the subjects'
beliefs about what constituted preventive health behaviors for BSEs and
PAPs.

The questionnaire was reviewed critically by a professor of nursing, a
nurse practitioner specializing in women's health, and a Taiwanese graduate
nursing student, who reviewed for translation accuracy and cultural
validity. Two Chinese women residing in the community participated in a
pilot test of the instrument prior to data collection. Face validity was
deemed satisfactory when responses were classified readily into similar
categories of the Health Belief Model by the researchers, although content
validity in the analysis was limited in part by the exploratory design.

Following university IRB approval, subjects for the study were contacted
and informed consent was obtained in Mandarin. The principal investigator
met each subject once in a private area of the university health clinic.
Data were collected by the first investigator interviewing in Mandarin and
using the instrument to guide the interview and discussion parameters. Data
were translated into written English for analysis. Subject anonymity was
maintained by coding original and translated responses. To ensure subjects'
confidentiality, only researchers had access to locked data files.

                              ANALYSIS OF DATA

Demographic information and true or false answers were summarized using
descriptive statistics. An inductive approach was used to perform content
analysis of responses to open-ended questions (McCain, 1988). After all
data were collected and translated, two researchers, working independently,
conducted a line-by-line review of each response to each question
individually and in comparison to the subject's overall response until the
main topic in each response could be identified and labeled. Throughout the
analysis, areas of disagreement among researchers were discussed until
topics could be categorized into a schemata of "emerging themes" that
corresponded with several components of the Health Belief Model. The
researchers, and an independent reader knowledgeable about qualitative
methods, again reviewed the data and categorical assignments, reaching
close agreement for all responses (Brink & Wood, 1994). The frequency with
which responses occurred across the sample was tabulated. These themes were
then organized and tabulated according to concepts of the Health Belief
Model (Miles & Huberman, 1994).

                                  FINDINGS

Individual Perceptions

With regard to perceived susceptibility to breast and cervical cancer, the
data analysis revealed a theme of Chinese women believing themselves to
have a lower cancer risk than American women and associating the need for
preventive health behaviors with American women rather than themselves. For
example, one subject responded, "People should do preventive health
behaviors to detect and treat disease earlier, especially in the United
States where girls are sexually active at a younger age This is not a
problem in Taiwan, however."

Although the cause of cervical cancer was believed to be related to early
sexual activity in American women, the perceived causes and treatment of
breast cancer were grounded in Chinese holistic health beliefs. One woman
recalled an instance when a friend "got mastitis due to too much stress. .
. . Mastitis is related to too much stress and bad temper. . . . People
must reduce their levels of stress and tendencies to be bad-tempered to
prevent mastitis and breast cancer." Another told a story of a friend who
had mastitis; a Chinese doctor massaged the breast and "the swelling went
down."

Mo (1992) reported cancer as being a relatively new disease within the
Chinese population for which, from a Chinese perspective, there is no cure.
Mo noted that breast cancer, called yee nham, is not discussed in Chinese
medicine texts. During the interviews, none of the women commented on the
perceived medical seriousness of having breast or cervical cancer.

However, in this study, the women repeatedly referred to energy balance and
function in relation to health and the importance of food in maintaining
balance and good functioning. In a 1981 National Cancer Institute study (as
cited in Mo, 1992) researchers found that Chinese Americans believed cancer
"could remain undetected in the body forever . . . [and] poor or inadequate
nutrition could make people susceptible to cancer" (p. 261) or that an
imbalance of yin and yang can result in illness or disease (Louie, 1985;
Rawl, 1992).

Subjects in this study possibly did not believe themselves to be
susceptible to diseases that are not a health priority in China, result
from risk behaviors they do not practice, or are believed to be
"preventable" or controllable (i.e., balanced by maintaining energy levels
and eating properly).

Modifying Factors

Applying these findings to the framework, several characteristics of the
Chinese culture may be related to sociopsychological factors. In Chinese
health practices, self-care and treatment such as diet therapy, herbal
remedies, and exercise are valued (Rawl, 1992). The persons in this study
made numerous references to the importance of self-care--for example, "need
to do health prevention the traditional Chinese way to help balance energy
by eating foods not too cold and not too hot" and "need self-care skills to
do [preventive behaviors]." The notion of maintaining the humors in balance
as part of well-being is central to health beliefs of a number of cultures.
One woman reported that she "used to have bad health in China because I did
not exercise," but now she exercises regularly and feels she "has good body
function for preparation to deliver a baby."

Five women had received pelvic examinations and PAPs within the past few
years, but none knew the outcome of the exams or laboratory analyses. The
phrase "no news is good news" was each one's response when asked why they
had not followed up on the results. Mo (1992) stated that ham suup is a
Cantonese term that means "salty and wet," a colloquial term for referring
to sexual matters. Most frequently used in a derogatory manner, the words
are used to describe anyone who is inappropriate sexually. Thus expressing
curiosity or being knowledgeable about the body is ham suup. When ham suup
is considered along with the Chinese tendency to discourage social
assertiveness (Louie, 1985), it can be reasoned that Chinese women may
choose not to follow up on gynecological test results because it may be
considered socially inappropriate to seek such information. An alternative
explanation is that the theme of "no news is good news" is a cross-cultural
phenomenon related to women being responsible for following up on study
results or the inherent problem of deciding whether to take action based on
knowing the results. hic variables that emerged from the data as being
relevant to preventive health behaviors. More than a third of the women
believed that preventive health behaviors should be deferred until an
individual reaches middle age; that is, 40 years of age and older. One
person, who reported a family history of both breast and cervical cancer,
stated she is "still young and does not need to do [preventive health
behaviors] or worry about them until I am middle aged." Three women thought
preventive health behaviors should not be "done until they get older," and
three others thought they should practice preventive health behaviors "all
their lives." Three persons also identified marriage as a time when
preventive health behaviors should be initiated because women experience
more reproductive problems at this time.

The subordinate position and passive role reported for women in Chinese
societies (Mo, 1992) became evident once the responses were analyzed. For
example, one woman indicated that she "did not know what kind of preventive
health care I should receive" and needed to "discuss it with my husband. .
. . If he thinks I need to, I might do breast exams and make an appointment
with the doctor for a PAP." For several women, a husband's involvement was
a cue to action.

A theme of a "fatalistic view" of prevention emerged from the data
analysis. When the investigator asked subjects what should be done in terms
of preventive health, one person indicated she "would do such behaviors
when I felt something was wrong in my body." Another woman stated that
preventive health behaviors

     are not necessary for the young unless feeling sick. . . . Only sick
     people need to visit doctors. Preventive visits will make people think
     too much about their health and make them sick. I do not need to know
     about preventive health behaviors right now because future things are
     for the future; people do not need to worry about them now because we
     never know what will be happening in the future.

Other responses--such as "do regularly, but do not let it become a burden,"
"do not need to do preventive health behaviors if you're healthy and have
no symptoms," and "if I do not consider health issues, I feel fine; if I
think about these issues too much, I will worry about it. Therefore, it is
doubtful if it is necessary for people to know more about health
issues"--support the notion of a culturally based resistance to preventive
health behaviors.

Structural variables barely emerged from the data analysis. One person
reported a family history of breast and cervical cancer but did not
participate in screening for either type of cancer because she herself "had
no need." Another woman had a past report of an abnormal PAP. Results of
the follow-up PAP 3 years prior to the study were normal. The subject has
not had another PAP because she "does not have now this health need."

Cues to Action

Three cues to action emerged from the data. The first was the influence of
spouses, several of whom helped their wives perform BSEs. In addition,
several women were considering having a PAP done because their husbands
wanted them to do so. The second cue to action was the mass media, which
influenced the decision to engage in preventive health behaviors and
provided a source of information for BSE techniques in books and articles.

The most influential cue to action was the primary goal of gaining access
to the health care system for obstetrical services, whereby a physical
examination and PAP were prerequisites to the desired services. One woman
reported, "I had a PAP done twice because it is the law in the USA that if
women need birth control pills, they must have a PAP done first."

Although access into the system may have been a cue to action, once the
desired services were rendered the subjects discontinued the behaviors.
Five women stopped performing breast self-exams and did not continue PAPs
after giving birth. Eighty percent of the subjects were "overdue" for a PAP
(ACS, 1993). One woman had received no gynecological care since her IUD
insertion 5 years earlier.

                  PERCEIVED BENEFITS OF PREVENTIVE ACTION

Mo (1992) noted that Chinese Americans in the 1981 National Cancer
Institute study "had much general knowledge about cancer, not all of it
accurate" (p. 262). Women in this study spoke about their perceived
benefits of participating in preventive health behaviors that included the
avoidance of transferring bad genes to the next generation, the provision
of a sense of being personally safe, and the perception that such behaviors
were good for reproductive function.

One unanticipated finding was the women's misperception about the purposes
and benefits of preventive health behaviors. For example, 82.6% of all
subjects believed that doing a BSE monthly would by itself prevent breast
cancer. Similarly, 56% believed B SE was an adequate substitute for a
periodic examination by a qualified physician or nurse practitioner, and
69.5% believed having PAPs would prevent cervical cancer. In part, these
findings may be related to differences within Chinese and Western
philosophies about achieving and maintaining health and well-being. The
researchers considered that the women may have underlying misconceptions
about breast cancer as a diagnosis, such as confusion with mastitis, which
reportedly is treated with massage in traditional medicine.

The results also led researchers to raise the question of whether the term
preventive health behaviors is being used imprecisely by health
professionals themselves. Many health professionals casually interchange
terms when referring to preventive services and to primary care or primary
level interventions. Although preventive health behaviors are not
preventive in themselves, using this term may unintentionally imply rather
than clarify the part preventive health behaviors play in primary care
screening and in enabling early detection that is followed by intervention.

                   PERCEIVE BARRIERS TO PREVENTIVE ACTION

The most frequently cited barrier to a woman's participation in preventive
health care behaviors was cost. This response was offered even though 82.6%
of the women reported they had insurance coverage at the clinic. The women
indicated they would have preferred using private medical care over the
clinic. Several women indicated they did not plan to seek health care until
they were able to return to China, reportedly because of the cost of care
in the United States.

Although there is no cost involved in personally performing BSEs, the
Chinese women in this study cited modesty as a personal inhibitor for
obtaining PAPs, which supports modesty as a barrier (Mo, 1992; Rawl, 1992).
For example, one woman reported that "my husband wants me to have a PAP,
but I hesitate because my Chinese upbringing makes me more conservative. .
. . I am afraid of having a stranger [someone other than her husband] to
touch my body." There may be other facets to learn about modesty as a
barrier. Although the nurse practitioner at the clinic was female, this
woman said she refused a PAP, although she was also receiving treatment for
a vaginal infection. Studies in countries where health services are
provided without cost would add to understanding about the influence of
cost on participation in services.

Although feeling "safe about one's health" was found to be a benefit from
engaging in preventive health behaviors, concern for personal safety while
using the health system emerged as a barrier. For example, one woman
reported she had not received a PAP in the 4 years since she had arrived in
the United States because of her concern about "catching AIDS." She had
"heard someone got AIDS by visiting a dentist in the United States."

Another woman reported that she did not like receiving a PAP in the United
States because principles she regarded as basic to cleanliness were not
followed. She described how the physician wore gloves and "touched other
places before he began to check my reproductive system. I was disgusted by
this type of unclean behavior and was afraid of catching AIDS or some
sexually transmitted disease from dirty equipment or unclean procedures."
Mo (1992) discussed fear of exploitation as a characteristic of Chinese
women based on cultural beliefs about the role of women, their reproductive
functions, the attention to birthing, and other culturally defined role
behaviors.

Surprisingly, language barriers were a concern identified by only four
women. This finding may be accounted for by the relatively high level of
education achieved by the women in the sample, personal expectations or
pride about language skills, the social support provided by spouses, or the
lack of intention to access the health care system for preventive health
services from the outset, thus negating any concerns with language. Or the
women simply may not have been aware of operating from language-related
misunderstandings, such as those that researchers have begun to associate
with the term preventive health behaviors.

Time constraints were mentioned by several women who stated they were too
busy caring for their families to participate in preventive health
behaviors. Although time is known to be a cultural variable that emerged as
a barrier in this study, analysis of data did not allow more information
about what time constraints meant or how they influenced participation in
preventive health behaviors. Additional research is needed concerning the
influence of time on use of early detection practices in this population.

                                 DISCUSSION

The results of this study support the literature findings that cite the
importance of sociocultural factors when planning and providing health care
to married Chinese women residing in the United States. Relevant variables
include modesty, husband's involvement, importance of self-care,
relationship between health and body functions, and dismissing preventive
health behaviors when in the absence of illness or when feeling well
(Lovejoy et al, 1989; Mo, 1992; Rawl, 1992).

The finding of cultural differences about perceived susceptibility to
cancer exhibited by the sample has implications for professionals who are
planning health promotion programs. Although women in the sample stated
they planned limited stays in the United States, nearly half (n = 10) had
resided in the country for more than 3 years, and several had married
American citizens. Ziegler et al. (1993) found that exposure to Western
lifestyles significantly increased the risk of breast cancer in Asian women
who migrated to the United States. Subjects in this study held health
beliefs regarding susceptibility to cancer that were congruent with their
country of origin rather than with their country of residence. Thus health
education regarding lifestyle changes and risk factors are best directed
toward those who plan long-term residence in the United States.

Although the importance of self-care was evident from the data analysis,
the cues to action for preventive health behaviors were found to be
 externally motivated rather than internally motivated. Accessing the
health system to obtain reproductive care was an active cue to action until
services were completed, and then preventive behaviors were discontinued.
The cues provided by spouses were major factors in the women's behaviors.
Thus including spouses in plans for care may increase participation.
However, the behavior must be transformed into a belief before ongoing
participation will occur, ideally through culturally sensitive education
and relevant counseling programs.

The finding that more than 80% of the women believed that performing a
monthly BSE would prevent breast cancer and that nearly 70% believed annual
PAPs would prevent cervical cancer deserves attention in future research.
Labeling early detection practices as preventive may create confusion or
misunderstandings. It cannot be ascertained whether this finding is
grounded in cultural or language issues or is a misperception that may
occur among many women in the United States. Certainly, nurses may
reconsider how their clients' interpretation of the meaning of
professionally relayed information, such as with the earlier quote from
Otto (1991) equating women who practice routine cervical cytology screening
with preventing deaths from cervical cancer, may affect outcomes.

Limitations of this study included having only married, well-educated
subjects, several of whom were planning to defer nonemergency health care
until returning to their home country. The findings are not generalizable,
however; replicating the study with unmarried, less educated persons or
varying years in the United States to reflect "generational differences"
(Louie, 1985) may provide insight for programs. Only face validity could be
established.

A strength of the study is the common culture and life situation shared by
the investigator and the subjects. Levy (1985) suggests that people who
share similar cultural patterns, values, and problems are more likely to
feel comfortable and understand one another. Although there is diversity
among Chinese cultures (Rawl, 1992), the ability of the investigator to
communicate with the participants in Mandarin and as a fellow in the
university system while in a foreign land facilitated the data collection
process. The changing demographics across the United States will continue
to challenge providers in the Western health system to offer relevant and
sensitive health care services to members of a variety of diverse groups.
Failure to recognize and respond to these differences in beliefs and the
meanings of behaviors may result in individuals being labeled as
"noncompliant" and may create service gaps for segments of the population
or may neglect aggregate risk profiles that occur with lifestyle changes.

      TABLE 1: Demographic Characteristics of Sample

Characteristic                                N = 23

Age (X = 30.4 years; SD = 3.1)
 20-24                                      1      4.3
 25-29                                      6     26.1
 30-34                                     14     60.9
 35-39                                      2      8.7

Native residence
 People's Republic of China                10     43.5
 Taiwan                                    13     56.5

Religious preference
 Buddhism                                   5     21.7
 Catholicism                                2      8.7
 Christianity                               2      8.7
 No preference                             14     60.9

Educational level
 High school graduate                       1      4.3
 Associate degree                           1      4.3
 Baccalaureate degree                       9     39.1
 Master's degree                            8     34.8
 Doctoral degree                            4     17.4

Language
 Mandarin (primary)                        23    100.0
 Basic English (secondary)                 23    100.0

Length of time residing in the United
 States (X= 3.2 years; SD= 1.5 years)
 Less than 1 year                           1      4.3
 12-24 months                               6     26.1
 25-36 months                               6     26.1
 37-48 months                               5     21.7
 49-60 months                               3     13.0
 61-72 months                               2      8.7

Number of children
 (range = newborn to 9 years)
 None                                       6     26.1
 One                                       15     65.2
 Two                                        2      8.7

Student financial assistance received
in household
 Yes                                       22     95.6
 No                                         1      4.4

Currently covered by insurance
 Yes                                       19     82.6
 No                                         4     17.4

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~~~~~~~~

By Shirley P. Hoeman, Ya Lie Ku, Diana Roth Ohl

Shirley P. Hoeman, Ph.D., M.P.H., R.N., C.R.R.N, Associate Professor,
Fairfield University, CT; Ya Lie Ku, R.N., M.S., doctoral student, Northern
Illinois University; Diana Roth Ohl, R.N.C., B.S.N., O.C.N., M.S.N.
candidate, Pennsylvania State University.
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