Opening Pathways to Cancer Screening for Vietnamese-American Women: Lay Health Workers Hold a Key

Purpose.We describe a controlled trial of a community outreach intervention to promote recognition, receipt, and screening-interval maintenance of clinical breast examinations (CBE), mammograms, and Pap smears among Vietnamese-American women.Methods.Over a 3-year period, indigenous lay health workers conducted small-group sessions of Vietnamese women in a low-income district of San Francisco, California. Women in Sacramento, California, served as controls. Lay workers conducted 56 sessions on general prevention, 86 on cervical cancer, and 90 on breast cancer. Surveys of 306 to 373 women were conducted in the study communities in 1992 and 1996.Results.In the intervention community, recognition of screening tests increased significantly between pre- and postintervention surveys: CBE, 50 to 85%; mammography, 59 to 79%; and Pap smear, 22 to 78% (P= 0.001 for all). Receipt of screening tests also increased significantly: CBE, 44 to 70% (P= 0.001); mammography, 54 to 69% (P= 0.006); and Pap smear, 46 to 66% (P= 0.001). Best-fitting logistic regression models, adjusting for preintervention rates and significant covariates, also showed statistically significant odds ratios for the intervention effect (P< 0.0001).Conclusions.Trained Vietnamese lay health workers significantly increased Vietnamese women's recognition, receipt, and maintenance of breast and cervical cancer screening tests.     

Papanicolaou testing among Vietnamese Americans: results of a multifaceted intervention

BACKGROUND: Vietnamese-American women have the highest incidence of cervical cancer of any ethnic group, and they underutilize Papanicolaou (Pap) tests. DESIGN: Development and implementation of a multifaceted intervention using community-based participatory research (CBPR) methodology and evaluated with a quasi-experimental controlled design with cross-sectional pre-intervention (2000) and post-intervention (2004) telephone surveys. Data were analyzed in 2005. SETTING: Santa Clara County, California (intervention community) and Harris County, Texas (comparison community). PARTICIPANTS: Vietnamese-American women aged 18 and older (n =1566 at pre-intervention and 2009 at post-intervention). INTERVENTION: A community-academic coalition developed and implemented six components: Vietnamese-language media campaign, lay health worker outreach, Vietnamese Pap clinic, patient registry/reminder system, restoration of a government-funded low-cost screening program, and continuing medical education for Vietnamese physicians. OUTCOME MEASURE: Pap test receipt. RESULTS: Overall response rate was 56%. Pap test receipt increased in the intervention (77.5% to 84.2%, p <0.001), but not in the comparison community (73.9% to 70.6%, p >0.05). In multivariate analyses, the intervention was associated with increased Pap test receipt (odds ratio [OR]=2.02, 95% confidence interval [CI]=1.37-2.99). Other factors associated with increased Pap testing included longer U.S. residence, having health insurance, having a regular site of care, having a respectful physician, having a non-Vietnamese or a female Vietnamese physician, and recalling exposure to Vietnamese-language media about Pap testing. Factors associated with reduced likelihood of Pap test receipt were age 65 years and older, never married, less than high school education, and income below poverty level. CONCLUSIONS: A multifaceted CBPR intervention was associated with increased Pap test receipt among Vietnamese-American women in one community.     

Demographic predictors of cancer screening among Filipino and Korean immigrants in the United States

BACKGROUND: Little is known about cancer-screening practices of various Asian subgroups, and even less is known about factors that may predict screening in these populations. DESIGN: Two independent surveys were conducted with 218 Filipino and 229 Korean female immigrants, aged 50 years and older, residing in Los Angeles. RESULTS: In these convenience samples, 48% of Filipino and 41% of Korean women reported receipt of a Pap smear within the past 2 years; 41% of Filipino and 25% of Korean women reported receipt of a mammogram and a clinical breast exam within the past 2 years; and 25% of Filipino and 38% of Korean women reported colorectal cancer screening (blood stool test within the past 12 months or sigmoidoscopy/colonoscopy within the past 5 years). Only 14% of Filipino and 10% of Korean women were adherent to cancer-screening guidelines for all three sites. These differences in screening rates were statistically significant in multivariate analyses of the combined sample, controlling for all demographic characteristics, including age, percent of lifetime in the United States, education, marital status, health insurance, employment, and ethnicity. The two variables that were most consistently independently associated with adherence to cancer screening in both samples were higher percentage of lifetime spent in the United States and ever having had a checkup when no symptoms were present. CONCLUSIONS: These two variables-percent of lifetime in the United States and ever having had a checkup when no symptoms were present-can alert a physician that cancer-screening tests may be overdue among Korean and Filipino immigrants in the United States. Future research should identify predictors of cancer screening among other Asian immigrant groups and U.S.-born Asian women to assist in targeting intervention efforts.     

Predictors of cervical Pap smear screening awareness,intention, and receipt among Vietnamese-American women

BACKGROUND: Compared with white women, Vietnamese women in the United States have a higher rate of cervical cancer and lower Papanicolau (Pap) test utilization. We evaluated factors associated with awareness of the Pap test, intention to obtain it, and its receipt in Vietnamese-American women. METHODS: In 2000, we conducted a telephone survey of Vietnamese-American women aged >or=18 years living in Santa Clara County, California, and Harris County, Texas. We collected data on sociodemographics, healthcare system access and attitudes, as well as Pap test awareness, attitudes, intentions, and practices. RESULTS: Of 1566 subjects, 74% had heard of the Pap test, and 76% had had at least one. Only 42% of those who never had a Pap test had considered obtaining one. There were no significant differences between the two sites. Women aged >or=65 had the lowest rates for all three outcomes. For all women, younger age, being married, having requested a Pap test, physician recommendation, and preferring a female standby if the doctor was male were associated with Pap test intention. Being married, higher level of education, having a female doctor, having a respectful doctor, having requested the test, and physician recommendation were associated with Pap test receipt. CONCLUSION: Vietnamese-American women have low rates of Pap test awareness, intention, and receipt. The patient-doctor interaction is an important determinant. Efforts to increase Pap test utilization in this population need to be directed at encouraging physicians to offer the Pap test and empowering women to ask for the test.     

Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population

BACKGROUND: Screening mammogram and Pap smear rates are lower for women in underserved racial and ethnic groups, yet may be overestimated due to reliance on patients' self-reports. The purpose of this study was to determine accuracy of self-reports of mammograms and Pap smears in a multiethnic, multilingual population of African American, Latina, Chinese, Filipina, and White women residing in low-income census tracts of Alameda County, California. METHODS: Following a baseline telephone survey of 1,464 women regarding receipt of mammograms and Pap smears, we examined computerized and written medical records to validate the dates and locations of tests reported by women. RESULTS: Of 1,464 subjects, 94.9% reported having had a Pap smear, and 87% reported having had a mammogram. For Pap smears, in a subsample of 448 cases, we validated only 69.4% of the women's self-reports, and for mammography, in a subsample of 846 women, we validated only 75.4% of the self-reports. Validation rates differed significantly by ethnicity and site of care for both Pap smears and mammograms. CONCLUSIONS: Population estimates of breast and cervical cancer screening rates based upon patient self-reports need to be adjusted downward, by as much as one-quarter to one-third, for low-income, ethnic women.     

Sociodemographic predictors of pap test receipt,currency and knowledge among Australian women

BACKGROUND: Knowledge of sociodemographic variations in cervical cancer screening can help identify population groups at risk of underutilization of cervical cancer procedures and practices. The aim of this research was to examine sociodemographic predictors of receipt, currency (being up-to-date for), and knowledge of Pap test. METHODS: We used data from the 1995 National Health Survey. A subsample of women was given self-administered questionnaires that included questions about the Pap test. The sample size was 7,572. Using multiple logistic regression, we examined the association of age, marital status, region of residence, country of birth, Index of Relative Socioeconomic Disadvantage (IRSD), and education with Pap test receipt, currency, and knowledge. RESULTS: Women under 30 and over 49 years of age, those not presently married, those with lower levels of education, and those born in the Middle East or Asia (compared with the Australian/New Zealand-born women) were at a greater risk of not receiving and having no knowledge of Pap test. CONCLUSIONS: The results of this study suggest that, as part of a comprehensive cancer screening strategy, women who are unlikely to obtain a Pap smear might benefit from targeted interventions to improve adherence to cervical cancer screening programs.     

Association between CBE,FOBT, and Pap smear adherence and mammography adherence among older low-income women

BACKGROUND: Adherence to regular and timely mammography screening, especially in older low-income women, continues to fall below objectives. The primary aim of this study was to examine whether engaging in other cancer screenings was associated with mammography adherence for older women. METHODS: Women, ages 52 and over, without a self-reported history of breast cancer (N = 862) were selected from a larger sample of women residing in Washington, DC, census tracts with >/=30% of households below 200% of the federal poverty threshold. A computer-assisted telephone survey was used to collect data on health care system factors, demographics, cultural beliefs, clinical breast exam (CBE), Pap smear, fecal occult blood testing (FOBT), and mammography. Adherence was defined as receipt of the last two screening tests within recommended intervals for age. RESULTS: After controlling for other variables, adherence to CBE (OR = 4.15; 95% CI, 2.55-6.73) and Pap smear (OR = 1.82; 95% CI, 1.07-3.12) were highly predictive of mammography adherence. Adherence to FOBT (OR = 1.66; 95% CI, 0.97-2.84) was marginally predictive. CONCLUSIONS: Results of this study indicate that nonadherence to other cancer screenings can help identify women in need of additional interventions to improve mammography adherence.     

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.     

Caregiving associated with selected cancer risk behaviors and screening utilization among women: cross-sectional results of the 2009 BRFSS

ABSTRACT: BACKGROUND: Informal caregiving is increasingly common as the U.S. population ages, and there is concern that caregivers are less likely than non-caregivers to practice health-promoting behaviors, including cancer screening. We examined caregiving effects on cancer risk behaviors and breast and cervical cancer screening in the 2009 Behavioral Risk Factor Surveillance System. METHODS: Women age [GREATER-THAN OR EQUAL TO]41 with data on breast and cervical cancer screening were included (weighted frequency 3,478,000 women). Cancer screening was classified according to American Cancer Society guidelines. We evaluated the association of caregiving with cancer risk behaviors (obesity, physical activity, alcohol intake, smoking status, and fruit/vegetable consumption) and cancer screening (mammography, clinical breast exam [CBE], and Pap test) using logistic regression overall and with stratification on age (<65, [GREATER-THAN OR EQUAL TO]65) or race (white, non-white). RESULTS: Caregivers had greater odds of being obese, physically active, and current smokers. Subgroup analyses revealed that caregiving was associated with obesity in younger women and whites, and with less obesity in older women. Also, caregiving was associated with smoking only among younger women and non-whites. Caregivers had greater odds of ever having had a mammogram or CBE, yet there was no association with mammogram, CBE, or Pap test within guidelines. CONCLUSIONS: Caregiving was associated with some health behaviors that increase cancer risk, yet not with cancer screening within guidelines. Effects of caregiving by age and race require confirmation by additional studies.     

Pap smear screening among women >/=40 years residing at the United States-Mexico border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctor's recommendation for a Pap smear, appears to have a positive effect on women's Pap smear screening rates in U.S.-Mexico border communities.     

Breast and Cervical Cancer Screening Among South Asian Women in New York City

The purpose of this paper is to document the breast and cervical cancer screening practices of a community sample of South Asian women living in the New York City area. A convenience sample of 98 women was engaged in face-to-face interviews regarding their socio-demographic characteristics and cancer screening utilization. Sixty-seven percent of women had ever had a Pap test; 54% had one in the last 3 years. Seventy percent of women over 40 had ever had a mammogram; 56% had one in the last 2 years. Sixty-six percent of women had knowledge of breast self-exam (BSE); 34% of women ever practiced BSE. Multiple logistic regression analysis indicated that insurance status was a significant predictor of ever having a Pap test or mammogram, receiving timely Pap tests, and ever practicing BSE. Education was a significant predictor of ever having a Pap test and having knowledge of BSE. Marital status was a predictor of receiving timely Pap tests, and having spent more time in the U.S. was a predictor of ever practicing BSE. The study concludes that increased educational efforts must be developed targeting immigrant South Asian women of low socioeconomic status with limited access to healthcare.     

Pap Smear Screening Among Women ≥40 years Residing at the United States–Mexico Border

Invasive cervical cancer is a preventable disease due to screening for precursor lesions using the Papanicolaou cytological testing (Pap smear). Participants were assessed regarding their access to and utilization of health care services, prevention orientation, history of chronic disease screening, and reproductive health history. Factors independently positively associated with Pap smear screening were age, clinical breast exam (CBE) in the last year, doctor recommendation of a Pap test, living in the United States, and checkup in the past year. Having a regular source of health care, as well as a doctor's recommendation for a Pap smear, appears to have a positive effect on women's Pap smear screening rates in U.S.–Mexico border communities.     

The timing of preventive services for women and children: the effect of having a usual source of care.

OBJECTIVES: This study investigated the causal effect of having a usual source of medical care on the timing of preventive services by women and children. METHODS: Data on 17,110 children and 23,488 women from the 1988 and 1990 National Health Interview Surveys were used to estimate ordered probit models of the effect of having a usual source of medical care on the time since the last receipt of each preventive service (routine checkups for children; blood pressure checks, Pap smears, and breast exams for adult women; mammograms for older women). Two-stage instrumental variables methods were used to eliminate simultaneity bias. RESULTS: The existence of a usual source of medical care was strongly correlated with the earlier receipt of preventive services, and the relationship appears to be causal for Pap smears, breast exams, and mammograms. However, there was little evidence that having a regular provider caused an increased rate of routine checkups for children or blood pressure checks for adult women. CONCLUSIONS: Delivery systems that encourage the development of long-term relationships with medical providers may increase cancer screening rates among women.     

Breast Cancer Knowledge, Attitude and Screening Behaviors Among Hispanics in South Texas Colonias

This study examines breast cancer knowledge, attitudes and screening behaviors of Hispanic women living in the South Texas colonias of Maverick and Val Verde Counties. We used the Health Belief Model to analyze the effects of HBM constructs on clinical breast exam (CBE) and mammogram screening. Using a multistage systematic sampling approach we interviewed women living within these colonias. Logistic regression analysis was used to predict CBE and mammography screening behaviors. The results indicate that knowledge, susceptibility, barriers and source of health information were statistically significant in predicting CBE among these women. In addition, background variables such as marital status and health insurance were also significant in predicting CBE. Findings further indicate that source of health information, barriers, and health insurance significantly predicts mammography screening behaviors. Results suggest that for women living in colonias along the South Texas Border socio-demographic variables play a significant role in CBE and mammography utilization.     

The Impact of Near‐Universal Insurance Coverage on Breast and Cervical Cancer Screening: Evidence from Massachusetts

This paper investigates the effect of expansion to near‐universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states. We also consider the effect specifically among low‐income women. We find positive effects of Massachusetts health reform on cancer screening, suggesting a 4 to 5% increase in mammograms and 6 to 7% increase in Pap tests annually. Increases in both breast and cervical cancer screening are larger 3 years after the implementation of reform than in the year immediately following, suggesting that there may be an adjustment or learning period. Low‐income women experience greater increases in breast and cervical cancer screening than the overall population; among women with household income less than 250% of the federal poverty level, mammograms increase by approximately 8% and Pap tests by 9%. Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low‐income women. Our results suggest that reform was successful in promoting preventive care among targeted populations. Copyright © 2015 John Wiley & Sons, Ltd.     

Cancer preventive screening behavior among elderly women

Screening procedures and recommendations for early detection of cervical and breast cancer are reviewed with special reference to suggested guidelines for screening among the elderly. Data on preventive practices related to cancer detection were obtained from 675 women in Maryland by telephone interviews. The elderly (65 years of age and older) reported fewer detection tests of any type; specifically, 23% report never having had a Pap test and an additional 28% have not had one within 5 years, compared with women under the age of 65, where 98% report having had a Pap test and 79% have had one within the past two years. Elderly women were also less likely than younger women to report receiving routine breast examinations by their physicians, to perform BSE, or to have been taught BSE by a health professional. Type of provider utilized, having a personal physician, and going to a gynecologist account for a significant proportion of the variance in screening practices.     

Preventive care: female cancer screening, 1996-2000

BACKGROUND: Low-income and uninsured women have lower odds of receiving age-appropriate cancer screens that can detect cancers earlier and reduce morbidity/mortality. A key question is whether federal/state public health programs aimed at increasing screening and other public policies (e.g., welfare reform, managed care) have affected their receipt of these preventive services. METHODS: Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to estimate the effects of public programs, income, and insurance status on the odds that women received mammography, clinical breast examination (CBE), or Papanicolaou (Pap) smears from 1996 to 2000. State fixed-effects models are estimated. Effects of the age (measured in years) of states' National Breast and Cervical Cancer Early Detection Programs (NBCCEDPs) and level of federal funding are presented. RESULTS: Adjusted odds of uninsured women reporting female cancer screens were lower than for those privately insured, and did not change between 1996 and 2000 despite welfare reform and increasing numbers of uninsured. The age of states' NBCCEDPs were associated with increased odds of mammography, CBE, and Pap smear screens for non-elderly women. For example, the aging of a state's program from 0 to 5 years was associated with an increase in the percentage of women receiving mammography from 52.7% to 55.1%. CONCLUSIONS: Despite efforts to increase screening among low-income uninsured women, their average rates remain below those with higher incomes and/or insurance. However, initiation and maintenance of the states' NBCCEDPs over long periods is associated with increased screening. After accounting for program age, increased federal dollars are associated with slight increases in screening for women aged >65.     

Disparities in Receipt of Breast and Cervical Cancer Screening for Rural Women Age 18 to 64 with Disabilities

BackgroundPrevious research has found breast and cervical cancer screening disparities between women with and without disabilities, and between women living in rural versus urban areas. Living in a rural area may add to the barriers women with disabilities experience when attempting to obtain screening for breast and cervical cancer. The purpose of this study was to examine the combination of disability status and rurality in association with receipt of breast and cervical cancer screening among women age 18 to 64 in the United States.MethodsWe conducted cross-sectional analyses of data from the Medical Expenditure Panel Survey, using pooled annual data files from 2002 through 2008. We compared recent receipt of breast and cervical cancer screening among four groups: 1) urban women without disabilities, 2) urban women with disabilities, 3) rural women without disabilities, and 4) rural women with disabilities.FindingsOverall, women with disabilities were less likely to be up to date with mammograms and Pap tests compared with women with no disabilities. Similarly, women in rural areas were less likely to have received breast or cervical cancer screening within recommended timeframes. Women who both had a disability and lived in a rural area were the least likely to be current with screening.ConclusionsOur findings suggest that living in rural regions compounds disparities in receipt of cancer screening among women with disabilities. Increased attention is needed to improve receipt of cancer screening among rural women with disabilities.     

Whatever happened to clinical breast examinations?

BACKGROUND: The purpose of this study was to examine trends in the use of clinical breast examinations (CBE), mammography, and both tests between the years 1990 and 2000. METHODS: Receipt of breast cancer screening tests (CBE, mammography, and both tests combined) for white, black, and Hispanic women in 1990, 1994, 1998, and 2000 were examined by sociodemographic, access, and health risk indicators using data from the National Health Interview Survey. RESULTS: The use of mammography increased from 1990 to 2000, but the proportion of women reporting a recent CBE decreased for almost all groups of women. Differential use of CBE by sociodemographic characteristics is consistent with what has been documented for mammography. CONCLUSIONS: Although the use of mammography has increased since 1990, there has been a downward trend in the use of CBE. Healthcare providers should be aware of the lower rates of CBE, particularly among women with compromised access to health care, and should not assume that women who get mammograms have received comprehensive screening for breast cancer.     

The Relationship Between Religiosity and Cancer Screening Among Vietnamese Women in the United States: The Moderating Role of Acculturation

In this study the authors explore the relationship between intrinsic, personal extrinsic, and social extrinsic religiosity to breast and cervical cancer screening efficacy and behavior among Vietnamese women recruited from a Catholic Vietnamese church and a Buddhist temple in the Richmond, Virginia metropolitan area. The potential moderating effect of acculturation was of interest. Participants were 111 Vietnamese women who participated in a larger cancer screening intervention. Data collection began early fall of 2010 and ended in late spring 2011. High levels of acculturation were associated with increased self-efficacy for Pap tests and having received a Pap test. Acculturation moderated the relationships between religiosity and self-efficacy for breast and cervical cancer screening. Higher levels of social extrinsic religiosity were associated with increased efficacy for cancer screening among less acculturated women. Acculturation also moderated the relationship between religiosity and breast cancer screening. Specifically, for less acculturated women, increasing levels of intrinsic religiosity and personal extrinsic religiosity were associated with lower likelihood probability of Pap testing. For highly acculturated women, increasing levels of intrinsic religiosity and personal extrinsic religiosity were associated with higher likelihood probability of Pap testing. The authors' findings demonstrate the need for further investigation of the dynamic interplay of multi-level factors that influence cancer screening.