Understanding barriers to cervical cancer screening among Hispanic women

Research

www. AJOG.org

ONCOLOGY

Understanding barriers to cervical cancer screening among Hispanic women Luisa 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 smear

screening access, health services utilization, acculturation, social networking, and media venues most conducive to acquiring health information among Hispanics. STUDY DESIGN: Self-identified Hispanics were surveyed. Participants

were stratified based on age, time living in the United States, and Papanicolaou 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, 1.706 times more likely to speak a second language, and 1.712 times less likely to need a translator during their health care encounter. CONCLUSION: Age and years living in the United States may be

independent risk factors for participation in Papanicolaou screening programs. Social difficulties inherent to acculturation inform health behavior and translate to health disparity among Hispanics. Our results may help design federally funded and community-level programs. 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 Papanicolaou screening program, both the incidence 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 all racial and ethnic groups, significant disparities 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

From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (Ms Watts, Ms Joseph, Ms Velzquez, and Drs Gonzalez, 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 02114. [email protected]. 0002-9378/$36.00 © 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.05.014

Results database, Hispanic women are diagnosed with cervical cancer twice as often as non-Hispanic white women.1 The average annual cervical cancer mortality rate from 2000 to 2004 for Hispanic women in the United States was reported to be 1.5 times greater than that for nonHispanic white women.1 Several factors may account for the observed disparity in cervical cancer incidence and mortality among Hispanic women in the United States, as compared with these rates among non-Hispanic white women. These factors include differences in screening and follow-up rates and practices, treatment, behavioral risk factors, and potentially underlying biological variations. Although this disparity in cervical cancer incidence and rate is not uniquely shouldered 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 proficiency, cultural preferences, legal status, and social networking. Hispanics represent the fastest growing minority group in 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 total population.2 As Hispanics become a growing segment of the US population, this continued disparity may have a significant impact on their community’s infrastructure secondary to increased morbidity 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 Hispanic women’s cervical cancer screening and treatment need to be elucidated to better design program and create opportunities 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 issues affecting their access of Papanicolaou

AUGUST 2009 American Journal of Obstetrics & Gynecology

199.e1

Research

Oncology

smear screening programs and utilization of general health care services as well as their acculturation, social networking, and media venues most conducive to acquiring health care information in their community.

M ATERIALS AND M ETHODS Study population and design Using radio, newspaper, and web-based announcements, self-identified Hispanic women in the Boston area, aged 18-99 years, were invited to participate in a written survey. The study accrued participants from Aug. 1, 2007, through June 15, 2008. Hispanic ethnicity was defined according to the categories listed in the US Census 2000. These included Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or “other” Spanish/Hispanic or Hispanic ethnicity. This means study participants were originally or directly descending from Spain, a Spanish-speaking part of Central or South America, or the Dominican Republic. Based on the federal government’s distinction between race and ethnicity as 2 separate concepts, we used the US Census 2000 definitions of race and ethnicity for consistency and future comparisons. To minimize any confusion over the 2 terms and to avoid Hispanics over-selecting “other” as their race, we placed the question on race after a brief explanation that to qualify for study participation, the respondent had to be of Hispanic origin or ethnicity, as defined in previous text. The survey was available in both Spanish and English, either in hard copy or on the web. The survey was comprised of 7 different sections and included a total of 121 questions. There was no identifying information collected. The questions and instructions for the survey were written using language that would be understandable with a fourth-grade level of education. Participants with limited literacy were offered the opportunity to have the survey read to them for completion. The survey was designed using questions from the cancer control supplement of the National Health Interview Survey, the US Census 2000 survey, 199.e2

www.AJOG.org and questions from other published sources in the literature.3-5 Some questions were modified by the study investigators to collect more detailed information or improve question readability. The survey was pretested during a series of 4 focus group sessions among women eligible for participation but not included in the study. The instrument included questions on demographics, health utilization, acculturation, knowledge, and behavior. The study was reviewed and approved by the institutional review board of the Dana Farber Harvard Cancer Center.

Study variables The survey instrument included 7 sections collecting information pertinent to the respondents’ demographic background, current socioeconomic situation, venues through which new information is acquired, health utilization, acculturation, knowledge and access to screening programs, and reproductive history and behaviors. Acculturation questions included inquiries into the respondents’ perception that others in their community and in the health care system could relate to them in their language and cultural paradigm. Respondents were also asked specific questions about their basic knowledge, access to services, and screening practices including Papanicolaou smears, mammography, and colonoscopy. Finally, women were asked about their reproductive history and behavior, focusing on those practices placing them at increased risk of acquiring sexually transmitted infections. The demographic section in the survey collected detailed information on the respondent’s country of origin, religious background and current practices, marital status, primary and preferred spoken and written language, and education level. The section on current socioeconomic status collected data on the respondent’s present employment status, annual income, legal status, and health insurance coverage. Respondents were also asked detailed questions about how they learn new information, including their use of radio, television, newspaper, and computer media venues. These

American Journal of Obstetrics & Gynecology AUGUST 2009

questions detailed the participant’s language preference when using these venues as well as the time of day they were more likely to access them. The health utilization section collected information on the women’s access and use of basic health maintenance, screening, and emergency room services.

Statistical analysis Comparisons were made within the respondents’ group. Participants were stratified on the basis of age, the length of time living in the United States, and Papanicolaou smear screening frequency. For example, respondents were asked how long they had lived in the United States, and the responses were categorized into less than 5 years or 5 years or longer. The responses were also analyzed based on the study participants’ age. Age 30 years was chosen, given that studies have shown herpes papillomavirus prevalence and cervical cancer incidence are a function of a woman’s age.6,7 Women older than 30 years of age have been shown to have a greater risk for developing high-grade lesions and cancer.6,7 The decision made to stratify based on lifetime Papanicolaou smears was made up front and before the study was initiated. For each question analyzed, nonresponses were excluded. Descriptive statistics, such as frequencies and means, were provided for all the data. Two-sample Student t test and Pearson ␹2 statistics were used to analyze continuous and categorical outcomes, respectively. Logistic regression models fit to provide odds ratios (confidence interval) for outcomes of interest such as the influence 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 interest and a set of outcome variables. Response rates for all questions were assessed and analyzed to determine the existence of potential source of bias. All computations were done using SAS statistical software (SAS Institute, Cary, NC).

Oncology

www.AJOG.org

TABLE 1

Demographic characteristics of survey respondents Characteristics

na

Percentageb (%)

Religious behavior

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

Nonpracticing

76

25

156

51

72

24

3

1

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

Practicing Catholic

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

Practicing Protestant

..................................................................................................................................................................................................................................... c

Other

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

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

..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. d

Education

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

Some high school, ⱕ eighth grade

86

28

High school diploma/GED/vocational or trade school graduate

82

27

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

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

Associate’s degree

61

20

Bachelor’s degree

39

13

Advanced degree

38

12

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

Current employment status

..................................................................................................................................................................................................................................... e

Employed

181

60

Not employed

119

40

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

Annual household income, $

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

ⱕ 24,999

123

43

25,000-49,999

92

32

⬎ 50,000

69

24

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

Years living 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 degree received; 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. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

R ESULTS Respondent characteristics A total of 318 Hispanic women either entirely or partially completed the survey and provided data available for analysis. The mean response rate for each question on the survey was 87%. The respondents were aged 19-78 years, with a mean age of 42 years. The majority of respon-

dents were originally from the Dominican 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 lived in Boston longer than 5 years.

Research

The majority of respondents were bilingual. However, 88% indicated Spanish as their primary spoken language and 87% indicated Spanish as their primary written language. Fifty-six percent of respondents had a high school level education or less; 69% specified that more than half of their education had been obtained outside the United States and in Spanish. Most of the women reported being married, Catholic, and employed and declared an annual income of less than US $25,000. The demographic characteristics of survey respondents are listed in Table 1.

Language preferences and length of time in the United States and use of screening Responses were categorized for analysis based on age and length of time residing in the United States. The data reflected that Hispanics aged 30 years or older and living in the United States less than 5 years maintain Spanish as the preferred language at home and for communication of health care information. Analysis of the data based on length of time residing in the United States showed that although 80% of total respondents prefer speaking Spanish, only 65% of Hispanics living in the United States less than 5 years are bilingual compared with 85% of Hispanics residing in the United States for 5 years or longer (P ⫽ .0026). Also, 93% of Hispanics living in the United States less than 5 years prefer speaking Spanish at home compared with 78% of those Hispanics living in the United States 5 years or longer (P ⫽ .0420). Further analysis of the data based on length of time living in the United States, indicated that Hispanics living in the United States less than 5 years were 2.950 times more likely to speak only Spanish (P ⫽ .0026) and 3.304 times more likely to prefer speaking Spanish (P ⫽ .0420). Hispanics living in the United States for 5 years or longer were also more likely to visit a health care provider for scheduled visits (P ⫽ .0201), to have 4 or more routine health care visits in the preceding 5 years (P ⫽ .0417), and to have had routine screening mammograms and Papanicolaou smears (P ⫽ .0016 and P ⫽ .0053, respectively). Table 2 shows lan-

AUGUST 2009 American Journal of Obstetrics & Gynecology

199.e3

Research

Oncology

www.AJOG.org

TABLE 2

Characteristics of Latina respondents according to US residency duration Characteristic

n

%a

> 5 y (%)b

< 5 y (%)b

P value

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 provider’s office for scheduled appointment in the past year

297

96

97

90

.0201

296

73

75

59

.0417

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

Had ⱖ 4 routine health care visits in the last 5 y

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

Had ⱖ 4 mammograms in the last 5 y

271

33

36

11

.0016

Had ⱖ 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.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

guage and health care utilization practices among respondents based on length of time living in the United States.

Age Hispanics aged 30 years or older similar to those living in the United States 5 years or less prefer speaking Spanish at home (P ⫽ .0053) and receiving health care information in Spanish (P ⱕ .0001). Hispanics 30 years old or older were 0.495 less able to independently fill out the health encounter form in English (P ⫽ .0410). When assessed between age groups and time in the United States, women 30 years old or older were more likely to be among those who did not want to know of cancer diagnosis and did consider cancer to be incurable; however, this was not statistically significant. Table 3 lists language preference, health care services utilization practices, and attitudes toward cancer for respondents based on age. Socioeconomic status and social networking and screening practices The relationship between socioeconomic status (SES) and social networking on Papanicolaou smear practices was also investigated. Women with 5 or more lifetime Papanicolaou smears were 1.610 199.e4

times more likely to have lived in the United States 5 years or longer, 1.706 times more likely to speak a second language, and 1.712 times less likely to need a translator during their health care encounter. They were also 1.363 times more likely to be employed and 1.544 times 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 abnormal Papanicolaou smear, history of cervical dysplasia, and an abnormal colposcopy. These trends were not statistically significant. Table 4 shows the influence of SES and social networking on Papanicolaou smear screening practices, as reported by these women.

Knowledge and attitudes about dysplasia and cancer Forty-nine percent of respondents (n ⫽ 124) correctly identified the Papanico-

American Journal of Obstetrics & Gynecology AUGUST 2009

laou smear as a test performed on the cervix and screening for cancer. Although 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 provider 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 diagnosis, and a belief that cancer is 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), irrespective 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 per week, whereas 72% (n ⫽ 191) reported

Oncology

www.AJOG.org

Research

TABLE 3

Characteristics of Latina respondents according to age Characteristic

%a

n

> 30 y (%)b

< 30 y (%)b

P value

Language preference

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

Live in the United States ⱖ 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 provider’s health history and information form in English

304

71

69

82

.0410

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

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

Health care services utilization practices

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

Visited health care provider’s 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

....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................ c

Attitudes toward cancer

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

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.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

watching at least 1 hour of television per week, also preferably in Spanish. Eightyfour percent (n ⫽ 254) of the women stated that they read health care information in posters or pamphlets at the health

care providers’ office. However, 74% of them (n ⫽ 223), irrespective of age or length of time living in the United States, declared that most of the information was difficult to comprehend.

Comment The current investigation evaluated barriers present earlier in the cervical cancer screening continuum via assessment of self-conceived obstacles to obtaining Pa-

TABLE 4

Influence of socioeconomic status and social networking on Papanicolau smear screening practices among respondentsa Characteristic

< 5 lifetime Papanicolaou smears

> 5 lifetime Papanicolaou smearsb 88 (53%)

OR

P value

1.172

.5008

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

75 (57%)

Are employed or have been employed within the past 12 mo

73 (56%)

Comfortable asking employer for time off to visit health care provider

29 (23%)

Participate in weekly church-sponsored, nonreligious activity

22 (20%)

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

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

103 (64%)

1.363

.1974

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

52 (31%)

1.544

.0797

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

29 (22%)

1.069

.8326

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

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.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

AUGUST 2009 American Journal of Obstetrics & Gynecology

199.e5

Research

Oncology

panicolaou smears. To our knowledge, this study is the first to examine these barriers among a large sample of exclusively Hispanic women living in the Northeast and directly surveyed, with a 121 question instrument. The study is unique in having directly surveyed the women with a detailed questionnaire instrument, as well as in asking specific questions measuring basic knowledge and the use of screening services, acculturation, and health utilization practices among a large group of Hispanics in the United States. Our study also evaluated the role of age and length of time living in the United States as potential variables affecting acculturation and screening knowledge and practices. Our study is limited in that the group of women surveyed reside in a metropolitan city in the Northeast and excluded Portuguese Hispanic women. However, the distribution across racial categories was similar to the results of the 2000 US Census, suggesting a similar racial distribution in the general Hispanic population and among our respondents. In addition, the study has a selection bias for women who have the literacy to read pamphlets and the newspaper. Nonetheless, in spite of the potential bias for more educated and acculturated women, we still saw differences in health care utilization practices. Of concern, we found that the population of women at the highest risk for cervical dysplasia and cancer (those ⱖ 30 years old and living in the United States ⬍ 5 years) were those who reported decreased screening practices compared with women younger than 30 years and living in the Unites States for 5 years or longer. In addition, we found the preference for Spanish to be more marked among Hispanic women aged 30 years or older and living in the United States less than 5 years. Although bilingual, these women preferred speaking Spanish and as such favored having health care information communicated in Spanish. These women were less capable of independently filling out health forms. Our study would suggest that older age (ⱖ 30 years) and length of time living in the United States (⬍ 5 years) are associated with lower levels of accultur199.e6

www.AJOG.org ation and this may be related to the lower percentages of patients screened in this population. These results are consistent with previous studies of health care utilization by more diverse populations. Previous studies have investigated barriers to screening, suggesting that the major ones are personal or cultural, socioeconomic, and institutional.8-10 Cultural and personal barriers include origin of birth, language proficiency, level of acculturation, and patient-health provider relationship.8-10 The demographic results in this study reflect some of these personal and cultural barriers. Our results support previous findings that Hispanics prefer Spanish as their written and spoken language, even if they report being bilingual. 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 respondents cited a Latin American country as their birth place, with only 13% claiming the United States as their country of birth. Among our study population, 76% (n ⫽ 226) reported living in the 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 woman’s 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 identified the Papanicolaou smear as a test performed 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 minority women who may be at a higher risk of developing cervical cancer.

American Journal of Obstetrics & Gynecology AUGUST 2009

Our study supports previous investigations reporting that Hispanic women have a fatalistic attitude toward the discovery of a cancer following a screening test.3,16 The majority of women in our survey considered a cancer diagnosis to be deadly. However, the majority of these women reported wanted to be informed of their cancer diagnosis. In this respect, our results contradict previous investigations showing that Hispanics prefer not knowing a cancer diagnosis and that this attitude in turn may influence their nonadherence to screening programs.3,16 Our respondents did report a desire to keep their families uninformed of a cancer diagnosis. This attitude may manifest a special personal barrier among these women for providers caring for them in their ability to partner with family members as part of the support and resource network for these patients. It may represent a special opportunity for the design of strategies aimed at improving a culturally appropriate exchange of pertinent medical information among Hispanic patients and their families. The patient-provider relationship may also play a critical role in adherence to health care guidelines and participation in screening programs. In our study, a statistically significant proportion of women 30 years of age or older as well as those living in the United States for less than 5 years stated a preference for having their health care information communicated in Spanish as well as having their provider be of the same cultural background. However, only 19% of respondents (n ⫽ 56) reported having a health care provider of Hispanic background. The preference among our respondents for Spanish-speaking providers underscores the fact that sociocultural differences between patients and health care providers affect communication and clinical decision-making processes.17 Language may be only 1 of the many factors that, at least from the patient perspective, dictates a culturally competent encounter. If these sociocultural differences are not identified, understood, communicated, and addressed in the clinical encounter, they may result in

Oncology

www.AJOG.org lack of patient satisfaction, inadequate participation, and worse health outcomes.18 As Hispanics become a growing population in the United States, it is imperative to continue investigating the sociocultural differences that obstruct care and to create programs with the intent of alleviating these barriers. In the case of cervical cancer, the impact of these cultural differences needs to be better understood in the context of cervical cancer screening and diagnosis. A better understanding of these differences will result in the design of cross-cultural medical education. These culturally competent frameworks will ultimately facilitate the exploration and negotiation of critical health care issues and decisions and result in better health outcomes, especially among the older and more recent immigrant population. Socioeconomic factors (such as education and income level, medical insurance, and medical cost of care) have been described as forces contributing to disparities in health care. Studies have shown that medically uninsured women are less likely to participate in screening programs.19 Data from 2000 generated by the Behavioral Risk Factor Surveillance Survey linked to state data on the National Breast and Cervical Cancer Early Detection Program showed that low income and lack of medical insurance were major barriers to Papanicolaou screening among Hispanic and African American women. The majority of these women reported medical costs as a barrier.20 Similar barriers were reported for all racial/ethnic groups in data obtained from the 2000 National Health Interview Survey and confirmed in other studies.13,16,21,22 In our study, 99% of women (n ⫽ 277) reported having some form of health insurance, suggesting that lack of health insurance is not the only factor affecting a woman’s ability to participate with screening programs and corroborating other investigations noting that despite the presence of adequate health insurance, underserved minorities are still at risk of disparities in accessing the health care system.16 In 2007, the Commonwealth of Massachusetts passed a constitutional amend-

ment to assure universal health coverage for all state residents, which may in part explain the high insurance rate seen in our study. It is important to underscore that our study did not collect detailed information on insurance coverage. The level of coverage among respondents was not assessed, and indeed some women may have had to pay more than others to cover the cost of their health care. The lack of association between health care insurance and screening practices may be an important consideration to contemplate in the design of strategies aiming at improving screening rates among Hispanics in the United States. These programs must address some of these other barriers, beyond health insurance, and not assume that adequate cost of care coverage will result in higher compliance rates with screening. Fifty-six percent of respondents reported an education level of high school or less. Several other investigations have shown that low levels of education are reliable indicators for screening nonadherence.14,16 Forty-three percent of respondents reported an annual income of less than US $25,000. Metaanalyses of studies identifying barriers to screening have shown that, irrespective of other variables, poverty is a strong predictor of screening, diagnosis, treatment, and survival odds.10 Structural barriers have also been shown to affect participation in the health care system. Subset analysis of the women living in the United States for 5 years or longer showed that they were also more likely to visit their health care provider’s office for regularly scheduled appointments (as opposed to emergency room services) and to have routine screening tests. This may reflect a previously described association between physician recommendation and participation in appropriate screening regimens.11,15,21,22 Bazargan et al19 reported that women who stated that their health care provider had never told them to have a Papanicolaou smear were half as likely to undergo screening when compared with the women whose provider recommended the test.20 Sixty percent of our respondents reported working at least 1 job. Special consideration needs to be given to work-

Research

ing Hispanic women in the design of screening programs. Institutional barriers to screening, as stated by many of our respondents, include long wait time at health centers, transportation difficulties, family support, and difficulty with child care. Programs targeted to improve on these disparities must also take into consideration strategies to address and overcome these institutional barriers. An important discovery of the current study is the identification of radio and television as potential venues to disseminate information among Hispanics. Information campaigns should consider these media venues because they may help increase knowledge and awareness of cervical cancer and its prevention among Hispanic women in the United States. Our study provides important information as to the time of day these messages may be more effectively disseminated. Lastly, our respondents declared reading written information (pamphlets and posters) displayed at their health centers. Importantly, few of them reported understanding the information. Education campaigns should be designed to respect the cultural and education background of the population they are targeting. For Hispanics in the United States, these messages may be more effective if written in Spanish and if they address some of the barriers described earlier, which may be unique to this vulnerable segment of the US population. The existence of disparities in health care for cervical cancer screening and treatment is well recognized. Recent research has focused on identifying and alleviating the barriers that contribute to these disparities. Minority populations in the United States are younger and increasing in proportion at faster rates than the Caucasian population and represent an especially vulnerable segment of the population. The persistence of these disparities and the continued population growth may equate to an increasing burden on our health care system. This may also result in a social and economic impact affecting underserved communities shouldering increased morbidity and mortality from screening and treatment

AUGUST 2009 American Journal of Obstetrics & Gynecology

199.e7

Research

Oncology

of cervical cancer. Culturally appropriate education regarding cervical cancer, the importance of cervical screening, and the role of prophylactic vaccination can significantly reduce incidence and mortality rates for all populations. Such education should target not only members of high-risk populations but also the physicians who treat them. Developing culturally competent physicians will make a significant impact in overcoming barriers and reducing health disparities. To our knowledge, our study represents the largest group of directly surveyed Hispanic women in the United States on questions regarding cervical cancer screening. Our results indicate that age and length of time living in the United States may be independent risk factors for barriers contributing to disparities in cervical cancer screening and potential treatment, consistent with previous studies. The social difficulties inherent to acculturation inform health behavior and translate to health disparity in this population. The findings suggest that cultural differences between patients and providers create a discomfort among these patients, which is not easily bridged. In fact, television and radio may be an effective way to reach this population. In addition, materials in Spanish that are readily available in health care centers do make a difference for patients. Our results may help in the design of continued federally funded and community-level programs or in the training of patient navigators by identifying barriers that may be especially relevant to older and more recent Hispanic immigrants in the United States. Future studies validating our re-

199.e8

www.AJOG.org sults among Hispanics in other regions of the United States would be helpful. f REFERENCES 1. Ries L, Harkins D, Krapcho M, et al. SEER cancer statistics review, 1975-2005. Bethesda, MD: National Cancer Institute. Available at: http://seer. cancer.gov/faststats/selections.php?series⫽ race. 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 Papanicolaou test screening in an urban population. Obstet Gynecol 2004;104:1355-61. 4. Suarez L, Roche RA, Nichols D, Simpson DM. Knowledge, behavior, and fears concerning breast and cervical cancer among older lowincome Mexican-American women. Am J Prev Med 1997;13:137-42. 5. Chavez LR, Hubbell FA, Mishra SI, Valdez RB. The influence of fatalism on self-reported use of Papanicolaou smears. Am J Prev Med 1997;13:418-24. 6. Ries LA, Wingo PA, Miller DS, et al. The annual report to the nation on the status of cancer, 1973-1997, with a special section on colorectal cancer. Cancer 2000;88:2398-424. 7. Sellors JW, Mahony JB, Kaczorowski J, et al. Prevalence and predictors of human papillomavirus 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. Factors underlying disparities in cervical cancer incidence, screening, and treatment in the United States. Curr Probl Cancer 2007;31:157-81. 9. Engelstad LP, Stewart SL, Nguyen BH, et al. Abnormal Papanicolaou smear follow-up in a high-risk population. Cancer Epidemiol Biomarkers Prev 2001;10:1015-20. 10. Newmann SJ, Garner EO. Social inequities along the cervical cancer continuum: a structured review. Cancer Causes Control 2005; 16:63-70. 11. De Alba I, Sweningson JM. English proficiency and physicians’ recommendation on

American Journal of Obstetrics & Gynecology AUGUST 2009

Pap smears among Hispanics. Cancer Detect Prev 2006;30:292-6. 12. Coronado GD, Thompson B, Koepsell TD, Schwartz SM, McLerran D. Use of the Pap test among Hispanics and non-Hispanic whites in a rural setting. Prev Med 2004;38:713-22. 13. Rodriguez MA, Ward LM, Perez-Stable EJ. Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas. Ann Fam Med 2005;3:235-41. 14. Nguyen TT, McPhee SJ, Nguyen T, Lam T, Mock J. Predictors of cervical Pap smear screening awareness, intention, and receipt among Vietnamese-American women. Ann J Prev 2002;23:207-14. 15. Taylor VM, Yasui Y, Burke N, et al. Pap testing adherence among Vietnamese American women. Cancer Epidemiol Biomarkers Prev 2004;13:613-9. 16. del Carmen MG, Findley M, Muzikansky A, et al. Demographic, risk factor, and knowledge differences between Latinas and non-Latinas referred to colposcopy. Gynecol Oncol 2007;104:70-6. 17. Eisenberg JM. Sociologic influences on medical decision making by clinicians. Ann Intern Med 1979;90:9574. 18. Betancourt JR, Carrillo JE, Green AR. Hypertension in multicultural and minority populations: linking communication to compliance. Curr Hypertens Rep 1999;1:482-8. 19. Bazargan M, Bazargan SH, Farooq M, Baker RS. Correlates of cervical cancer screening among underserved Hispanic and AfricanAmerican women. Prev Med 2004;39:465-73. 20. Adams EK, Breen N, Joski PJ. Impact of the National Breast and Cervical Cancer Early Detection Program on mammography and pap test utilization among white, Hispanic, and African American women: 1996-2000. Cancer 2007;109:348-58. 21. Kagawa-Singer M, Pourat N. Asian American and Pacific Islander breast and cervical carcinoma screening rates and healthy people 2000 objectives. Cancer 2000;89:696-705. 22. Coughlin SS, Breslau ES, Thompson T, Benard VB. Physician recommendation for Papanicolaou testing among U.S. women, 2000. Cancer Epidemiol Biomarkers Prev 2005;14: 1143-8.