The role of health insurance on Pap smear and mammography utilization by immigrants living in the United States

BACKGROUND: Nearly half of recent immigrants to the United States lack health insurance. Access to cancer screening services for this group is problematic. We examine the role of health insurance and having a usual source of care (USC) on Pap smear and mammography utilization by immigrant women using a nationally representative sample. METHODS: We used a telephone survey that oversampled racial and ethnic minorities. We analyzed data on 3,622 women age 18-70. We classified the 822 foreign-born women as recent immigrants if they had resided in the United States for under 10 years; LT immigrants were those with a longer tenure. RESULTS: Among recent immigrants, 73% and 78% (SE 4%) reported a Pap smear or mammogram, respectively, in the previous 2 years versus 89% and 89% of U.S.-born women (P < 0.05 for both comparisons). Among those with insurance or a USC, differences in screening between recent immigrants and U.S.-born women were four percentage points or less and not statistically significant. However, uninsured recent immigrants were less likely than uninsured U.S.-born women to have Pap smears [60% (SE 7%) versus 71%, P < 0.05]. Adjusting for differences in sociodemographics, health attitudes or beliefs, patient or provider communication, and the medical care environment, insurance remained the strongest predictor of screening. CONCLUSION: Disparities in screening were greatly attenuated among the insured population. Increasing awareness of available safety net sources of care may also improve cancer screening among uninsured recent immigrants.     

Cervical Cancer Screening by Immigrant and Minority Women in Canada

Cervical cancer is one of the most preventable forms of cancer and the Pap smear test is one of the most widely accessible forms of cancer screening. An important public health issue is the extent to which Canadian women are engaging in regular screening for cervical cancer, particularly potentially at-risk groups such as recent immigrants and women from minority ethnic backgrounds. We use recent population health surveys to analyze immigrant and native-born women's use of Pap smear testing, with a focus on how screening rates differ by ethnic background and characteristics of immigration. We find that almost all recent immigrant women have markedly lower use of Pap smear testing than comparable Canadian-born women, but these rates slowly increase with years in Canada. However, we find wide variation in rates of screening by ethnic background. Screening rates for White immigrant women from countries where the official language is neither English nor French approach Canadian-born women's utilization rates after 15-20 years in Canada, as do the screening rates of Black and Hispanic women. Screening rates for those from Asian backgrounds remain significantly below native-born Canadian levels even after many years in Canada. As well, immigrant women of Asian background who arrived as children and second-generation Asian Canadians both exhibit significantly lower rates of Pap smear testing than Canadian-born White women.     

Pap smear use in a population of older Mexican-American women

BACKGROUND: Hispanic women and older women (age > or = 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears. OBJECTIVE: To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years. DATA SOURCE: The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50-74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999. RESULTS: We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32-0.82) and those below the poverty line (OR 0.52, 95% CI 0.33-0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96-14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55-11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use. CONCLUSION: Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.     

Low knowledge of cervical cancer and cervical pap smears among women in Peru, and their ideas of how this could be improved

Estimates of the percentage of women who have had Pap smears in Peru vary between 7% and 43%. This study explores what women know about cervical cancer and Pap smears, as well as their barriers to obtaining Pap smears. Focus group discussions (FGD) were conducted with a total of 177 women in four Peruvian cities. Discussions reveal that most women did not know what causes cervical cancer. Most women did not know the purpose of Pap smears, although knowledge about Pap smears was higher than knowledge about cervical cancer. Fear, embarrassment, and lack of knowledge were the main barriers identified for not getting Pap smears. Programs and policies aiming to increase Pap smear coverage must start by educating women on cervical cancer and its prevention in order to improve women's perceptions about the screening test and increase Pap smear seeking behaviors in the long term.     

Pap smear screening at an urban Aboriginal health service: report of a practice audit and an evaluation of recruitment strategies

A culturally appropriate women's health service was established at an Aboriginal community-controlled health service in Darwin in 1994. An initial file audit found that 48% of included women had ever been screened with a Pap smear and 37% of women were considered to have been adequately screened. The enhancement of opportunistic screening by file tagging had a modest effect on screening coverage over a 12-month period for women who attended the health service. The proportion of these women who were adequately screened increased from 43% to 48% and of those ever screened increased from 54% to 62%. A randomised trial of recruitment interventions including personal approach, letter and control groups was subsequently performed for women for whom Pap smears were overdue or not recorded. The impact of both interventions on the number of Pap smears performed was low, with 7% of women in the personal approach group, 2% of women in the letter group and no women in the control group having Pap smears during the three-month follow-up period. Low rates of abnormalities were observed for women having Pap smears over a two-year period. The minimal effect of a formal reminder system and letters at this urban Aboriginal health service has resulted in a re-orientation of activities towards strengthening opportunistic screening and the continued promotion of Pap smears in a range of clinic and community settings. It is important to place Pap smear screening in the context of other social, economic and health priorities for Aboriginal women and health workers.     

Who has Pap smears in New South Wales? Patterns of screening across sociodemographic groups

Abstract: The aim of this study was to determine whether Pap smear screening at adequate intervals is associated with area of residence, frequency of consultations with a general practitioner, socioeconomic status and non-English-speaking background. A representative 10 per cent sample of women from New South Wales and the Australian Capital Territory, aged 25 to 69 years and registered with the Health Insurance Commission (Medicare) (N = 155 281) was used to obtain age, postcode, frequency of Pap smears and frequency of consultations with general practitioners in the three-year period from February 1985 to January 1988. Census data for each postcode area were used as an indicator of other sociodemographic characteristics. Age-specific screening rates did not vary between Sydney, Newcastle/Wollongong, Canberra, and nonmetropolitan areas. In all age groups, having had a smear was most strongly associated with the frequency with which a woman consulted a general practitioner. Women who visited a general practitioner at least four times a year on average were about twice as likely to have had a recent Pap smear as those who averaged less than one visit per year. Screening rates were lowest among women living in areas with the most non-English-speakers and the lowest socioeconomic status. Sociodemographic factors and health service usage patterns influence the proportion of women who are currently being screened. Evaluation of interventions to improve Pap smear screening rates should consider whether the percentage of women screened increases overall, and also whether the imbalances in screening rates between different groups are diminishing.     

Rate of Cervical Cancer Screening Associated with Immigration Status and Number of Years Since Immigration in Ontario, Canada

Cervical cancer screening is a vital public health measure intended to reduce the morbidity and mortality from what is a largely preventable cancer. Previous Canadian studies have documented that immigrants have significantly lower Papanicolaou (Pap) testing rates than women born in Canada. However, the impact of number of years since immigration is less clear. Data were taken from the 2007–2008 Canadian Community Health Survey. Responses from 16, 706 women living in Ontario, Canada were included. The focus was on self-reported Pap testing rates within the last 3 years, immigrant status and number of years since immigration. A robust Poisson regression model was used to determine prevalence ratios (PR) with 95 % confidence intervals (CIs) after adjustment for covariates. The results demonstrated that recent immigrant women (less than 10 years in Canada) were less likely to have had a Pap test in the past 3 years than those who were Canadian-born (PR = 0.77; 95 % CI: 0.71, 0.84). In contrast, immigrants who had lived in Canada for 10 years or longer showed similar compliance with recommended Pap testing intervals as non-immigrants. Higher income, higher level of education, younger age and being married were independently associated with better Pap testing rates. A strategy targeting recent immigrants to Canada is needed to promote Pap testing in this population and reduce their risk of invasive cervical cancer.     

Cervical cancer screening: who is not screened and why?

BACKGROUND: The decline in death rates from cervical cancer in the United States has been widely attributed to the use of Papanicolaou (Pap) smears for early detection of cervical cancer. METHODS: Pap smear screening rates, beliefs about appropriate screening intervals and factors affecting screening were examined using 1987 National Health Interview Survey data. RESULTS: Results indicate that through age 69, Blacks are screened at similar or higher rates than Whites. Hispanics, particularly those speaking only or mostly Spanish, are least likely to have received a Pap smear within the last three years. Of women who had never heard of or never had a Pap smear, nearly 80 percent reported contact with a medical practitioner in the past two years, while more than 90 percent reported a contact in the past five years. Overall, the most frequently reported reason for not having a recent Pap smear was procrastinating or not believing it was necessary. CONCLUSIONS: Thus, in developing screening programs, Hispanics, particularly Spanish speakers, must be targeted. In addition, educational programs should target unscreened women who forego the test due to underestimating its importance, procrastination, or because their medical care provider did not suggest the procedure. Women must be intensively educated that Pap smears should be scheduled routinely to detect asymptomatic cervical cancer.     

Race and Ethnic Disparities in Cervical Cancer Screening in a Safety-Net System

Objectives: The three objectives of this research were: 1) to examine the use of Pap smear tests among low-income women, including minority and immigrant women who were patients in a safety-net healthcare system; 2) to identify policy relevant variables that could lead to changes in use of Pap smear screening services for these women; and 3) to contribute to the literature on use of Pap smear screening, especially among minorities and immigrants. The Behavioral Model for Vulnerable Populations was used as the theoretical framework. Methods: Pap smear screening predictors were examined using telephone interviews with a random sample of women aged 18–60, including 465 Non-Hispanic Whites, 285 African Americans, 164 Hispanic Americans, and 256 Hispanic immigrants, enrolled in a safety-net healthcare system in Texas in Fall 2000. Binary logistic regression analysis was used. Results: The research revealed that Non-Hispanic Whites were most likely to have been screened ever and in the past 3 years, followed by African Americans, Hispanic immigrants, and Hispanic Americans. Among Hispanics, immigrants were most likely to have had Pap smear screening, supporting the “healthy immigrant hypothesis.” Older women were most likely to have ever been screened, with younger women, most likely in the past year. Having a usual source of healthcare and a checkup for current pregnancy increased screening, while competing needs (food, clothing, housing) affected screening negatively. Conclusions: Culturally competent, community-based care for women is needed to increase Pap smear screening among minority groups, especially Hispanic immigrant and Hispanic American women.     

Cervical cancer screening among Chinese immigrants in Seattle, Washington

Introduction: Chinese American women have high rates of invasive cervical cancer, compared to the general population. However, little is known about the Pap testing behavior of ethnic Chinese immigrants.Methods: We conducted a community-based survey of Chinese immigrants living in Seattle, Washington, during 1999. Two indicators of cervical cancer screening participation were examined: at least one previous Pap smear and Pap testing in the last 2 years.Results: The overall estimated response rate was 64%, and the cooperation rate was 72%. Our study sample for this analysis included 647 women. Nearly one quarter (24%) of the respondents had never had a Pap test, and only 60% had been screened recently. Factors independently associated with cervical cancer screening use included marital status, housing type, and age at immigration.Conclusion: Our findings confirm low levels of cervical cancer screening among Chinese immigrants to North America. Culturally and linguistically appropriate Pap testing intervention programs for less acculturated Chinese women should be developed, implemented, and evaluated.     

Screening for cervical cancer in Jamaica

Invasive cervical cancer is a leading cause of death in Jamaica despite the availability of Pap smear screening. 90% of women who die from cervical cancer have never been screened. The effectiveness of Pap smear screening depends on women's knowledge of and attitudes toward screening, the availability of this service, the adequacy of laboratory facilities to process the smears, staffing of clinics and laboratories, quality control, a system of recall of women with positive smears, and economic factors. This article reviews the impact of each of these factors in the Jamaican context. Most women have heard of the Pap smear but believe its purpose is to detect rather than prevent cervical cancer. Screening rates are low among poor, uneducated women. As a result of staff shortages in government laboratories, there is a long delay before Pap smear results are returned. The problem of cervical cancer is severe enough in Jamaica to justify the reallocation of funds from less critical areas.     

Pap smear use in California: are we closing the racial/ethnic gap?

BACKGROUND: Minority women continue to be disproportionately affected by cervical cancer. Minority population groups at high risk for cervical cancer may be failing to fully comply with screening recommendations. The use of Pap smears among women in California was evaluated to identify ethnic groups at higher risk for noncompliance with cervical cancer screening. METHODS: Cross-sectional analysis of 2001 California Health Interview Survey data. Logistic regression was used to assess the independent contribution of race/ethnicity to the use of Pap smears. RESULTS: Hispanic (aPR = 1.03, 95% CI 1.02-1.05) and Black (aPR = 1.03, 95% CI 1.001-1.06) women are more likely to report a Pap smear in the past 3 years as compared to White women. Asians were the least likely to report cervical cancer screening despite a more favorable sociodemographic profile. Screening rates varied among Hispanic or Asian subgroups; Mexicans, Vietnamese, Chinese, and South Asians are particularly underserved. CONCLUSIONS: In contrast to the country as a whole, Hispanic women in California are more likely to report a recent Pap smear as compared to White women. However, racial/ethnic disparities in Pap smear use persist; Asian women are the least likely to report cervical cancer screening as compared to any other group.     

Cervical cancer screening among South Asian women in Canada: the role of education and acculturation

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated (p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women (p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

CERVICAL CANCER SCREENING AMONG SOUTH ASIAN WOMEN IN CANADA: THE ROLE OF EDUCATION AND ACCULTURATION

Cervical cancer screening by Papanicolaou (Pap) smear lowers the incidence and provides early detection of cervical cancer and is a preventative health care measure that should be available on a regular basis to all women at risk. As the population of ethnic women increases, it is important to assess whether these women are aware of and are utilizing this health service. A self-administered questionnaire was completed by 124 South Asian women, aged 18 to 60 years. Sixty-two South Asian students were selected from a university setting and 62 Tamil women were selected from a community center for South Asian women. This study examined the knowledge and use of Pap smears in South Asian women in Canada, and whether their level of acculturation or formal education influenced whether they know about and receive Pap smears. Low level of knowledge about the Pap test and a low prevalence of Pap testing behaviour was significantly correlated ( p < 0.001) with a low level of formal education, education taking place outside of Canada, and a low index of acculturation. South Asian students were significantly more acculturated than Tamil women ( p < 0.001). In conclusion, there was a low level of knowledge and prevalence of cervical cancer screening among South Asian women. This study highlights the need for educational interventions in Canada directed to ethnic women especially from South Asia.     

Pap smear rates among Haitian immigrant women in eastern Massachusetts

OBJECTIVE: Given limited prior evidence of high rates of cervical cancer in Haitian immigrant women in the U.S., this study was designed to examine self-reported Pap smear screening rates for Haitian immigrant women and compare them to rates for women of other ethnicities. METHODS: Multi-ethnic women at least 40 years of age living in neighborhoods with large Haitian immigrant populations in eastern Massachusetts were surveyed in 2000-2002. Multivariate logistic regression analyses were used to examine the effect of demographic and health care characteristics on Pap smear rates. RESULTS: Overall, 81% (95% confidence interval 79%, 84%) of women in the study sample reported having had a Pap smear within three years. In unadjusted analyses, Pap smear rates differed by ethnicity (p=0.003), with women identified as Haitian having a lower crude Pap smear rate (78%) than women identified as African American (87%), English-speaking Caribbean (88%), or Latina (92%). Women identified as Haitian had a higher rate than women identified as non-Hispanic white (74%). Adjustment for differences in demographic factors known to predict Pap smear acquisition (age, marital status, education level, and household income) only partially accounted for the observed difference in Pap smear rates. However, adjustment for these variables as well as those related to health care access (single site for primary care, health insurance status, and physician gender) eliminated the ethnic difference in Pap smear rates. CONCLUSIONS: The lower crude Pap smear rate for Haitian immigrants relative to other women of color was in part due to differences in (1) utilization of a single source for primary care, (2) health insurance, and (3) care provided by female physicians. Public health programs, such as the cancer prevention programs currently utilized in eastern Massachusetts, may influence these factors. Thus, the relatively high Pap rate among women in this study may reflect the success of these programs. Public health and elected officials will need to consider closely how implementing or withdrawing these programs may impact immigrant and minority communities.     

A mobile unit: an effective service for cervical cancer screening among rural Thai women

BACKGROUND: We carried out a systematic screening programme using a mobile unit with the purpose of increasing use of Papanicolaou (Pap) smear screening among rural Thai women. The mobile unit campaign was carried out initially between January and February 1993 and then in 1996 in all the 54 rural villages in Mae Sot District, Tak Province, northern Thailand. METHODS: To evaluate the effect of the programme on changes in knowledge and use of screening, we compared the results of three interview surveys of women, 18-65 years old, in villages selected by systematic sampling for each survey; first in 1991 (before the operation of the programme), secondly in 1994 (one year after the first screening campaign), and last in 1997 (one year after the second campaign). This report also compares data on Pap smears taken by the mobile unit with other existing screening services in the study area. RESULTS: A total of 1603, 1369, and 1576 women respectively, participated in each survey. The proportion of women reported knowing of the Pap smear test increased from 20.8% in 1991 to 57.3% in 1994 and to 75.5% in 1997. The proportion of women who had ever had a Pap smear increased from 19.9% in 1991 to 58.1% in 1994 and to 70.1% by 1997. Screening by the mobile unit accounted for 85.2% of all cervical intraepithelial neoplasia (CIN) III and all invasive cancers identified among the Pap smears taken by screening services in the area between 1992 and 1996. The rate of CIN III was 3.5/1000 smears in this screening programme, which was 5.2 and 2.0 times higher than the rates in the maternal and child health/family planning clinic and the annual one-week mass screening campaign respectively. CONCLUSIONS: The use of a mobile unit may be an effective screening programme in rural areas where existing screening activities cannot effectively reach the female population at risk.     

Cervical cancer screening among Latinas recently immigrated to the United States

BACKGROUND: Little is known about the cancer screening practices of women whose behavior may place them at a high risk for cervical cancer. We explored factors that influence repeated Pap smear screening among recently immigrated Latinas working in bars also called cantinas. METHODS: Face-to-face interview were administered to 360 women working in 60 cantinas. Participants provided information about their cancer screening practices including the number of Pap smears completed in the 5 years before the interview. A theory-based model proposing that demographic characteristics, cancer screening barriers and facilitators, and psychosocial factors influence repeated Pap smear screening was tested with a hierarchical linear regression. RESULTS: Facilitators of cancer screening (recent visit to a physician and receiving a Pap smear in a clinic) and psychosocial variables (Pap smear beliefs, cancer screening intentions and lack of encouragement) were significantly associated with the total number reported Pap smears (adjusted R2 = 0.31, P < 0.0001). Cervical cancer risk behaviors were not significantly associated with repeated screening. CONCLUSIONS: While risk behaviors did not act as barriers, access to health care measures facilitated repeated Pap smear screening. Psychosocial factors hypothesized to function as antecedents of Pap smear screening appear instead to follow from repeated experience with the examination.     

Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey

BACKGROUND: Cervical cancer screening is not fully utilized among all groups of women in the United States, especially women without access to health care and older women. METHODS: Papanicolaou (Pap) test use among U.S. women age 18 and older is examined using data from the 2000 National Health Interview Survey (NHIS). RESULTS: Among women who had not had a hysterectomy (n = 13,745), 83% reported having had a Pap test within the past 3 years. Logistic regression analyses showed that women with no contact with a primary care provider in the past year were very unlikely to have reported a recent Pap test. Other characteristics associated with lower rates of Pap test use included lacking a usual source of care, low family income, low educational attainment, and being unmarried. Having no health insurance coverage was associated with lower Pap test use among women under 65. Despite higher insurance coverage, being age 65 and older was associated with low use. Rates of recent Pap test were higher among African-American women. CONCLUSIONS: Policies to generalize insurance coverage and a usual source of health care would likely increase use of Pap testing. Also needed are health system changes such as automated reminders to assist health care providers implement appropriate screening. Renewed efforts by physicians and targeted public health messages are needed to improve screening among older women without a prior Pap test.     

Differences in Cervical Cancer Screening Between African-American Versus African-Born Black Women in the United States

Although the incidence of cervical cancer has been declining steadily since the Pap smear became standard of care in the U.S., many African immigrants are unfamiliar with this screening test and its potential benefits. Using data from the CDC’s National Health Interview Surveys, we identified respondents who were black women living in the United States, distinguishing U.S.-born (n = 620) and African-born (n = 36). We constructed a measure of current Pap status and used multivariate logistic regression models to compare Pap status between the two groups. Controlling for income, age, education, health insurance, and marital status, African American women were over 3 times more likely to have reported a current Pap smear than African-born women [Adjusted OR = 3.37, 95 % CI = (1.89, 5.96)]. Being an African-born woman was the strongest predictor of current Pap status. Distinguishing immigrant status in an analysis of cervical cancer screening rates for black women indicated much lower Pap smear rates for African-born women, compared with African-American women. More research on the impact of education and culturally specific care is needed to address the disparity in Pap smear rates for African-born black women.     

Medicaid coverage of screening tests for breast and cervical cancer.

Although most women receive periodic Papanicolaou smear (Pap) those who do not are more likely to be of lower socioeconomic status. Similarly, for the many women who do not receive periodic mammography for early diagnosis of breast cancer, cost has often been cited as a reason. Medicaid provides health benefits to roughly 9.4 million women of the appropriate ages for Pap tests and roughly 3.3 million women of the appropriate ages for mammography. The decision to provide such coverage is made on the state level. Of the 50 states and the District of Columbia, 49 provide some level of coverage for Pap smears, 39 for screening mammography. Knowing the extent of coverage allows public health professionals to take advantage of this funding source to provide services for lower-income women and may help initiate coverage in those states where it is not currently available.