Cervical cancer screening in rural NSW: Health Insurance Commission data compared to self-report

There are several sources of data for estimates of community Pap test rates, including self-report, pathology laboratory records and Health Insurance Commission (HIC) data. Estimates of screening rates can vary considerably according to the sampling frame and data source. This study aimed to compare the self-reported estimates of cervical cancer screening with HIC estimates for women in rural NSW towns. Self-report of a Pap test in the past two years from 2,498 women in 19 rural towns of NSW was compared to HIC-provided Pap test rates. Self-report levels were adjusted for non-HIC providers and HIC levels included data from the Victorian Cytology Register. Self-report estimates were significantly higher than HIC estimates in 18 of the 19 towns, with discrepancies ranging from 13% to 29%. HIC-recorded providers accounted for between 65% and 100% of Pap tests per town, according to self-report. The highest Pap test rate by self-report was 70.1%, the highest by HIC was 49.2%. The lowest Pap test rate by self-report was 45.2%, the lowest by HIC was 26.1%. There was significant variation in Pap test rates between towns for adjusted self-report estimates, but not for the crude self-report estimates. Researchers should always be aware of both the possible variations according to data source and the inherent biases for whichever data source is used. An extra caution is given to consider the public/private provider profile when exploring possible geographical differences in Pap test rates.     

Opting off the New South Wales Pap Test Register in a sexual health setting

OBJECTIVES: To determine the proportion of women having a Pap smear at Sydney Sexual Health Centre (SSHC) who opted off the NSW Pap Test Register (PTR) and to establish the characteristics of these women. DESIGN: Retrospective cross sectional study involving three time periods during 1996 and 1997. SETTING: A public sexual health centre in Sydney. PARTICIPANTS: 985 women who had a Pap smear at SSHC. Main outcome measures: The participant's decision to opt on or off, and the demographic and behavioural characteristics associated with opting off the PTR. RESULTS: 590 (59.9%) women opted off the PTR. Using logistic regression, young age (p=0.005), birth outside Australia and New Zealand (p=0.0001), not speaking English at home (p=0.005) and being a commercial sex worker (CSW) (p=0.0001) were variables associated with opting off the PTR. Women from countries outside of Australia and New Zealand were more likely to opt off, whether or not they were a CSW and CSWs were more likely to opt off the PTR irrespective of their country of birth (p=0.013). CONCLUSION: The majority of women (60%) attending the SSHC opted off the PTR. Studies to evaluate culturally appropriate health promotion material particularly for CSWs and women with poor English skills living in Australia are needed and if successful may improve uptake on the PTR.     

Comparison of papanicolaou (Pap) test rates across Ontario and factors associated with cervical screening

BACKGROUND: Cervical cancer remains a significant yet preventable disease despite the widespread availability of Pap test screening, which detects cervical cancer and its precursor lesions. The aims of this study were to: i) estimate and compare age- and hysterectomy-adjusted Pap test rates across the 37 Ontario public health units (PHUs), and ii) explore the association between several factors and Pap test rates (at the ecological level). METHODS: Cytobase, an Ontario Pap test registry, captures more than 80% of all Pap tests in Ontario. Cytobase was used to determine Pap test rates adjusted for age, hysterectomy and Cytobase coverage for the year 2001. Multiple linear regression analyses were used to evaluate the relationship between Pap test rates and various factors at an ecological level, RESULTS: Age-, hysterectomy- and Cytobase-adjusted one-year Pap rates ranged from 11.6% to 73.9% among PHUs. The overall rate for Ontario was 40.7%. Multivariate analyses indicated that the presence of a teaching hospital was associated with higher Pap test rates. CONCLUSION: One-year Pap test rates varied greatly across the 37 public health units in Ontario. Pap test rates determined using Cytobase were lower than self-reported rates obtained from the Canadian Community Health Survey, possibly due to "over-reporting". In general, women were not screened as frequently as recommended by the Ontario Cervical Screening Program. A positive association was observed between Pap test rates and the presence of a teaching hospital. Data quality issues limit the ability to monitor cervical screening. A provincial registry would address these issues.     

Cost-effectiveness of the conventional papanicolaou test with a new adjunct to cytological screening for squamous cell carcinoma of the uterine cervix and its precursors

OBJECTIVE: To estimate costs and outcomes of conventional annual Papanicolaou (Pap) test screening compared with biennial Pap test plus speculoscopy (PPS) screening for cervical neoplasms. DESIGN: A Markov model compared cost-effectiveness and outcomes of annual Pap tests with biennial PPS. The model includes direct costs of screening, diagnostic testing, and treatment for squamous intraepitheial lesions and invasive cancers; indirect costs (eg, lost productivity because of cervical cancer); and newer management practices, including human papillomavirus DNA testing. PATIENTS: Women aged 18 to 64 years. INTERVENTION: Screening for cervical neoplasms with either annual Pap smear test or biennial PPS. MAIN OUTCOME MEASURE: Marginal cost per life-year gained. RESULTS: The probability of women having squamous intraepithelial lesions, cervical cancer, or death from cervical cancer was lower among women undergoing PPS biennially. A total of 12 additional days of life per woman was gained with biennial PPS during the 47-year model period. Total average cumulative direct medical costs per patient were $1419 for biennial PPS compared with $1489 for annual Pap tests. Total costs, including direct medical costs and indirect costs, were $2185 for PPS compared with $3179 for Pap tests alone. Increased savings and patient outcomes were observed in high-risk populations. CONCLUSION: Our simulations indicate that biennial screening with PPS is expected to provide cost savings for women older than 18 years compared with annual Pap test screening, especially for those in high-risk populations.     

Collecting and using aboriginal health information in New South Wales

OBJECTIVE: To describe the development of guidelines for the management of Aboriginal health information in NSW. The purpose of the guidelines is to promote the ethical management of Aboriginal health information, with appropriate consideration for cultural factors. METHODS: The guidelines were developed collaboratively by the NSW Aboriginal Health Partnership, which comprises NSW Health (the central administrative office, named NSW Department of Health, and the Area Health Services) and the NSW Aboriginal Health and Medical Research Council (AHMRC), the peak body representing member Aboriginal Community Controlled Health Services in NSW. A lengthy and comprehensive consultation process enabled a wide range of interested groups to have input into the guidelines. RESULTS: The project culminated in the production of the NSW Aboriginal Health Information Guidelines, covering the collection, ownership, storage, security, release, usage, interpretation and reporting of information, as well as issues of privacy and confidentiality. The Guidelines formed the basis of a formal Memorandum of Understanding, signed by the NSW Minister for Health, NSW Department of Health and the AHMRC, on 24 August 1998. CONCLUSIONS AND IMPLICATIONS: The Guidelines make an important contribution to meeting a need for protocols on the collection, ownership and use of Aboriginal health information. Their production reflects successful collaboration between government and Aboriginal Community Controlled Health Services in NSW. Future reviews of the Guidelines will ensure their effectiveness and consistency with Aboriginal community principles.     

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.     

Pilot of a novel cervical screening intervention: interactive voice response

OBJECTIVE: This paper describes the pilot of an interactive voice response (IVR) cervical screening brief advice interface. METHOD: In September 2000, 5,000 households within Cessnock, New South Wales, were contacted by an IVR system. The system randomly selected eligible women aged 18-69, assessed their cervical screening status and provided a tailored message about cervical screening. A computer-assisted telephone interview (CATI) evaluated intervention acceptability. Participation rates, participant demographics, IVR use by women, and IVR costs were also examined. RESULTS: 549 (12%) women listened to the IVR call and 587 (59%) completed the CATI interview. IVR listeners under-represented younger and older women, and over-represented women who were married, and of Aboriginal descent. The majority of women (98%) found IVR easy to answer and 90% agreed IVR reminders were a good idea. Unscreened and older women used the system more than screened or younger women. CONCLUSIONS: The IVR call was successfully used by a large number of women to obtain information on cervical cancer screening, with higher use by recognised risk groups. IMPLICATIONS: These results suggest that an IVR reminder might be useful to increase cervical screening rates since those most at risk also used IVR the most. The potential for linking IVR to a database to issue reminders in the same manner as Pap Test Register postal reminders needs to be explored.     

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 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.     

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.     

Cancer screening among the overweight and obese in Canada

BACKGROUND: Despite increased cancer incidence and mortality among overweight and obese men and women, U.S. studies have reported the reduced use of cancer screening among these subjects. We sought to analyze the relationship between overweight/obesity and cancer screening practices using population-based Canadian data. METHODS: Responses from adults surveyed in the Canadian Community Health Survey 2003 who provided complete information regarding variables of interest were analyzed. Cancer screening modalities included Pap smear testing, mammography, and fecal occult blood testing, and were based on contemporary recommendations of the Canadian Task Force for Preventive Health. The association between overweight/obesity and cancer screening was explored using logistic regression after adjusting for demographic and socioeconomic factors, health habits, healthcare access, and obesity-related comorbidity. The analysis was conducted in 2007. RESULTS: Compared to normal-weight controls, overweight and obese women were significantly less likely to have undergone cervical cancer screening. In the fully adjusted model, increasing obesity was associated with decreasing odds of Pap smear testing, with overweight, Class-I, -II, and -III obesity having 95% ORs of 0.87 (0.81, 0.94); 0.79 (0.72, 0.88); 0.62 (0.54, 0.71); and 0.61 (0.53, 0.72), respectively. The prevalence of biennial breast and colorectal cancer screenings was largely unaffected by weight in the adjusted analyses. CONCLUSIONS: Overweight and obesity are associated with markedly lower utilization of cervical cancer screening, despite increased disease risks. This association is independent of sociodemographic factors, comorbidity, and healthcare access. This is consistent with findings in U.S. populations, and suggests that patient and provider factors serve as greater barriers to screening than do healthcare system factors.     

Effect of a community action intervention on cervical cancer screening rates in rural Australian towns: the CART project

BACKGROUND. The effect of community action on cervical cancer screening rates was explored in 20 rural Australian towns. METHODS. Town quarterly Pap test counts, from the Australian Health Insurance Commission, were converted to town rates using Census populations. Pap test rates for 12 quarters before and after mobilization were examined. RESULTS. Wilcoxon-Mann-Whitney tests demonstrated significantly higher per capita Pap test rates pre- to postmobilization for intervention towns compared to matched control towns for women whose last Pap test was more than 2 years ago (P=0.008). Maximum efficiency robust tests examining the equality of mean differences (intervention-control) of per capita rates between pre- and post-mobilization periods also found significant differences for Pap tests where last procedure was between 1 and 2 years ago (R = 13.9, P = 0.039) and near significance for Pap tests where last procedure was less than one year ago (R = 10.6, P = 0.087). CONCLUSIONS. It appeared that underscreened women were more likely and overscreened women were less likely to have a Pap test in response to the intervention. The results indicate that a community action program can positively impact cervical cancer screening rates.     

Reinvigorating public health core functions: restructuring Los Angeles county's public health system.

In 1997, the Los Angeles County Department of Health Services launched an effort to revitalize its Public Health Services division. County investments resulted in the creation of 241 new positions, facilitating the establishment of new offices addressing neglected chronic disease prevention, staff development, training, and communication. Service effectiveness and community responsiveness were enhanced by decentralizing leadership through eight Area Health Offices and strengthening partnerships with private health care providers, community-based organizations, and managed care organizations. Infrastructure enhancements included the development of program performance measures, countywide health indicators, a central health assessment and epidemiology office, and a new countywide biennial survey.     

Why many visible minority women in Canada do not participate in cervical cancer screening

Objective. To determine a high-risk group of visible minority women in Canada who do not participate in cervical cancer screening and the reasons why they do not participate.

Design. We combined two cycles of a large Canadian health survey, Canadian Community Health Survey (CCHS), to obtain a large sample size of visible minority women. Proportions of ‘never having a Papanicalaou (Pap) test’ and ‘not having a Pap test within the last three years’ were then calculated for different ethnic groups using sampling weights advised by Statistics Canada to account for the complex sampling procedure used in CCHS. A logistic regression model was developed to test the association between demographic and health-related variables and not having a Pap test. To identify visible minority women who were at a high risk of not having a Pap test, we stratified these women simultaneously on three variables that were significant in the logistic regression model.

Results. Visible minority women were more than twice as likely never to have had a Pap test. Among visible minority women, those who recently immigrated to Canada and did not have a regular physician had the highest risk for not having a Pap test. Common reasons reported for not having a Pap test included believing it was not necessary and simply not getting around to it.

Conclusion. Visible minority women in Canada may not be participating in regular Pap testing because of cultural beliefs and a lack of an understanding of the importance of Pap testing. A culturally appropriate cervical cancer screening intervention program that involves members of visible minority communities may increase participation of this subgroup of Canadian women. This study provides preliminary information on why visible minority women in Canada do not participate in cervical cancer screening. However, the lumping together of all visible minority may obscure differences between different ethnic groups. Therefore, further research on each ethnic group is required to develop tailored culturally appropriate intervention.     

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.     

Use of self-report to monitor overweight and obesity in populations: some issues for consideration

OBJECTIVE: To examine the validity of self-reported height and weight data reported over the telephone in the 1997 NSW Health Survey, and to determine its accuracy to monitor overweight and obesity in population surveys. METHOD: Self-reported and measured heights and weights were collected from 227 people living in Western Sydney, who had participated in the NSW Health Survey 1997. RESULTS: Self-reported (SR) weights and heights led to misclassification of relative weight status. BMI, based on measured weights and heights, classified 62% of males and 47% of females as overweight or obese, compared with 39% and 32%, respectively, from self-report. CONCLUSIONS: Caution should be used when interpreting SR height and weight data from surveys, because BMI derived from these is likely to underestimate the true prevalence of overweight and obesity. IMPLICATIONS: SR data have a place in nutrition monitoring because they are relatively inexpensive and easy to collect. However, classifying people into weight categories on the basis of accepted cut-points, using SR heights and weights, yields inaccurate prevalence estimates. Periodic sub-studies of the validity of SR heights and weights are needed to indicate the extent to which the validity of SR is changing.     

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.     

Perceptions of cervical cancer threat, benefits, and barriers of Papanicolaou smear screening programs for women in Iran

OBJECTIVES: The main purpose was to assess associations between HBM variables and participation in cervical cancer screening programs in a sample of Iranian women. METHODS: A total of 333 married women of childbearing age were recruited with cluster sampling. The study was conducted from spring 2002 to spring 2003 and a self-report questionnaire and structured interview were designed to measure the four HBM constructs and Iranian women's knowledge about Pap smear screening. RESULTS: A total of 68.5% reported having undergone at least one Pap test. Women were more likely to participate in Pap smears when they had access to knowledge about cervical cancer and screening programs. Furthermore, the perceived benefit and barrier variables of the Health belief model were two factors related to participation in Pap smear testing. CONCLUSIONS: Health care professionals must provide women with more information about cervical cancer and the benefits of participating in cervical cancer screening programs.     

Breast and Cervical Cancer Screening Disparities Associated with Disability Severity

BackgroundPrior research has noted disparities between women with and without disabilities in receipt of timely screening for breast and cervical cancer. Some studies suggest greater disparities for women with more severe disabilities, but the research to date has yielded inconsistent findings. Our purpose was to further examine differences in receipt of breast and cervical cancer screening in relation to severity of disability.MethodsWe analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. Logistic regression analyses examined whether Pap smears and mammograms had been received within the recommended timeframe according to U.S. Preventive Services Task Force Guidelines. We compared four groups of women aged 18 to 64 years, categorized by presence and complexity of disability: 1) No limitations, 2) basic action difficulties only, 3) complex activity limitations only, and 4) both basic and complex activity limitations.FindingsWomen both with and without disabilities fell short of Healthy People 2020 goals for breast and cervical cancer screening. Overall, women with disabilities were less likely to be up to date with both mammograms and Pap tests. The magnitude of disparities was greater for women with complex limitations. Disparities in Pap testing, but not mammography, remained significant when controlling for demographic, geographic, and socioeconomic factors.ConclusionsWomen with more complex or severe disability were less likely to be up to date with breast and cervical cancer screenings. Targeted efforts are needed to reduce barriers to breast and cervical cancer screening for women with significant disabilities, especially those who also experience other socioecological disadvantages.     

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.