Cervical cancer among Hispanic women: assessing the impact on farmworkers

The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982–98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991–93 (19.8/100,000) and for Mexico in 1990 (115–220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20–50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.     

Cervical cancer screening beliefs among young Hispanic women

OBJECTIVES: This study examined beliefs, attitudes, and personal characteristics that correlated with self-reported cervical cancer screening history among Hispanic women aged 18 to 25 years old in El Paso, TX, a large metropolitan area on the U.S.-Mexico border. METHODS: Data were collected through a cross-sectional, face-to-face survey. The study questionnaire was based primarily on the Health Belief Model, and included scales that measured perceived susceptibility and seriousness of cervical cancer, and perceived benefits and barriers to Pap test screening. The study questionnaire also included measures of acculturation, Pap test history, pregnancy and sexual history, use of birth control, type of medical insurance, and educational attainment. RESULTS: Sixty-nine percent reported ever having had a Pap test and 56% reported having had a test in the past year. Eighty percent reported that they were sexually active, and of these, 63% reported using birth control. Respondents understood the seriousness of cervical cancer, their susceptibility to cervical cancer, and the benefits of Pap testing; however, only 61% agreed that most young women whom they know have Pap tests. Greater acculturation and the belief that most young unmarried women have Pap tests were positively associated with ever having screening. The perception that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test. CONCLUSIONS: This study found suboptimal rates of screening for cervical cancer in a sample of young Hispanic women residing along the U.S.-Mexico border. Although women may understand the seriousness of cervical cancer and the benefits of screening, perceptions about Pap tests may pose barriers to undergoing screening. Efforts to increase screening also may need to focus specifically on women who are least acculturated, as they also were least likely to have had prior Pap tests.     

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.     

Exploration of factors linked with high cervical cancer rates in women from the former Yugoslavia in Victoria,Australia

Objectives: The aim of the project was to identify the cervical screening rate and other factors that may be associated with high rates of cervical cancer in women from the former Yugoslavia compared to the general population in Victoria, Australia. Design: A cross-sectional survey was conducted by structured personal interviews of 42 Bosnian, 56 Croatian, 49 Macedonian, and 35 Serbian women, and 39 women who identified as Yugoslav or of mixed background. Self-report data were collected on Pap testing behaviour, estimated screening rate of each community, stage-based barriers to cervical screening, and women's theories about causes of cervical cancer within their community. Results: Women in this study had an acceptable screening rate, but barriers to cervical screening were similar to those of other groups. While Macedonian women believed more of their community had Pap tests than the other cultural groups, just under half were under-screened themselves. Smoking rates were very high for women in this study. The most common causes of cervical cancer suggested by women in the study were: a low screening rate, lifestyle stress, and chemicals. Conclusion: It is unlikely that the high cervical cancer rate in women from the former Yugoslavia is a result of under-screening, lifestyle stress, or chemicals. Smoking may well contribute to the cancer rate, however the most likely explanation is that cancers not previously detected in Yugoslavia are now being found, together with cervical abnormalities, within the systematic two yearly screening programme of PapScreen Victoria, in Australia.     

Rural physicians' perspectives on cervical and breast cancer screening: a gender-based analysis

Several studies highlight the role of physicians in determining cervical and breast cancer screening rates, and some urban studies report higher screening rates by female physicians. Rural women in North America remain underscreened for breast and cervical cancers. This survey was conducted to determine if there were significant gender differences in practices and perceptions of barriers to breast and cervical cancer screening among rural family physicians in Ontario, Canada. One hundred ninety-one family physicians (response rate 53.1%) who practiced in rural areas, small towns, or small cities completed a mail questionnaire. The physicians' mean age was 44.4 years (SD 9.9), and mean number of years in practice was 16.6 years (SD 10.3). Over 90% of physicians reported that they were very likely to conduct a Pap test and clinical breast examination (CBE) during a periodic health examination, and they had high levels of confidence and comfort in performing these procedures. Male (68%) and female (32%) physicians were similar in their likelihood to conduct screening, levels of confidence and comfort, and knowledge of breast and cervical cancer screening guidelines. However, the self-reported screening rates for Pap tests and CBE performed during last year were higher for female than male physicians (p < 0.01). Male physicians reported they were asked more frequently by patients for a referral to another physician to perform Pap tests and CBE (p < 0.001). Also, male physicians perceived patients' embarrassment as a stronger barrier to performing Pap tests (p < 0.05) and CBE (p < 0.01) than female physicians. No gender differences were observed in screening rates or related barriers to mammography referrals. These findings suggest that physicians' gender plays a role in sex-sensitive examination, such as Pap tests and CBE. There is a need to facilitate physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves. The feasibility of providing sex-sensitive cancer screening examinations by a same-sex health provider should also be explored.     

Pap Smear Screening among Urban Southwestern American Indian Women

Background. American Indian women have among the highest incidence and mortality rates of cervix cancer in the United States. The incidence of cancer of the cervix among American Indians is 19.5/100,000 versus 7.8/100,000 in U.S. whites, and comparison by geographic region/tribe indicates that the rate is four to six times higher in some tribes. Papanicolaou cytological testing (Pap smear) permits the detection of cervical lesions before they become cancerous, effectively reducing the incidence of cervical cancer by 75–90%. The American Cancer Society recommends a Pap smear every year beginning at age 18 years or when sexually active, and more frequent screening in high-risk populations.Methods. A random household cross-sectional survey was conducted in Phoenix, Arizona, to assess cervical cancer screening rates among 519 adult urban American Indian women. Logistic regression was used to identify predictors of Pap smear use.Results. Three-quarters (76.1%) of urban women American Indian surveyed received a Pap smear within the past 3 years, but only 49.5% received a Pap smear within the last year. Women over age 50 years were significantly less likely to have received a recent Pap smear in comparison to younger women.Conclusions. The results of this study indicate that limited access to health care and lack of knowledge about the procedure were important barriers to Pap smear use. Improving cervix cancer screening participation rates is an important step in reducing the disease burden in this high-risk population.     

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.     

Health beliefs and Pap smears among Thai women in Brisbane,Australia

Although a number of studies have assessed the use of Pap smear among Thai women in Thailand, little is known about factors influencing the use of this cervical cancer screening among potentially high risk Thai migrant women. We related health belief model (HBM) factors and sociodemographic variables to the use of Pap smears among migrant Thai women in Brisbane, Australia. A cross-sectional study was conducted in Brisbane, Queensland, Australia. A snowball sampling method was used to recruit 145 women. Thirty-nine percent reported regular Pap smears. Summary HBM index and self-efficacy index were positively associated with Pap smears. Barriers to screening were negatively associated. The HBM appears to be a useful framework for planning cervical cancer prevention. Strategies that reduce barriers to the screening and increase the confidence of women and their self-efficacy are likely to increase their participation.     

Evaluating the stage of change model to a cervical cancer screening intervention among Ohio Appalachian women

ABSTRACT

Cervical cancer incidence and mortality rates are disproportionally high among women living in Appalachia Ohio. This study used the Transtheoretical Model to examine screening barriers before and after a lay health advisor (LHA) intervention (2005–2009) to increase cervical cancer screening rates. Ohio Appalachian women (n = 90) who were in need of a Pap test, based on risk-appropriate guidelines, were randomized to a 10-month LHA intervention and received two in-person visits, two phone calls, and four mailed postcards targeted to the participant’s stage of change. Findings revealed that 63% had forward stage movement 10 months after the intervention. The most frequently reported screening barriers were time constraints, forgetting to make an appointment, and cost. Women who reported the following barriers—doctor not recommending the test; being unable to afford the test; and being embarrassed, nervous, or afraid of getting a Pap test—were less likely to be in the action stage. Understanding the stages of change related to Pap testing and reported barriers among this underserved population may help inform researchers and clinicians of this population’s readiness for change and how to set realistic intervention goals.     

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.     

Hispanic acculturation and utilization of cervical cancer screening in the US

BACKGROUND: Hispanic women have an incidence rate of invasive cervical cancer that is twice as high as that of non-Hispanic White women. Previous investigations have reported that Hispanics are less likely to utilize cancer screening services. Using data from the 2000 National Health Interview Survey, this study examined whether acculturation of Hispanic women was associated with cervical cancer screening. METHODS: The subjects included 2307 Hispanic women aged 21-70 who did not have a history of cervical cancer or a hysterectomy. Women were analyzed by acculturation level according to whether or not they ever had a Pap smear and had one in the previous year and previous 3 years. RESULTS: Acculturation levels tended to be inversely correlated with no Pap smear. Compared to lower acculturated women, women who were more acculturated were less likely to never had a Pap smear (OR = 0.86; 95% CI = 0.58-1.27 for moderate acculturated women and OR = 0.51; 95% CI = 0.29-0.89 for higher acculturated women). Similar results were found for having no Pap smear within the past 3 years (OR = 0.83; 95% CI = 0.61-1.13 for moderate acculturated women and OR = 0.73; 95% CI = 0.49-1.08 for higher acculturated women). CONCLUSION: The findings show that lower acculturation was associated with the under use of cervical cancer screening and suggest that these women might have barriers in accessing and utilizing Pap smears.     

Pressing the key pad: trial of a novel approach to health promotion advice

BACKGROUND: A relatively simple procedure, the Pap test, is effective in detecting early changes in the cervix; however, many at-risk women, even in developed countries, do not have regular Pap tests. METHODS: A randomized controlled trial of an interactive voice response (IVR) cervical screening brief advice involving 17,008 households is described. The IVR system automatically made calls to households and explained the nature of the call; selected one eligible woman aged 18-69 years; determined her screening status; delivered a message appropriate to her screening status; offered additional messages to counter common barriers; offered additional information on cervical screening and cancer; offered additional contact numbers; and offered to arrange for someone to call back. Cervical screening rate data were obtained from the Australian Health Insurance Commission (HIC) for 6 months before and following the intervention. RESULTS: The cervical screening rate was found to have increased by 0.43% in intervention compared to the control postcodes, and the increase was greater for older women at 1.34%. CONCLUSIONS: The overall conclusion was that IVR technology was a feasible means to contact women to deliver brief interventions aimed at increasing cervical screening rates and could economically target at-risk groups. The potential for linking IVR to centralized Pap test Registers to issue Pap test reminders should be explored.     

Use of Pap test among Hispanics and non-Hispanic whites in a rural setting

BACKGROUND: Hispanic women in the United States have a higher incidence of invasive cervical cancer than non-Hispanic whites. A key factor related to the relatively high incidence is the underutilization of cancer-screening services. Several previous investigations have reported that Hispanic women are less likely to comply with screening recommendations for Pap testing; some have identified factors that are associated with non-compliance with screening recommendations. METHODS: Using baseline personal interview data from a randomized community trial on cancer prevention in a rural area, we assessed the association between health barriers and non-compliance with cervical screening recommendations. RESULTS: Among Hispanic women (n = 382), those with a lower level of acculturation were more likely than highly acculturated Hispanic and non-Hispanic white women (n = 385) to report personal barriers as reasons for not getting an initial or subsequent screening exam. Such barriers include fear of finding cancer, fear of finding diseases other than cancer, and embarrassment about receiving a physical exam. Certain structural barriers, such as cost of care, no time off work, and lack of transportation, were reported to be associated with non-compliance with routine cervical cancer screening, especially among non-Hispanic white women. CONCLUSIONS: Future research should examine barriers related to initial and subsequent screening among Hispanics with varying levels of acculturation.     

Young Asian Americans’ Knowledge and Perceptions of Cervical Cancer and the Human Papillomavirus

Cervical cancer is a major health disparity among Asian Americans, with cervical cancer rates of Vietnamese women being significantly higher than for the general US female population and low screening rates reported for Asian American females. Focus groups and interviews were conducted with young Vietnamese, Filipino, and Korean adults (ages 18–29) to collect information on knowledge, perceptions and sources of information regarding cervical cancer, Pap tests and the human papillomavirus. 16 Korean, 18 Vietnamese, and 18 Filipino (50% female) adults participated in the study. Many participants had never heard of HPV, cervical cancer and Pap testing. Cervical cancer screening rates were low for Korean and Vietnamese females and were influenced by moral beliefs and lack of awareness. Culturally relevant education materials that consider specific Asian ethnicity and language are needed to increase awareness of cervical cancer, Pap testing, and HPV among Asian American young adults     

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.     

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.     

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.     

Cancer screening behaviors among U.S. women: breast cancer, 1987-1989, and cervical cancer, 1988-1989.

Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to examine trends in breast and cervical cancer screening behaviors among U.S. women in selected states. Data reported are from the 1987, 1988, and 1989 BRFSS for breast cancer screening (mammography) and from the 1988 and 1989 BRFSS for cervical cancer screening (Papanicolaou [Pap] smear). Results are presented as either state-specific or state-aggregate data for the years noted above. State-specific analyses indicated that self-reported mammography utilization increased between 1987 and 1989. Although whites and blacks reported similar mammography utilization rates both for screening and for a current or previous breast problem, disparities were evident among women of different ages and incomes. The proportion of women who reported ever having had a Pap smear and having heard of a Pap smear were extremely high and remained fairly consistent across the 2 survey years. State-aggregate analyses, however, showed that the percentage of women who had had a Pap smear within the previous year was negatively associated with age and positively associated with income. A higher proportion of blacks than whites obtained Pap smears. These results indicate that certain segments of the population are not taking full advantage of available breast and cervical cancer screening technologies. Public health strategies, such as those outlined in the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354), should enhance screening opportunities for these women.     

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.