barriers to cervical cancer among hispanic women

8/9/2019 Barriers to Cervical Cancer Among Hispanic Women

1/8

O N C O L O G Y

Understanding barriers to cervical cancer

screening among Hispanic womenLuisa Watts, BA; Naima Joseph, MS; Amanda Velazquez, BA; Marisa Gonzalez, MD; Elizabeth Munro, MD;

Alona Muzikansky, MA; Jose A. Rauh-Hain, MD; Marcela G. del Carmen, MD, MPH

OBJECTIVE:We investigated issues affecting Papanicolaou smearscreening access, health services utilization, acculturation, social net-working, and media venues most conducive to acquiring health infor-mation among Hispanics.

STUDY DESIGN:Self-identified Hispanics were surveyed. Participantswere stratified based on age, time living in the United States, and Pa-panicolaou screening frequency.

RESULTS:Of 318 participants, Hispanics aged 30 years or older and

living in the United States less than 5 years prefer speaking Spanish.Women with 5 or more lifetime Papanicolaou smears were 1.610 times

more likely to have lived in the United States 5 or more years, 1.706times more likely to speak a second language, and 1.712 times lesslikely to need a translator during their health care encounter.

CONCLUSION: Age and years living in the United States may beindependent risk factors for participation in Papanicolaou screen-ing programs. Social difficulties inherent to acculturation informhealth behavior and translate to health disparity among Hispanics.Our results may help design federally funded and community-levelprograms.

Key words:cervical cancer screening, disparities, Hispanics

Cite this article as: Watts L, Joseph N, Velazquez A, et al. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol

2009;201:199.e1-8.

S ince the institution of Papanicolaouscreening program, both the inci-dence and mortality of cervical cancer in

the United States have steadily declined.1

Although the decline in incidence and

mortality rates of cervical cancer in the

United States have occurred across allra-cial and ethnic groups, significant dis-

parities in these rates continue to exist.1

Hispanic women in the United States

shoulder a disproportionate burden,

both in rates of incidence and mortality

from cervical cancer. According to the

Surveillance, Epidemiology, and End

Results database, Hispanic women are

diagnosed with cervical cancer twice as

often as non-Hispanic white women.1

The average annual cervical cancer mor-

talityratefrom2000to2004forHispanic

women in theUnited States was reported

to be 1.5 times greater than that for non-Hispanic white women.1

Several factors may account for the

observed disparity in cervical cancer in-

cidence and mortality among Hispanic

women in the United States, as com-

pared with these rates among non-His-

panic white women. These factors in-

clude differences in screening and

follow-up rates and practices, treatment,

behavioral risk factors, and potentially

underlying biological variations. Al-

though this disparity in cervical cancer

incidence and rate is not uniquely shoul-

dered by Hispanic women in the United

States and also affects African American

and American Indian/Alaskan Native

and Asian-American/Pacific Islander

women, Hispanic women represent a

special group with certain unique needs.

These needs include language profi-

ciency, cultural preferences, legal status,

and social networking. Hispanics repre-

sent the fastest growing minority groupin the United States, with an estimated

41 million Hispanics currently living

in this country (14% of the total

population).2

It is estimated that by the year 2050,

102.6 million Hispanics will live in the

United States, comprising 24% of the to-

tal population.2 As Hispanics become agrowing segment of the US population,

this continued disparity may have a sig-

nificant impact on theircommunitys in-

frastructure secondaryto increasedmor-

bidity and mortality rates from an

entirely preventable malignancy.2 The

growing number of Hispanics in the

United States and their disparity across

many disease spectra, including cervical

cancer, will result in a continued burden

to the US health care system.

The factors that may play a role in His-

panic womens cervical cancer screening

and treatment need to be elucidated to

better design program and create oppor-

tunities that will lead to the resolution of

the disparity that currently exists. To

better understand the factors that have

an impact on cervical cancer screening

and care among Hispanics in the United

States, we conducted a large-scale survey

study, in which self-identified Hispanic

women were directly asked about issuesaffecting their access of Papanicolaou

From the Division of Gynecologic Oncology,

Department of Obstetrics and Gynecology

(Ms Watts, Ms Joseph, Ms Velzquez, and DrsGonzalez, Munro, Raugh-Hain, and del

Carmen), and the Department of

Biostatistics (Ms Muzikansky),

Massachusetts General Hospital, Harvard

Medical School, Boston, MA.

Received Jan. 30, 2009; revised April 10,2009; accepted May 12, 2009.

Reprints: Marcela G. del Carmen, MD, MPH,55 Fruit St., Yawkey 9E, Boston, MA [email protected].

0002-9378/$36.00 2009 Mosby, Inc. All rights reserved.

doi: 10.1016/j.ajog.2009.05.014

Research www.AJOG.org

AUGUST 2009 American Journal of Obstetrics&Gynecology 199.e1
mailto:[email protected]:[email protected]:[email protected]


2/8

smear screening programs and utiliza-tion of general health care services as wellas their acculturation, social networking,and media venues most conducive to ac-quiring health care information in theircommunity.

MATERIALS AND METHODS

Study population and design

Using radio, newspaper, and web-basedannouncements, self-identified His-panic women in the Boston area, aged18-99 years, were invited to participatein a written survey. The study accruedparticipants from Aug. 1, 2007, throughJune 15,2008. Hispanic ethnicity wasde-fined according to the categories listed in

the US Census 2000. These includedMexican, Mexican-American, Chicano,Puerto Rican, Cuban, or other Span-ish/Hispanic or Hispanic ethnicity. Thismeans study participants were originallyor directly descending from Spain, aSpanish-speaking part of Central orSouth America, or the DominicanRepublic.

Based on the federal governments dis-tinction between race and ethnicity as 2separate concepts, we used the US Cen-

sus 2000 definitions of race and ethnicityfor consistency and future comparisons.To minimize any confusion over the 2terms and to avoid Hispanics over-se-lecting other as their race, we placedthe question on race after a brief expla-nation that to qualify for study participa-tion, the respondent had to be of His-panic origin or ethnicity, as defined inprevious text.

The survey was available in both Span-ish and English, either in hardcopyor on

the web. The survey was comprised of 7different sections and included a total of121 questions. There was no identifyinginformation collected. The questionsand instructions for the survey werewritten using languagethat would be un-derstandable with a fourth-grade level ofeducation. Participants with limited lit-eracy were offered the opportunity tohave the survey read to them for comple-tion. The survey was designed usingquestions from the cancer control sup-

plement of the National Health Inter-view Survey, the US Census 2000 survey,

and questions from other publishedsources in the literature.3-5

Some questions were modified by thestudy investigators to collect more de-tailed information or improve questionreadability. The survey was pretested

during a series of 4 focus group sessionsamong women eligible for participationbut not included in the study. The in-strument included questions on demo-graphics, health utilization, accultura-tion, knowledge, and behavior. Thestudy was reviewed and approved by theinstitutional review board of the DanaFarber Harvard Cancer Center.

Study variables

The survey instrument included 7 sec-

tions collecting information pertinent tothe respondents demographic back-ground, current socioeconomic situa-tion, venues through which new infor-mation is acquired, health utilization,acculturation, knowledge and access toscreening programs, and reproductivehistory and behaviors. Acculturationquestions included inquiries into the re-spondents perception that others intheir community and in the health caresystem could relate to them in their lan-

guage and cultural paradigm.Respondents were also asked specificquestions about their basic knowledge,access to services, and screening prac-tices including Papanicolaou smears,mammography, and colonoscopy. Fi-nally, women were asked about their re-productive history and behavior, focus-ing on those practices placing them atincreased risk of acquiring sexuallytransmitted infections.

Thedemographicsection in the survey

collected detailed information on the re-spondents country of origin, religiousbackground and current practices, mar-ital status, primary and preferred spokenand written language, and educationlevel. The section on current socioeco-nomic status collected data on the re-spondents present employment status,annual income, legal status, and healthinsurance coverage. Respondents werealso asked detailed questions about howthey learn new information, including

their use of radio, television, newspaper,and computer media venues. These

questions detailed the participants lan-

guage preference when using these ven-

ues as well as the time of day they were

more likely to access them. The health

utilization section collected information

on the womens access and use of basic

health maintenance, screening, andemergency room services.

Statistical analysis

Comparisons were made within the re-

spondents group. Participants were

stratifiedonthebasisofage,thelengthof

time living in the United States, and Pa-

panicolaou smear screening frequency.

For example, respondents were asked

how long they had lived in the United

States, and the responses were catego-

rized into less than 5 years or 5 years orlonger.

The responses were also analyzed

based on the study participants age. Age

30 years was chosen, given that studies

have shown herpes papillomavirus prev-

alenceand cervical cancerincidence are a

function of a womans age.6,7 Women

older than 30 years of age have been

shown to have a greater risk for develop-

ing high-grade lesions and cancer.6,7

The decision made to stratify based on

lifetime Papanicolaou smears was madeup front and before the study was initi-

ated. For each question analyzed, nonre-

sponses were excluded. Descriptive sta-

tistics, such as frequencies and means,

were provided for all the data. Two-sam-

ple Studentttest and Pearson 2 statis-

tics were used to analyze continuous and

categorical outcomes, respectively.

Logistic regression models fit to pro-

vide odds ratios (confidence interval) for

outcomes of interest such as the influ-

ence of socioeconomic status and social

networking on Papanicolaou smear

screening practices among respondents.

Multiple models were constructed to

better explain more complex patterns of

association between covariates of inter-

est and a set of outcome variables. Re-

sponse rates for all questions were as-

sessed and analyzed to determine the

existence of potential source of bias.

AllcomputationsweredoneusingSAS

statistical software (SAS Institute, Cary,NC).

Research Oncology www.AJOG.org

199.e2 American Journal of Obstetrics &Gynecology AUGUST 2009


3/8

RESULTS

Respondent characteristics

A total of 318Hispanicwomeneitheren-

tirely or partially completed the survey

and provided data available for analysis.

The mean response rate for each ques-

tion on the survey was 87%. The respon-

dents were aged 19-78 years, with a meanage of 42 years.The majorityof respon-

dents were originally from the Domin-

ican Republic (28%), Puerto Rico

(22%), Central America (19%), and

the United States (13%, born in the

United States). Eighty-seven percent of

respondents reported living in the

United States for longer than 5 years,

with 77% having livedin Bostonlongerthan 5 years.

The majority of respondents were bi-lingual. However, 88% indicated Span-ish as their primary spoken language and87% indicated Spanish as their primarywritten language. Fifty-six percent of re-spondents had a high school level educa-

tion or less; 69%specifiedthat more thanhalf of their educationhad been obtainedoutside the United States and in Spanish.Most of the women reported being mar-ried, Catholic, and employed and de-clared an annual income of less than US$25,000. The demographic characteris-tics of survey respondents are listed inTable 1.

Language preferences and length

of time in the United States

and use of screening

Responses were categorized for analysisbased on age and length of time residingin the United States. The data reflectedthat Hispanics aged 30 years or older andliving in the United States less than 5years maintain Spanish as the preferredlanguage at home and for communica-tion of health care information. Analysisof the data based on length of time resid-ing in the United States showed that al-though 80% of total respondents prefer

speaking Spanish, only 65%of Hispanicsliving in the United States less than 5years are bilingual compared with 85%of Hispanics residing in theUnited Statesfor 5 years or longer (P .0026). Also,93% of Hispanics living in the UnitedStates less than 5 years prefer speakingSpanish at home compared with 78% ofthose Hispanics living in the UnitedStates 5 years or longer (P .0420).

Further analysis of the data based onlength of time living in the United States,

indicated that Hispanics living in theUnited States less than 5 years were 2.950times more likely to speak only Spanish(P .0026) and 3.304 times more likelyto prefer speaking Spanish (P .0420).Hispanics living in the United States for5 years or longer were also more likely tovisit a health care provider for scheduledvisits (P .0201), to have 4 or more rou-tine health care visits in the preceding 5years (P .0417), and to have had rou-tine screening mammograms and Papa-

nicolaou smears (P

.0016 and P

.0053, respectively).Table 2shows lan-

TABLE 1

Demographic characteristics of survey respondents

Characteristics na Percentageb (%)

Religious behavior.....................................................................................................................................................................................................................................

Nonpracticing 76 25.....................................................................................................................................................................................................................................

Practicing Catholic 156 51.....................................................................................................................................................................................................................................

Practicing Protestant 72 24.....................................................................................................................................................................................................................................

Otherc 3 1..............................................................................................................................................................................................................................................

Marital status..............................................................................................................................................................................................................................................

Married 150 49.....................................................................................................................................................................................................................................

Unmarried, live with partner 50 17.....................................................................................................................................................................................................................................

Divorced/separated/widowed 65 21.....................................................................................................................................................................................................................................

Never married/never lived with partner 39 13..............................................................................................................................................................................................................................................

Language preference.....................................................................................................................................................................................................................................

Primary spoken, Spanish 271 87.....................................................................................................................................................................................................................................

Primary written, Spanish 253 81..............................................................................................................................................................................................................................................

Educationd.....................................................................................................................................................................................................................................

Some high school, eighth grade 86 28..............................................................................................................................................................................................................................................

High school diploma/GED/vocational ortrade school graduate

82 27

.....................................................................................................................................................................................................................................

Associates degree 61 20.....................................................................................................................................................................................................................................

Bachelors degree 39 13.....................................................................................................................................................................................................................................

Advanced degree 38 12..............................................................................................................................................................................................................................................

Current employment status.....................................................................................................................................................................................................................................

Employede 181 60.....................................................................................................................................................................................................................................

Not employed 119 40..............................................................................................................................................................................................................................................

Annual household income, $.....................................................................................................................................................................................................................................

24,999 123 43.....................................................................................................................................................................................................................................

25,000-49,999 92 32.....................................................................................................................................................................................................................................

50,000 69 24..............................................................................................................................................................................................................................................

Years l iving in United States.....................................................................................................................................................................................................................................

1-5 40 13.....................................................................................................................................................................................................................................

5 260 87..............................................................................................................................................................................................................................................a Total number of survey respondents equaled 318. Nonresponses are not included in the data; b Percentages express the

fraction of total number of respondents answering the specific question; c Other included more than 1 religion (n 7) or

no religion (n 7); d Educational attainment question asked the highest grade of school completed or highest degreereceived; e Of this number, 25% have more than 2 jobs, 55% work 26-40 h/wk, and 25.5% work over 40 h/wk.

Watts. Understandingbarriersto cervical cancer screeningamong Hispanicwomen. Am J Obstet Gynecol 2009.

www.AJOG.org Oncology Research



4/8

guage and health care utilization prac-ticesamong respondents based on lengthof time living in the United States.

Age

Hispanics aged 30 years or older similar

to those living in the United States 5years or less prefer speaking Spanish athome (P .0053) and receiving healthcare information in Spanish (P .0001).Hispanics 30 years old or older were0.495 less able to independently fill outthe health encounter form in English (P .0410). When assessed between agegroups and time in the United States,women 30 years old or older were morelikely to be among those who did notwant to know of cancer diagnosis and

did consider cancer to be incurable;however, this was not statistically signif-icant.Table 3lists language preference,health care services utilization practices,and attitudes toward cancer for respon-dents based on age.

Socioeconomic status and social

networking and screening practices

The relationship between socioeco-nomic status (SES) and social network-ing on Papanicolaou smear practices was

also investigated. Women with 5 or morelifetime Papanicolaou smears were 1.610

times more likely to have lived in the

United States 5 years or longer, 1.706

times more likely to speak a second lan-

guage, and 1.712 times less likely to need

a translator during their health care en-

counter. They were also 1.363 times

more likely to be employed and 1.544times more likely to feel comfortable

asking for time off from work to see a

health care provider.

Analysis of health utilization behavior

among Hispanics stratified according to

number of lifetime Papanicolaou smears

demonstrated that Hispanics with 5 or

more Papanicolaou smears were 1.712

times more likely to have had 4 or more

mammograms in the previous 5 years (P

.0424). These women were also more

likely to have had a history of an abnor-

mal Papanicolaou smear, history of cer-

vical dysplasia, and an abnormal colpos-

copy. These trends were not statistically

significant.Table 4shows the influence

of SES and social networking on Papani-

colaou smear screening practices, as re-

ported by these women.

Knowledge and attitudes about

dysplasia and cancer

Forty-nine percent of respondents (n

124) correctly identified the Papanico-

laou smear as a test performed on the

cervix and screening for cancer. Al-

though the majority of respondents (n

221; 74%) believed cancer is deadly, they

also indicated wanting to be informed of

a cancer diagnosis (n 290; 97%;Table

3). However, only 152 women (51%)reported wanting their health care pro-

vider to inform a family member of the

cancer diagnosis. When asked if they

considered a cancer diagnosis to be

fatal, 221 women (74%) answered

affirmatively.

When these responses were analyzed

based on age stratification, respondents

reported wanting to know about a cancer

diagnosis, primary fear of a cancer diag-

nosis,and a beliefthat canceris incurable

in similar proportions, irrespective of

age. Analysis of responses measuring the

venues through which women learn

health care information demonstrated

that 88% of the women (n 262), irre-

spective of age or time living in the

United States, cited radio or television

over written material as their preferred

media for learning new information.

Among all respondents, 77% (n 220)

stated that they listened to the radio,

preferably in Spanish, at least 1 hour perweek, whereas 72% (n 191) reported

TABLE 2

Characteristics of Latina respondents according to US residency duration

Characteristic n %a > 5 y (%)b < 5 y (%)b Pvalue

Language preference................................................................................................................................................................................................................................................................................................................................................................................

Speak Spanish and a second language fluently 306 82 85 65 .0026................................................................................................................................................................................................................................................................................................................................................................................

Prefer speaking Spanish 303 80 78 93 .0420................................................................................................................................................................................................................................................................................................................................................................................

Prefer Spanish for health care information 304 63 59 88 .0005................................................................................................................................................................................................................................................................................................................................................................................

Health care services utilization practices................................................................................................................................................................................................................................................................................................................................................................................

Visited health care providers office for scheduled appointment in the past year 297 96 97 90 .0201.......................................................................................................................................................................................................................................................................................................................................................................

Had 4 routine health care visits in the last 5 y 296 73 75 59 .0417.......................................................................................................................................................................................................................................................................................................................................................................

Had 4 mammograms in the last 5 y 271 33 36 11 .0016.......................................................................................................................................................................................................................................................................................................................................................................

Had 5 Pap smears in the last 5 y 296 98 90 58 .0053................................................................................................................................................................................................................................................................................................................................................................................

Fatalistic attitudes towards cancer.......................................................................................................................................................................................................................................................................................................................................................................

Would not want to be informed of cancer diagnosis 295 3 2 5 .2996.......................................................................................................................................................................................................................................................................................................................................................................

Would want provider to inform family of cancer diagnosis 297 50 49 55 .5112.......................................................................................................................................................................................................................................................................................................................................................................

Believe cancer is deadly 296 74 76 67 .2401................................................................................................................................................................................................................................................................................................................................................................................a The percentages of overall respondents answering affirmatively to the question. The parenthetical n next to each case demonstrates total number of respondents for each question; b This is

the percentage of women within the age group that answered affirmatively to the question.





5/8

watching at least 1 hour of television perweek, also preferably in Spanish. Eighty-four percent (n 254) of the womenstated that they read health care informa-

tion in posters or pamphlets at the health

care providers office. However, 74% ofthem (n 223), irrespective of age orlength of time living in the United States,declared that most of the information was

difficult to comprehend.

CommentThe current investigation evaluated bar-

riers present earlier in the cervical cancer

screening continuum via assessment of

self-conceived obstacles to obtaining Pa-

TABLE 3

Characteristics of Latina respondents according to age

Characteristic n %a > 30 y (%)b < 30 y (%)b Pvalue

Language preference.......................................................................................................................................................................................................................................................................................................................................................................

Live in the United States 5 y 300 87 89 80 .0640.......................................................................................................................................................................................................................................................................................................................................................................

Prefer to speak Spanish at home 304 80 84 68 .0053.......................................................................................................................................................................................................................................................................................................................................................................

Fluency in Spanish and a second language 284 89 88 91 .6197.......................................................................................................................................................................................................................................................................................................................................................................

Prefer having health care information in Spanish 304 63 69 39 .0001.......................................................................................................................................................................................................................................................................................................................................................................

Independently fill out health providers health history and information form inEnglish

304 71 69 82 .0410

................................................................................................................................................................................................................................................................................................................................................................................

Health care services utilization practices.......................................................................................................................................................................................................................................................................................................................................................................

Visited health care providers office for scheduled appointment in the past year 294 96 98 91 .7797.......................................................................................................................................................................................................................................................................................................................................................................

Express discomfort with pelvic exam 289 84 85 81 .4424.......................................................................................................................................................................................................................................................................................................................................................................

Health care provider shares cultural background 292 19 21 13 .2279................................................................................................................................................................................................................................................................................................................................................................................

Attitudes toward cancerc.......................................................................................................................................................................................................................................................................................................................................................................

Would want health care provider to inform them of cancer diagnosis 293 97 97 98 .5167.......................................................................................................................................................................................................................................................................................................................................................................

Chose death as primary fear associated with cancer diagnosis 308 44 44 44 .8106.......................................................................................................................................................................................................................................................................................................................................................................

Believe cancer is incurable 308 23 24 18 .3202................................................................................................................................................................................................................................................................................................................................................................................a The percentages of overall respondents answering affirmatively to the question. The parenthetical n next to each case demonstrates total number of respondents for each question; b This is

the percentage of women within the age group that answered affirmatively to the question; c Other fears associated with cancer were unknown treatment and belief that cancer was incurable.


TABLE 4

Influence of socioeconomic status and social networking on Papanicolausmear screening practices among respondentsa

Characteristic< 5 lifetimePapanicolaou smears

> 5 lifetimePapanicolaou smearsb OR Pvalue

Have an education at or below high schooldiploma, GED, vocational, trade school

75 (57%) 88 (53%) 1.172 .5008

................................................................................................................................................................................................................................................................................................................................................................................

Are employed or have been employed withinthe past 12 mo

73 (56%) 103 (64%) 1.363 .1974

................................................................................................................................................................................................................................................................................................................................................................................

Comfortable asking employer for time off tovisit health care provider 29 (23%) 52 (31%) 1.544 .0797................................................................................................................................................................................................................................................................................................................................................................................

Participate in weekly church-sponsored,nonreligious activity

22 (20%) 29 (22%) 1.069 .8326

................................................................................................................................................................................................................................................................................................................................................................................

Need a translator during health care encounter 33 (26%) 28 (17%) 1.712 .0617................................................................................................................................................................................................................................................................................................................................................................................

Obtained 4 or more mammograms in 5 y 32 (26%) 56 (38%) 1.712 .0424................................................................................................................................................................................................................................................................................................................................................................................

Have a history of abnormal Papanicolau smear 18 (24%) 45 (38%) 1.867 .0570................................................................................................................................................................................................................................................................................................................................................................................

Have had a colposcopy 27 (39%) 54 (48%) 1.424 .2542................................................................................................................................................................................................................................................................................................................................................................................

Have a history of low-high grade dysplasia 11 (14%) 29 (24%) 1.920 .0900................................................................................................................................................................................................................................................................................................................................................................................

GED, general educational development; OR, odds ratio.a Data are expressed as number (percentages). Nonrespondents are not included in data; b The 2 test was used to compare categorical variables.





6/8

panicolaou smears. To our knowledge,this study is the first to examine thesebarriers among a large sample of exclu-sively Hispanic women living in theNortheast and directly surveyed, with a121 question instrument. The study is

unique in having directly surveyed thewomen with a detailed questionnaire in-strument, as well as in asking specificquestions measuring basic knowledgeand the use of screening services, accul-turation, and health utilization practicesamong a large group of Hispanics in theUnited States. Our study also evaluatedtheroleofageandlengthoftimelivinginthe United States as potential variablesaffecting acculturation and screeningknowledge and practices.

Our study is limited in that the groupof women surveyed reside in a metropol-itan city in the Northeast and excludedPortuguese Hispanic women. However,the distribution across racial categorieswas similar to the results of the 2000 USCensus, suggesting a similar racial distri-bution in the general Hispanic popula-tion and among our respondents. In ad-dition, the study has a selection bias forwomen who have the literacy to readpamphlets and the newspaper. Nonethe-

less, in spite of thepotential bias formoreeducated and acculturated women, westill sawdifferences in health care utiliza-tion practices.

Of concern, we found that the popula-tion of women at the highest risk for cer-vical dysplasia and cancer (those 30years old and living in the United States 5 years) were those who reported de-creased screening practices comparedwith women younger than 30 years andliving in the Unites States for 5 years or

longer.In addition, we found the preferencefor Spanish to be more marked amongHispanic women aged 30 years or olderand living in the United States less than 5years. Although bilingual, these womenpreferred speaking Spanish and as suchfavored having health care informationcommunicated in Spanish. These womenwere less capable of independently fillingouthealth forms. Ourstudy would suggestthat older age ( 30 years) and length of

time livingin theUnited States(

5 years)areassociatedwith lowerlevels of accultur-

ation and this may be related to the lower

percentages of patients screened in this

population.

These results are consistent with pre-

vious studies of health care utilization by

more diverse populations. Previous

studies have investigated barriers toscreening,suggesting that the major ones

are personal or cultural, socioeconomic,

and institutional.8-10 Cultural and per-

sonal barriers include origin of birth,

language proficiency, level of accultura-

tion, and patient-health provider rela-

tionship.8-10 The demographic results in

this study reflect some of these personal

and cultural barriers. Our results sup-

port previous findings that Hispanics

prefer Spanish as their written and spo-

ken language, even if they report beingbilingual. Lack of English proficiency

has been reported in other studies as a

factor contributing to nonadherence

to screening.11-14

Cultural assimilation may be a special

challenge for Hispanics born outside the

United States. In our study, 85% of re-

spondents cited a Latin American coun-

try as their birth place, with only 13%

claiming the United States as their coun-

try of birth. Among our study popula-

tion, 76% (n 226) reported living inthe United States for longer than 8 years.

Strategies to improve screening rates

among Hispanics in the United States

may need to address factors that pertain

to an older segment of the population

with less acculturation, despite length of

time residing in the United States.

Our results challenge previous results

indicating that a major personal barrier

in cervical cancer screening is the wom-

ans lack of knowledge about the role of

Papanicolaou smear in cervical cancer

prevention.12,15,16 In our study, 41% of

respondents (n 124) correctly identi-

fiedthe Papanicolaou smear as a test per-

formed on the cervix and screening for

cancer. Although this response is higher

than previously reported, increasing

knowledge about the rationale behind

Papanicolaou smear should still be the

target of future education strategies and

intervention among underserved mi-

nority women who may be at a higherrisk of developing cervical cancer.

Our study supports previous investi-gations reporting that Hispanic womenhave a fatalistic attitude toward the dis-coveryof a cancer following a screeningtest.3,16 The majority of women in oursurvey considered a cancer diagnosis to

be deadly. However, the majority ofthese women reported wanted to be in-formed of their cancer diagnosis. In thisrespect, our results contradict previousinvestigations showing that Hispanicsprefer not knowing a cancer diagnosisand that this attitude in turn may influ-ence their nonadherence to screeningprograms.3,16

Our respondents did report a desire tokeep their families uninformed of a can-cer diagnosis. This attitude may manifest

a special personal barrier among thesewomen for providers caring for them intheir ability to partner with family mem-bers as part of the support and resourcenetwork for these patients. It may repre-sent a special opportunity for the designof strategies aimed at improving a cul-turally appropriate exchange of perti-nent medical information among His-panic patients and their families.

The patient-provider relationshipmay also play a critical role in adherence

to health care guidelines and participa-tion in screening programs. In ourstudy,a statistically significant proportion ofwomen 30 years of age or older as well asthose living in the United States for lessthan 5 years stated a preference for hav-ing their health care information com-municated in Spanish as well as havingtheir provider be of the same culturalbackground. However, only 19% of re-spondents (n 56) reported havinga health care provider of Hispanic

background.The preference among our respon-dents for Spanish-speaking providersunderscores the fact that socioculturaldifferences between patients and healthcare providers affect communicationand clinical decision-making pro-cesses.17 Language may be only 1 of themany factors that, at least from the pa-tient perspective, dictates a culturallycompetent encounter. If these sociocul-tural differences are not identified, under-

stood, communicated, and addressed inthe clinical encounter, they may result in




7/8

lack of patient satisfaction, inadequate par-ticipation, and worse health outcomes.18

As Hispanics become a growing pop-ulation in the United States, it is imper-ative to continue investigating the socio-cultural differences that obstruct care

and to create programs with the intent ofalleviating these barriers. In the case ofcervical cancer, the impact of these cul-tural differences needs to be better un-derstood in the context of cervical cancerscreening and diagnosis. A better under-standing of these differences will resultinthe design of cross-cultural medical ed-ucation. These culturally competentframeworks will ultimately facilitate theexploration and negotiation of criticalhealth care issues and decisions and re-

sult in better health outcomes, especiallyamong the older and more recent immi-grant population.

Socioeconomicfactors (such as educa-tion and income level, medical insur-ance, andmedical cost of care) have beendescribed as forces contributing to dis-parities in health care. Studies haveshown that medically uninsured womenare less likelyto participate in screeningprograms.19 Data from 2000 generatedby the Behavioral Risk Factor Surveil-

lance Survey linked to state data on theNational Breast and Cervical CancerEarly Detection Program showed thatlow income and lack of medical insur-ance were major barriers to Papanico-laou screening among Hispanic and Af-rican American women. The majority ofthese women reported medical costs as abarrier.20

Similar barriers were reported for allracial/ethnic groups in data obtainedfrom the 2000 NationalHealth Interview

Survey and confirmed in other stud-ies.13,16,21,22 In our study, 99% of women(n 277) reported having some form ofhealth insurance, suggesting that lack ofhealth insurance is not the only factoraffecting a womans ability to participatewith screening programs and corrobo-rating other investigations noting thatdespite the presence of adequate healthinsurance, underserved minorities arestill at risk of disparities in accessing thehealth care system.16

In 2007, the Commonwealth of Massa-chusetts passed a constitutional amend-

ment to assure universal health coveragefor all state residents, which may in partexplain the high insurance rate seen in ourstudy. It is important to underscore thatour study didnot collectdetailedinforma-tion on insurance coverage. The level of

coverage among respondents was not as-sessed, and indeed some women may havehad to pay more than others to cover thecost of their healthcare. The lack of associ-ation between health care insurance andscreening practices may be an importantconsideration to contemplate in the designofstrategiesaimingatimprovingscreeningrates among Hispanics in the UnitedStates.These programs must address someof these other barriers, beyond health in-surance, and not assume that adequate

cost of care coverage will result in highercompliance rates with screening.Fifty-six percent of respondents re-

ported an education level of high schoolor less. Several other investigations haveshown that low levels of education arereliableindicators for screening nonad-herence.14,16 Forty-three percent of re-spondents reported an annual income ofless than US $25,000. Metaanalyses ofstudies identifying barriers to screeninghave shown that, irrespective of other

variables, poverty is a strong predictor ofscreening, diagnosis, treatment, and sur-vival odds.10

Structural barriers have also beenshown to affect participation in thehealth care system. Subset analysis of thewomen living in the United States for 5years or longer showed that they werealso more likely to visit their health careproviders office for regularly scheduledappointments (as opposed to emergencyroom services) and to have routine

screening tests. This may reflect a previ-ously described association betweenphysician recommendation and partici-pation in appropriate screening regi-mens.11,15,21,22 Bazargan et al19 reportedthat women who stated that their healthcare provider had never told them tohave a Papanicolaou smear were half aslikely to undergo screening when com-pared with the womenwhose providerrecommended the test.20

Sixty percent of our respondents re-

ported working at least 1 job. Specialconsideration needs to be given to work-

ing Hispanic women in the design ofscreening programs. Institutional barri-ers to screening, as stated by many of ourrespondents, include long wait time athealth centers, transportation difficul-ties, family support, and difficulty with

child care. Programs targeted to improveon these disparities must also take intoconsideration strategies to address andovercome these institutional barriers.

An important discovery of the currentstudy is the identification of radio andtelevision as potential venues to dissem-inate information among Hispanics. In-formation campaigns should considerthese media venues because they mayhelp increase knowledge and awarenessof cervical cancer and its prevention

among Hispanic women in the UnitedStates. Our study provides important in-formation as to the time of day thesemessages may be more effectivelydisseminated.

Lastly, our respondents declared read-ing written information (pamphlets andposters) displayed at their health centers.Importantly, few of them reported un-derstanding the information. Educationcampaigns should be designed to respectthe cultural and education background

of the population they are targeting. ForHispanics in the United States, thesemessages may be more effective if writ-ten in Spanish and if they address someof the barriers described earlier, whichmay be unique to this vulnerable seg-ment of the US population.

The existence of disparities in healthcare for cervical cancer screening andtreatment is well recognized. Recent re-search has focused on identifying and al-leviating the barriers that contribute to

these disparities. Minority populationsin the United States are younger and in-creasing in proportion at faster ratesthan the Caucasian population and rep-resent an especially vulnerable segmentof the population.

The persistence of these disparitiesand the continued population growthmay equate to an increasing burden onour health care system. This may also re-sult in a social and economic impactaffecting underserved communities

shouldering increased morbidity andmortality from screening and treatment




8/8

of cervical cancer. Culturally appropri-ate education regarding cervical cancer,the importance of cervical screening,andthe role of prophylactic vaccination cansignificantly reduce incidence and mor-tality rates for all populations. Such edu-

cation should target not only membersof high-risk populations but also thephysicians who treat them. Developingculturally competent physicians willmake a significant impact in overcomingbarriers and reducing health disparities.

To our knowledge, our study repre-sents the largest group of directly sur-veyed Hispanic women in the UnitedStates on questions regarding cervicalcancer screening. Our results indicatethat age and length of time living in the

United States may be independent riskfactors for barriers contributing to dis-parities in cervical cancer screening andpotential treatment, consistent with pre-vious studies. The social difficulties in-herent to acculturation inform healthbehaviorand translateto health disparityin this population.

The findings suggest that cultural dif-ferences between patients and providerscreate a discomfort among these pa-tients, which is not easily bridged. In fact,

television and radio may be an effectiveway to reach this population. In addi-tion, materialsin Spanish that are readilyavailable in health care centers do make adifference for patients. Our results mayhelp in the design of continued federallyfunded and community-level programsor in the training of patient navigators byidentifying barriers that may be espe-cially relevant to older and more recentHispanic immigrants in the UnitedStates. Future studies validating our re-

sults among Hispanics in other regionsof the United States would be helpful. f

REFERENCES

1.Ries L, Harkins D, Krapcho M, et al. SEER can-cer statistics review, 1975-2005. Bethesda, MD:National Cancer Institute. Available at: http://seer.cancer.gov/faststats/selections.php?seriesrace.Accessed Sept. 14, 2008.2.US Census Bureau. Available at: http://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.html. Accessed Sept. 14, 2008.3. Behbakht K, Lynch A, Teal S, Degeest K,Massad S. Social and cultural barrier to Papa-nicolaou test screening in an urban population.Obstet Gynecol 2004;104:1355-61.4. Suarez L, Roche RA, Nichols D, SimpsonDM. Knowledge, behavior, and fears concern-ingbreast andcervicalcancer amongolderlow-income Mexican-American women. Am J Prev

Med 1997;13:137-42.5.Chavez LR, Hubbell FA, Mishra SI, ValdezRB. The influence of fatalism on self-reporteduse of Papanicolaou smears. Am J Prev Med1997;13:418-24.6.Ries LA, Wingo PA, Miller DS, et al. The an-nual reportto thenation on thestatus of cancer,1973-1997, with a special section on colorectalcancer. Cancer 2000;88:2398-424.7.Sellors JW,Mahony JB,KaczorowskiJ, et al.Prevalence and predictors of human papilloma-virus infection in women in Ontario, Canada.Survey of HPV in Ontario Women (SHOW)Group. CMAJ 2000;163:503-8.

8.Akers AY, Newmann SJ, Smoth SK. Factorsunderlying disparities in cervical cancer inci-dence, screening, and treatment in the UnitedStates. Curr Probl Cancer 2007;31:157-81.9.Engelstad LP, Stewart SL, Nguyen BH, et al.

Abnormal Papanicolaou smear follow-up in ahigh-risk population. Cancer Epidemiol Biomar-kers Prev 2001;10:1015-20.10.Newmann SJ, Garner EO. Social inequitiesalong the cervical cancer continuum: a struc-tured review. Cancer Causes Control 2005;16:63-70.11.De Alba I, Sweningson JM. English profi-ciency and physicians recommendation on

Pap smears among Hispanics. Cancer DetectPrev 2006;30:292-6.12.Coronado GD, Thompson B, Koepsell TD,Schwartz SM, McLerran D. Use of the Pap testamong Hispanics and non-Hispanic whites in arural setting. Prev Med 2004;38:713-22.13.Rodriguez MA, Ward LM, Perez-Stable EJ.Breast and cervical cancer screening: impactof

health insurance status, ethnicity, and nativity ofLatinas. Ann Fam Med 2005;3:235-41.14.Nguyen TT, McPhee SJ, Nguyen T, Lam T,Mock J. Predictors of cervical Pap smearscreening awareness, intention, and receiptamong Vietnamese-American women. Ann JPrev 2002;23:207-14.15.Taylor VM, Yasui Y,Burke N, et al. Pap test-ing adherence among Vietnamese Americanwomen. Cancer Epidemiol Biomarkers Prev2004;13:613-9.16.del Carmen MG, Findley M, Muzikansky A,et al. Demographic, risk factor, and knowledgedifferences between Latinas and non-Latinas

referred to colposcopy. Gynecol Oncol2007;104:70-6.17.Eisenberg JM. Sociologic influences onmedical decision making by clinicians. Ann In-tern Med 1979;90:9574.18.Betancourt JR, Carrillo JE, Green AR. Hy-pertension in multicultural and minority popula-tions: linking communication to compliance.Curr Hypertens Rep 1999;1:482-8.19.Bazargan M, Bazargan SH, Farooq M,Baker RS. Correlates of cervical cancer screen-ing among underserved Hispanic and African-

American women. Prev Med 2004;39:465-73.20.Adams EK,BreenN, Joski PJ. Impactof the

National Breast and Cervical Cancer Early De-tection Program on mammography and paptest utilization among white, Hispanic, and Afri-can American women: 1996-2000. Cancer2007;109:348-58.21.Kagawa-Singer M, Pourat N. Asian Ameri-canand PacificIslanderbreast andcervicalcar-cinoma screening rates and healthy people2000 objectives. Cancer 2000;89:696-705.22.Coughlin SS, Breslau ES, Thompson T, Be-nard VB. Physician recommendation for Papa-nicolaou testing among U.S. women, 2000.Cancer Epidemiol Biomarkers Prev 2005;14:1143-8.


http://seer.cancer.gov/faststats/selections.php?series=racehttp://seer.cancer.gov/faststats/selections.php?series=racehttp://seer.cancer.gov/faststats/selections.php?series=racehttp://seer.cancer.gov/faststats/selections.php?series=racehttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://www.census.gov/Press-Release/www/releases/archives/facts_for_features_special_editions/005338.htmlhttp://seer.cancer.gov/faststats/selections.php?series=racehttp://seer.cancer.gov/faststats/selections.php?series=racehttp://seer.cancer.gov/faststats/selections.php?series=race

barriers to cervical cancer among hispanic women

Documents