Preventive Medicine 33, 9–17 (2001)doi:10.1006/pmed.2001.0845, available online at http://www.idealibrary.com on

Breast Cancer Screening among American Samoan Women1

Shiraz I. Mishra, M.D., Ph.D.,*,2 Pat H. Luce, M.S.,† and F. Allan Hubbell, M.D., MSPH*

*Center for Health Policy and Research, Department of M

University of California at Irvine, Irvine, California

Published onlin

Background. Little is known about breast cancerscreening practices or predictors of age-specificscreening for Samoan women.

Methods. Through systematic, random sampling pro-cedures, we identified and interviewed 720 adult ($30years) Samoan women residing in American Samoa,Hawaii, and Los Angeles. Multivariate logistic regres-sions were performed to determine independent pre-dictors for recent age-specific screening.

Results. Only 55.6% of women ($30 years) had everhad a CBE and 32.9% of women ($40 years) had everhad a mammogram. Furthermore, only 24.4 and 22.4%of Samoan women ($40 years) residing in Hawaii andLos Angeles, respectively, had an age-specific mammo-gram within the prior year. Independent predictors ofage-specific CBE screening included age, education,health insurance, ambulatory visit, and being a resi-dent of Hawaii or Los Angeles; those for mammographyincluded ambulatory visit and awareness of screen-ing guidelines.

Conclusion. Population-based estimates of age-specific breast cancer screening among Samoanwomen are lower than the national objectives andthose reported for other minorities. Targeted effortsthat address doctor–patient communication on pre-ventive behavior, improved access to health care ser-vices (especially in American Samoa), and focused

educational awareness programs are needed toimprove the dismal screening rates observed in thisindigenous population. q 2001 American Health Foundation and

Academic Press

Key Words: breast; cancer; screening; breast exam;

1 This project was supported by grants from the National CancerInstitute (U01-CA-64434 and P30-CA-62203). The contents of thearticle are solely the responsibility of the authors and do not necessar-ily represent the views of the funding agency.

2 To whom correspondence and reprint requests should be ad-dressed at the Center for Health Policy and Research, University ofCalifornia at Irvine, 100 Theory, Suite 110, Irvine, CA 92697-5800.Fax: (949) 824-3388. E-mail: simishra@uci.edu.

9

edicine, and Chao Family Comprehensive Cancer Center,92697-5800; and †National Office of Samoan Affairs

e June 6, 2001

mammography; Samoan; Pacific Islander; minorities;women’s health.

INTRODUCTION

Much progress has been made in the diagnosis andtreatment of breast cancer, the most common canceramong women in the United States [1]. However, theseadvances have not accrued evenly among the U.S. popu-lation. Several studies have documented substantialincreases in breast cancer screening practices in someparts of the United States, especially among minoritiessuch as Hispanics and African Americans [2–6], andimproved trends in stage-at-diagnosis and mortalityrates [6]. On the other hand, there is disproportionatelylower utilization of age-specific breast cancer screeningamong the small but growing Asian-American immi-grant minority groups such as the Korean Americans[7–9], Filipino Americans [9,10], and VietnameseAmericans [11,12] and indigenous groups such as Amer-ican Indian and Alaska Natives [13–15]. Little isknown, however, about breast cancer screening prac-tices and about factors that may predict screeningamong most Pacific Islanders and, in particular, Ameri-can Samoan (henceforth “Samoan”) women, the indige-nous peoples of the U.S. Territory of American Samoa.

Samoans, the largest Pacific Islander group after theHawaiians, comprise 17% of the total Pacific Islanderpopulation [16]. They live primarily in the U.S. Terri-tory of American Samoa and in a few urban areas inthe United States, principally in California and Hawaii.The U.S. Territory comprises the eastern Samoan archi-pelago, which was ceded by the Samoan chiefs to theU.S. government in 1900 and 1904. The Samoan migra-tion to Hawaii and the U.S. mainland began in the

1950s with the end of the U.S. naval administration inAmerican Samoa [17].

A comprehensive analysis of the health care systemon the U.S. Territory of American Samoa is beyond

0091-7435/01 $35.00Copyright q 2001 by American Health Foundation and Academic Press

All rights of reproduction in any form reserved.

, A

10 MISHRA, LUCE

the scope of this paper. Nonetheless, it is important toaddress a few factors that make the health care systemavailable on the U.S. Territory different from that ac-cessed by Samoans residing in Hawaii and Los AngelesCounty, California (the three study sites). The Ameri-can Samoa Government, through the American SamoaMedical Care Authority (ASMCA) and the Departmentof Health (DoH), provides free or low-cost health care forall the Territory’s residents (Taufete’e John Faumuina,Chief Executive Office, ASMCA, personal communica-tions). The ASMCA provides mainly primary care andgeneral surgical services. The DoH, through a networkof community-based clinics, focuses on preventive pro-grams such as childhood immunizations, diabetes edu-cation, and those for the early detection of cervical andbreast cancers. The cervical and breast cancer earlydetection program, funded by the Centers of DiseaseControl and Prevention, has been active for about thepast 5 years. ASMCA patients who require diagnosticand/or therapeutic services not available on-island arereferred to institutions in Hawaii, New Zealand, andCalifornia. The health care system in the Territory isfurther constrained by the lack of availability of ade-quate services in terms of trained providers and basicdiagnostic facilities. For instance, at the time of thisstudy, due to the nonavailability of a mammogram ma-chine, women from the Territory were referred off-island if they needed a mammogram.

Cancer is the second leading cause of death amongSamoans [18,19]. Breast cancer is the leading cause ofcancer-related morbidity among Samoan women.Breast cancer accounts for about 22% of all cancersdiagnosed among Samoan women in Hawaii and about27% of all cancers diagnosed among Samoan women inLos Angeles County [20,21]. Samoan and non-Hispanicwhite women have comparable site-specific incidenceof breast cancer and both ethnic groups have a lowersite-specific incidence than Hawaiian women [20]. Sa-moan women from the U.S. Territory have a higher site-specific incidence of breast cancer than Samoan womenfrom the independent country of Samoa [21]. Further-more, Samoan women compared with non-Hispanicwhite and Hawaiian women are more likely to receivea diagnosis of cancer (all cancers) at a younger age andto be diagnosed with cancer (all cancers) after metasta-sis has occurred [21]. Breast cancer-related knowledgeand attitude studies among Samoan women reveal aserious gap in knowledge about risk factors and symp-toms and a prevalence of attitudes that could poten-tially impede prevention efforts [22,23]. There is, how-ever, little information on the utilization of breast

cancer screening tests by Samoan women.

The purposes of this paper are twofold. First, we re-port on population-based estimates of utilization ofbreast cancer screening tests, clinical breast examina-tion (CBE), and mammography, by Samoan women.

ND HUBBELL

Second, we examine predictors of recent age-specific

utilization of the screening examinations (CBE andmammography) in an effort to characterize women whoare most likely to underutilize these examinations. Thestudy findings can be used to develop and implementtargeted breast cancer control programs.

METHODS

The data for this report are derived from a largerstudy of the cancer control needs of Samoans residingin three study sites, the U.S. Territory of AmericanSamoa (henceforth “Samoa”); Oahu, Hawaii (hence-forth “Hawaii”); and Los Angeles County, California(henceforth “Los Angeles”) [22,23]. The larger studydetermined site-specific cancer incidence and cancer-related knowledge, attitudes, and practices. In this re-port, we present results related to rates and predictorsof recent CBE and mammogram utilization among re-spondents to an in-depth survey. The Institutional Re-view Boards of the University of California at Irvineand the National Office of Samoan Affairs approvedthe research protocol. The study participants signedwritten informed consent prior to participating in thestudy.

Study Design and Procedures

Detailed accounts of the methodology including studydesign, sample frame, and sampling procedures are de-scribed elsewhere [22,24]. In brief, the cross-sectionalstudy used systematic, random sampling procedures toidentify and interview English- or Samoan-speaking,noninstitutionalized adult (18 or older) Samoan menand women residing in the three study sites [22,23].The populations of Samoans are approximately 60,000,30,000, and 45,000, respectively, in American Samoa,Oahu, and Los Angeles County.

The survey was conducted between June 1996 andApril 1997 by specially trained, supervised, and experi-enced bilingual and bicultural female interviewers. Theinterviewers screened eligible women and administeredthe survey at the respondent’s place of residence. Eachsurvey lasted approximately 40 min and the respon-dents received a token gift of $15 for their participation.To obtain a high cooperation rate, the majority of theinterviews were conducted during weekday eveningsand Saturdays and the interviewers made up to threeattempts to contact eligible respondents before elimi-nating them from the study [25].

The sampling strategy in Samoa differed from thatused in Hawaii and Los Angeles. In Samoa, the large

majority of households are occupied by Samoans; there-fore, random sampling of households from U.S. Censusdata listings was an efficient sampling method. Therelatively small proportions of Samoans residing inHawaii and Los Angeles coupled with the fact that the

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BREAST CANCER SCREENIN

U.S. Census data classified Samoan households underthe broad category of Asian and Pacific Islanders, wouldhave made population-based simple random samplingtechniques inefficient and very expensive (see [26,27]regarding sampling rare populations). Therefore, spe-cial procedures based on household address listing pro-vided by Samoan-speaking churches, social service or-ganizations, and community-based organizations weredesigned to develop the sample frames in Hawaii andLos Angeles for this rare population.

The cooperation rates, defined as the number of com-pleted interviews divided by the sum of the completedinterviews and refusals [25], were 99.8% in Samoa,95.9% in Hawaii, and 93.6% in Los Angeles. From the986 women surveyed in the three sites for the largerstudy, 720 women were 30 years of age and older andform the sample for this report.

Measures

The questionnaire was based on the National HealthInterview Survey (NHIS) [28], the NHIS Cancer Con-trol supplement [29], and findings from the presurveyfocus groups. Content areas of the questionnaire aredescribed elsewhere [22,23]. The questionnaire was de-veloped in English, translated into Samoan, and subse-quently back translated into English by different teamsof three linguistic experts [30]. Reviewers from the com-munity established the face validity of the two versions(English and Samoan) of the questionnaire. Prior toconducting the survey, the questionnaires were pilottested and revised using procedures described else-where [22,23]. This report focuses on demographics,health care access (insurance status and ambulatoryvisit), and recent utilization of age-specific breast can-cer screening tests such as CBE and mammogram.These independent variables have been shown as im-portant predictors of breast cancer screening in otherminority populations [3].

Independent variables included several sample char-acteristics, such as age, marital status, education, em-ployment status, and yearly family income. Accultura-tion was measured using a modified 5-item languageassimilation scale [31]. The scale contains items mea-suring language preference (English or Samoan) toread, to think, to talk with friends, and when growingup. The scale scores ranged from 1 through 5, with amean and median of 2.2 and Cronbach’s a 5 0.89. Thescale scores were dichotomized (see [31]) into groupsthat were “traditional” (,2.2) and “bicultural” or “as-similated” ($2.2). Measures of health care access in-clude health insurance status (uninsured or insured—

those covered by either private or public or both typesof insurance) and most recent ambulatory visit to agynecologist. For reasons discussed in the Introduction,all the women from American Samoa were coded asinsured.

AMONG SAMOAN WOMEN 11

For the two screening examinations, women wereasked if they had ever heard about the test (only formammography); if they had ever had the test; if theyhad had the test, when they obtained the most recenttest; and at what age physicians recommend womenshould initiate regular screening examinations. At thetime of the study, the American Cancer Society (ACS)guidelines recommended a CBE once every 3 years forwomen ages 20–39 and a yearly CBE and mammogramfor women ages 40 and older [32].

We used two dependent variables to characterize re-cent age-specific screening status. Based on the ACSguidelines, women 30–39 years who had obtained theirmost recent CBE within the prior 3 years and those 40or older who had obtained their most recent CBE in theprior year were classified as adherent to CBE screening.Women 40 and older who had obtained a mammogramwithin the prior year were classified as adherent tomammography screening.

Analysis

Analysis was performed using SPSS ProfessionalStatistic 7.5 [33]. We used the (x2 test statistic [34] toassess differences in age-specific CBE and mammogra-phy use according to sample characteristics (demo-graphic, social, economic, and health care access) andthe three study sites.

We constructed full logistic regression models to iden-tify independent predictors of utilization of CBE andmammography. The analyses generated odds ratios, in-dicating the increase (or decrease) in contribution madeby each independent variable to the odds of attainingthe dependent variable, after controlling for other inde-pendent variables in the model. The logistic regressionresults appear as odds ratios (ORs) and 95% confidenceintervals [35], which provide the basis for evaluatingthe magnitude of the differences. We also conductedregression diagnostics using stepwise logistic regres-sion analyses and the goodness-of-fit and Hosmer–Lemeshow test statistics. In general, removal of nonsig-nificant or poorly fitting predictors resulted in smallchanges in the ORs and in P values. For each categoricalvariable in the model, the referent category had anodds ratio of 1.0. Dummy variables were created fortrichotomous categorical variables such as age, ambula-tory visit to a gynecologist, and study site. Variableyearly family income was excluded from the multivari-ate analyses due to multicollinearity (r . 0.25); it hada relatively high correlation with education and studysite. All other independent variables were relatively

uncorrelated (all correlation coefficients ,0.25). Thelogistic regression model for the outcome variable onmammography use was constructed excluding womenfrom American Samoa since, as discussed in the Intro-duction, at the time of the study, women from American

12 MISHRA, LUCE,

Predictors of Reported Age-Specific Screening

Samoa were referred off-island if they needed a mam-mogram. Inclusion of women from American Samoa inmultivariate analyses with mammography as a depen-dent variable would artificially underestimate the ex-tent of utilization of the examination.

RESULTS

Sample Characteristics

The sample consisted of 720 Samoan women ages30 and older from American Samoa, Hawaii, and LosAngeles (Table 1). The majority of the women were ages30–49 years (68.9%), married (67.7%), with fewer than13 years of education (72.5%), not in the workforce(59.3%), with yearly family income of less than $20,000(71%), more traditional in their acculturation (56.9%),and with health insurance coverage (91.3%). Twenty-eight percent of women had visited a gynecologistwithin the prior year.

Awareness about and Reported Utilization of Breast

Cancer Screening Examinations

Most recent visit to a gynecologistNever 25.3**,12 months ago 28.1$12 months ago 46.7

* P , 0.05, **P , 0.01, †P , 0.001 by the x2 test. Proportions of wo

AND HUBBELL

prior year. Slightly less than one-third (31%) of thewomen surveyed had obtained a CBE according to age-specific ACS guidelines. Among women 40 and older(n 5 420), 58.1% of the women had ever heard about amammogram and about one-third (32.9%) of the womenhad ever obtained the test. About one-sixth (16.9%)of the women surveyed had obtained a mammogramaccording to age-specific ACS guidelines.

We also analyzed our data for screening utilizationto reflect obtaining a test within the prior 2 years (datanot shown). Among women 40 years and older, 29 and28.7% of women had obtained a CBE and a mammo-gram (among those residing in Hawaii and LosAngeles), respectively, within the prior 2 years. Fur-thermore, among women 50 years and older, 28.1 and30.8% of women had obtained a CBE and a mammo-gram (among those residing in Hawaii and LosAngeles), respectively, within the prior 2 years.

Bivariate relationships between reported age-specificAs Table 2 shows, 55.6% of the women ages 30 andbreast cancer screening and sample characteristics areolder had ever had a CBE. Among women who had

obtained a CBE, 48.3% had received the test within the displayed in Table 3. Women reporting their most recent

TABLE 1

Sample Characteristics of Samoan Women by Study Site

Total (%) Samoa (%) Hawaii (%) Los Angeles (%)

Characteristics (n 5 720) (n 5 237) (n 5 234) (n 5 249)

Age30–39 41.7 41.8 42.3 41.040–49 27.2 29.5 24.8 27.3$50 31.1 28.7 32.9 31.7

Marital statusSingle 32.3† 23.2 36.9 36.7Married 67.7 76.8 63.1 63.3

Education,13 years 72.5** 72.6 79.7 65.6$13 years 27.5 27.4 20.3 34.4

Employment statusIn the workforce 40.7** 48.5 32.9 40.6Not in the workforce 59.3 51.5 67.1 59.4

Yearly family income,$20,000 71.0† 75.5 84.6 54.3$$20,000 29.0 24.5 15.4 45.7

AcculturationTraditional 56.9* 64.1 54.7 52.2Bicultural/assimilated 43.1 35.9 45.3 47.8

Insurance statusUninsured 8.8† 0.0 11.5 14.5Insured 91.3 100.0 88.5 85.5

28.7 22.2 24.920.3 29.5 34.151.1 48.3 41.0

men differ on various characteristics by study site.

G

examinations among a randomly selected population of

ACS guidelines 31.0 16.9

Note. N/A, not applicable.a Women 30 years and older.b Women 40 years and older. Sample sizes: Samoa, 138; Hawaii,

135; and Los Angeles, 147.

age-specific CBE were more likely than other respon-dents to be younger (30–39 years), married, more edu-cated, with higher yearly family income, bicultural orassimilated, insured, with an ambulatory visit to a gy-necologist within the prior year, and residents of Hawaiior Los Angeles. In addition, women reporting their mostrecent age-specific mammogram were more likely thanother respondents to be bicultural or assimilated, withan ambulatory visit to a gynecologist within the prioryear, aware that women ages 40 and older should obtaina mammogram, and residents of Hawaii or Los Angeles.

We conducted separate logistic regression analysesfor the two dependent variables (Table 4). Amongwomen 30 years and older, the odds of recent age-specific CBE screening were higher among women whohad 13 or more years of education compared with thosewith fewer than 13 years of education, were insuredcompared with those without insurance, and had vis-ited a gynecologist within the prior year compared withthose who did not have a gynecologist visit and amongthose who resided in Hawaii compared with those whoresided in Los Angeles. The odds of recent age-specificCBE screening was lower among women ages 40–49years and women ages $50 years compared with

women ages 30–39 and among those residing in Ameri-can Samoa compared with those residing in LosAngeles. Among women 40 years and older and residingin either Hawaii or Los Angeles, the odds of recent age-specific mammography screening were higher among

AMONG SAMOAN WOMEN 13

BREAST CANCER SCREENIN

TABLE 2

Awareness about and Reported Utilization of Breast CancerScreening

Clinicalbreast exama Mammogramb

Characteristics (n 5 720), % (n 5 420), %

Ever heard of the exam N/A 58.1Ever had the exam 55.6 32.9When was the last exam

,13 months ago 48.3 43.513 to 24 months ago 14.5 18.825 to 36 months ago 7.9 10.9.36 months ago 29.3 26.8

Age M.D.’s recommend to start obtaining a CBE (mammogram)20 years and older (40 years

and older) 35.3 8.8Other 42.0 37.9Do not know 22.6 53.3

Ever had exam by study siteSamoa 43.5 5.8Hawaii 64.5 40.0Los Angeles 58.6 51.7

Obtained exam according to

women who had visited a gynecologist within the prioryear compared with those who had not visited a gynecol-ogist and those who were aware about the age womenshould initiate mammograms compared with those whowere unaware about the recommended guidelines.

DISCUSSION

To our knowledge, this is the first published reportto measure population-based estimates of utilization ofbreast cancer screening tests and to determine pre-dictors of recent age-specific utilization of screening

Samoan women in three distinct geographical areas.The National Cancer Institute and the U.S. PublicHealth Service Year 2000 goals bench-marked regularlyscreening 80% of age-eligible women for breast cancer

TABLE 3

Reported Age-Specific Cancer Screening by SampleCharacteristics

Clinicalbreast exam Mammogram

Characteristics (n 5 720), % (n 5 420), %

Age30–39 years 44.7† N/A40–49 years 22.4 17.9$50 years 20.1 16.1

Marital statusSingle 25.9* 17.3Married 33.5 16.7

Education,13 years 25.9† 16.0$13 years 44.9 20.2

Employment statusIn the workforce 34.5 17.3Not in the workforce 28.6 16.7

Yearly family income,$20,000 27.0† 15.6$$20,000 44.8 23.5

Acculturation levelTraditional 24.1† 13.5**Bicultural/assimilated 40.0 23.9

Insurance statusUninsured 15.9** 17.1Insured 32.4 16.9

Most recent visit to a gynecologistNever 15.4† 7.9†,12 months ago 60.4 43.9$12 months ago 21.7 11.8

Age M.D.’s recommend obtaining aCBE (mammogram)20 years and older (40 and older) 34.4 35.1**Other or do not know 29.4 15.1

Study site

Samoa 19.8† 3.6†Hawaii 39.7 24.4Los Angeles 33.3 22.4

Note. N/A, not applicable.* P , 0.05, **P , 0.01, †P , 0.001 by the x2 test.

Note. OR, odds ratio; CI, confidence interval.a Women 30 years or older from American Samoa, Hawaii, and Los Angeles (n 5 720).

).

b Women 40 years or older from Hawaii and Los Angeles (n 5 282* P , 0.05.** P , 0.01.† P , 0.001.

[36]. The ACS Year 2000 objectives called for increasingto 88% the proportion of women ages 40 and older whohad ever had a mammogram and to 63% the proportionof women ages 40 and older who have had a mammo-gram in the prior year [6]. The results of this studyindicate that Samoan women fell far short of thesegoals. Only 40.0 and 51.7%, respectively, of Samoanwomen 40 and older and residing in Hawaii and LosAngeles reported ever obtaining a mammogram, and24.4 and 22.4%, respectively, of Samoan women 40 andolder and residing in Hawaii and Los Angeles reportedhaving obtained an age-specific mammogram withinthe prior year.

The data from the present study also demonstratethat Samoan women are less likely to receive breastcancer screening tests than other small but growingimmigrant and indigenous populations. For instance,among Samoan women 40 years and older, 31% had

obtained a CBE within the prior year and 29% hadobtained a CBE within the prior 2 years. Among Sa-moan women 50 years and older, 28.1% had obtaineda CBE within the prior 2 years. Furthermore, amongSamoan women 40 years and older and residing inHawaii or Los Angeles, 16.9% had obtained a mammo-gram within the prior year and 28.7% had obtained amammogram within the prior 2 years. In addition,among Samoan women 50 years and older and residingin Hawaii or Los Angeles, 28.1% had obtained a mam-mogram within the prior 2 years. These rates of utiliza-tion of CBE and mammography screening reported inour sample are closer to the lower range of rates re-

14 MISHRA, LUCE, AND HUBBELL

TABLE 4

Adjusted Odds Ratios for Predictors of Screening

Clinical breast exama Mammogramb

Predictors OR 95% CI OR 95% CI

Age30–39 years 1.0040–49 years 0.40 0.25–0.63† 1.00$50 years 0.49 0.30–0.78** 0.95 0.49–1.85

Marital statusSingle 1.00 1.00Married 1.25 0.83–1.88 0.98 0.51–1.90

Education,13 years 1.00 1.00$13 years 1.73 1.13–2.65** 0.90 0.42–1.96

Employment statusIn the workforce 1.00 1.00Not in the workforce 0.93 0.63–1.38 1.12 0.55–2.27

Acculturation levelTraditional 1.00 1.00Bicultural/assimilated 1.31 0.88–1.95 1.54 0.76–3.11

Insurance statusUninsured 1.00 1.00Insured 2.51 1.12–5.64* 0.97 0.34–2.72

Most recent visit to a gynecologistNever 1.00 1.00,12 months ago 5.21 3.03–8.93† 7.38 2.92–18.62†$12 months ago 1.17 0.69–1.96 1.49 0.60–3.66

Age M.D.’s recommend obtaining a CBE (mammogram)Other or do not know 1.00 1.00$20 years ($40 years) 1.05 0.71–1.55 2.28 1.00–5.52*

Study siteLos Angeles 1.00 1.00Hawaii 1.77 1.13–2.76** 1.45 0.77–2.71American Samoa .56 0.34–0.91**

ported for other minority populations. For instance,rates for comparable age-specific screening indicatorsfor Asian Americans [7–12], American Indians andAlaska Natives [13], Hispanics [5,37,38], and AfricanAmericans and whites [38,39] range between 32 and

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health care services, proactive doctor–patient commu-

BREAST CANCER SCREENIN

75% for CBE use and range between 30 and 79% formammography use. Moreover, the utilization levelsamong Samoan women are much lower than thosebench-marked (i.e., 60%) in the Year 2000 Health Pro-motion Objectives of the Asian and Pacific IslanderTask Force Report [40]. As there are no published re-ports on screening practices by Samoan women andnational surveys do not specify screening rates for Sa-moan women, it is not possible to compare our findingswith other Samoans residing elsewhere in the UnitedStates.

In terms of multivariate independent predictors ofage-specific screening utilization, important predictorsfor CBE screening included factors such as age, educa-tion, insurance status, recent ambulatory visit to a gy-necologist, and site of residence. In addition, importantpredictors for mammography screening among Samoanwomen residing in Hawaii and Los Angeles includedrecent ambulatory to a gynecologist and awarenessabout recommended guidelines. Studies among non-Samoan women have reported with some consistencysome of the same variables such as age, education, andinsurance status as predictors of adherence to screen-ing [5,12,13,39].

Several factors may explain the underutilization ofage-specific breast cancer screening tests by Samoanwomen. Bivariate and multivariate evidence for factorssuch as age, marital status, insurance, acculturation,education, regular ambulatory visits, and place of resi-dence are provided in this report. Other factors mayinclude a relatively high prevalence of misconceptionsregarding breast cancer and its outcomes [22], a lackof preventive health orientation in this population asinferred from the serious underutilization of screeningservice for other cancers [24], and a distrust of non-Samoan health providers [41]. Still other factors mayinclude a lack of breast cancer awareness outreach ef-forts, a lack of targeted cancer education materials andprograms, group norms, use of traditional healers, anda lack of referrals for the tests by physicians. Thesefactors emerged as salient themes during postsurveyfocus groups conducted in Samoa, Hawaii, and LosAngeles to obtain information about intervention stud-ies. In Samoa, structural barriers such as a lack ofmammogram machine, a lack of targeted breast cancerawareness efforts, and factors such as modesty andembarrassment associated with a breast examinationmay limit utilization of services. As part of anotherstudy, we are currently modeling the impact of several

of these factors as they relate to screening behavior.

Limitations of this study are those inherent in surveyresearch. First, data are self-reported and subject torecall bias and desirability bias. These biases may over-estimate the frequency of utilization of services. If this

AMONG SAMOAN WOMEN 15

were the case, disparities observed in screening behav-ior would have been even more acute. Moreover, evi-dence from other studies suggest that there is goodcorrelation between self-reported data on utilizationand chart audits [42]. Second, there remains the poten-tial sample bias due to noninclusion of women (in LosAngeles and Hawaii) due to their nonaffiliation withsources that provided the household address listing. Tocheck for the completeness of the household lists atthese sites, we asked the respondents surveyed fornames and addresses of family members and Samoanfriends and neighbors. Over 90% of the names gener-ated by this approach were already in our data bank.The sampling procedure in Los Angeles and Hawaiiwould exclude Samoan women who have little or nodirect contact with Samoan-speaking churches and Sa-moan social networks and those who are social isolates.We do not know how this group of Samoan women willdiffer from those we surveyed. It is likely that womenexcluded from the survey are more likely to be assimi-lated into a culture (i.e., more “Westernized”) that isdifferent from their Samoan traditions and norms. Ifour assumptions about these women are true, thesewomen may be better versed about the myths and factsabout cancer and less likely to benefit from the targetedintervention programs developed for the community atlarge. Thus, the impact of their exclusion from the sam-ple may be minimal. Last, the unavailability of generaleconomic data precludes us from adjusting our familyincome variable to further explore the robustness of thebivariate relationship between family income and CBE.

In conclusion, this is the first study that presentspopulation-based estimates and predictors of age-specific CBE screening (for Samoan women residing inSamoa, Hawaii, and Los Angeles) and mammographyscreening (for Samoan women residing in Hawaii andLos Angeles) for this indigenous population. Our re-search group is currently evaluating a targeted educa-tional program for Samoan women residing in southernCalifornia. For Samoan women to meet the HealthyPeople 2010 goal of ensuring that at least 70% of women40 and older receive a mammogram within the prior 2years [43], a concerted effort that specifically targetsthe needs of this underserved population needs to beundertaken. Our findings suggest that these effortsshould include but not be limited to improved access to

nications regarding preventive practices, enhanced ac-cess to mammography services for women residing inthe U.S. Territory, and focused educational aware-ness programs.

REFERENCES

1. Harris JR, Lippman ME, Veronesi U, Willet W. Breast cancer.N Engl J Med 1992;327:319–28.

,

16 MISHRA, LUCE

2. Breen N, Kessler L. Changes in the use of screening mammogra-phy: evidence from the 1987 and 1990 National Health InterviewSurveys. Am J Public Health 1994;84:62–7.

3. Rimer BK. Mammography use in the U.S.: trends and the impactof interventions. Ann Behav Med 1994;16:317–26.

4. Kaplan RM, Navarro AM, Castro FG, Elder JP, Mishra SI,Hubbell FA, et al. Increased use of mammography among His-panic women: baseline results from the NCI Cooperative Groupon Cancer Prevention in Hispanic Communities. Am J PrevMed 1996;12:467–71.

5. Frazier EL, Jiles RB, Mayberry R. Use of screening mammogra-phy and clinical breast examinations among black, Hispanic, andwhite women. Prev Med 1996;25:118–25.

6. American Cancer Society, California Division, and Public HealthInstitute, California Cancer Registry. California facts and fig-ures, 2000. Oakland (CA): American Cancer Society, CaliforniaDivision, 1999 Sep.

7. Maxwell AE, Bastani R, Warda US. Mammography utilizationand related attitudes among Korean-American women. WomenHealth 1998;27:89–107.

8. Wismer BA, Moskowitz JM, Chen AM, Kang SH, Novotny TE,Min K, et al. Mammography and clinical breast examinationamong Korean-American women in two California counties. PrevMed 1998;27:144–51.

9. Maxwell AE, Bastani R, Warda US. Demographic predictors ofcancer screening among Filipino and Korean immigrants in theUnited States. Am J Prev Med 2000;18:62–8.

10. Maxwell AE, Bastani R, Warda US. Breast cancer screening andrelated attitudes among Filipino-American women. Cancer Epi-demiol Biomarkers Prev 1997;6:719–26.

11. McPhee SJ, Bird JA, Davis T, Ha NT, Jenkins CNH, Le B. Barriersto breast and cervical cancer screening among Vietnamese-Amer-ican women. Am J Prev Med 1997;13:205–13.

12. McPhee SJ, Stewart S, Brock KC, Bird JA, Jenkins CNH, PhamGQ. Factors associated with breast and cervical cancer screeningpractices among Vietnamese-American women. Cancer DetectPrev 1997;21:510–21.

13. Coughlin SS, Uhler RJ, Blackman DK. Breast and cervical cancerscreening practices among American Indian and Alaska Nativewomen in the United States, 1992–1997. Prev Med 1999;29:287–95.

14. Giuliano A, Papenfuss M, de Guernsey de Zapien J, Tilousi S,Nuvayestewa L. Breast cancer screening among southwest Amer-ican Indian women living on-reservation. Prev Med 1998;27:135–43.

15. Kaur JS. Native women and cancer. Health Care Women Int199920:445–53.

16. Bureau of the Census. Census of population (1990): Asians andPacific Islanders in the United States. Washington: U.S. Depart-ment of Commerce, Economics and Statistics Administration,Bureau of the Census, 1993.

17. Hecht JA, Orans M, Janes CR. Social settings of contemporarySamoans. In: Baker PT, Hanna JM, Baker TS, editors. The chang-ing Samoans: behavior and health in transition. New York: Ox-ford Univ. Press, 1986:39–62.

18. Crews DE. Cause-specific mortality, life expectancy, and debilita-tion in aging Polynesians. Am J Hum Biol 1989;1:347–53.

19. Chu KC. Cancer data for Asian Americans and Pacific Islanders.

Asian Am Pacific Islander J Health 1998;6:130–39.

20. Mishra SI, Luce-Aoelua P, Wilkens LR, Bernstein L. Canceramong American-Samoans: site-specific incidence in Californiaand Hawaii. Int J Epidemiol 1996;25:713–21.

21. Mishra SI, Luce-Aoelua P, Wilkens LR. Cancer among indigenouspopulations. Cancer 1996;78:1553–7.

AND HUBBELL

22. Mishra SI, Luce-Aoelua P, Hubbell FA. Knowledge and attitudesabout cancer among American Samoans. Cancer Prev Detect2000;24:186–95.

23. Mishra SI, Luce-Aoelua P, Hubbell FA. Identifying the cancercontrol needs of American Samoans. Asian Am Pacific IslanderJ Health 1998;6:277–85.

24. Mishra SI, Luce-Aoelua PH, Hubbell FA. Predictors of Papanico-laou smear use among American Samoan women. J Gen InternMed. In press.

25. Mishra SI, Dooley D, Catalano R, Serxner S. Telephone healthsurveys: potential health bias from non-completion. Am J PublicHealth 1993;83:94–9.

26. Kalton G, Anderson DW. Sampling rare populations. J StatSoc 1986;149:65–82.

27. Sudman S, Sirken MG, Cowan CD. Sampling rare and elusivepopulations. Science 1988;240:991–6.

28. National Health Interview Survey. Washington: U.S. Departmentof Commerce, Bureau of the Census, 1992.

29. National Health Interview Survey supplement booklet on cancercontrol. Washington: U.S. Department of Commerce, Bureau ofCensus, 1992.

30. Hendricson WD, Russell J, Prihoda TJ, Jacobsen JM, Rogan A,Bishop GD. An approach to developing a valid Spanish languagetranslation of a health-status questionnaire. Med Care 1989;27:959–66.

31. Marin G, Sabogal F, Marin BV, Otero-Sabogal R, Perez-StableEJ. Development of a short acculturation scale for Hispanics.Hispanic J Behav Sci 1987;9:183–205.

32. American Cancer Society and Public Health Institute, CaliforniaCancer Registry. California facts and figures, 1996. Oakland(CA): American Cancer Society, California Division, 1995 Sep.

33. SPSS, Inc. SPSS professional statistics 7.5 user’s guide. Chicago:SPSS, 1998.

34. Blalock HM. Social statistics. New York: McGraw–Hill, 1979.

35. Lemeshow S, Hosmer DW. Estimating odds ratio with categori-cally scaled covariants in multiple logistic regression analysis.Am J Epidemiol 1984;119:147–51.

36. Healthy People 2000: national health promotion and disease pre-vention objectives. Washington: U.S. Department of Health andHuman Services, Public Health Service, 1991. [DHHS Publica-tion No. (PHS) 91-50212]

37. Hubbell FA, Mishra SI, Chavez LR, Burciaga Valdez R. The influ-ence of knowledge and attitudes about breast cancer on mammog-raphy use among Latinas and Anglo women. J Gen InternMed 1997;12:505–8.

38. O’Malley, AS, Kerner J, Johnson AE, Mandelblatt J. Accultura-tion and breast cancer screening among Hispanic women in NewYork City. Am J Public Health 1999;89:219–27.

39. Rimer BK, Conaway MR, Lyna PR, Rakowski W, Woods-PowellCT, Tessaro I, et al. Cancer screening practices among womenin a community health center population. Am J Prev Med1996;12:351–7.

40. California Department of Health Services Health Promotion Sec-tion. Asian and Pacific Islander Task Force report on the Year

2000 health promotion objectives and recommendations for Cali-fornia. Sacramento: California Department of Health Services,1992 May.

41. Cook JM. Samoan patterns in seeking health services—Hawaii,1979–81. Hawaii Med J 1983;42:138–42.

BREAST CANCER SCREENING AMONG SAMOAN WOMEN 17

42. Gordon NP, Hiatt RA, Lampert DI. Concordance of self-reported 43. Healthy People 2010 (conference edition, in two volumes). Wash-

data and medical record audit for six cancer screening proce-dures. J Natl Cancer Inst 1993;85:566–70.

ington: U.S. Department of Health and Human Services, 2000Jan.