Differences in Predictors of Cervical and BreastCancer Screening by Screening Need in UninsuredLatina Women

Lydia P. Buki, PhD1

Jorja Jamison, MS2

Carolyn J. Anderson, PhD2

Anai M. Cuadra, PhD3

1 Department of Kinesiology and CommunityHealth, University of Illinois, Champaign, Illinois.

2 Department of Educational Psychology, Univer-sity of Illinois, Urbana-Champaign, Illinois.

3 Department of Pediatrics, Miller School of Med-icine, University of Miami, Miami, Florida.

BACKGROUND. Latina women experience higher mortality for cervical cancer and

lower 5-year survival for breast cancer than non-Latina White women. Adherence

with screening recommendations can increase chances of survival, yet the factors

that influence screening behaviors in uninsured women are not well documen-

ted.

METHODS. Uninsured Latina women (N 5 467) recruited in four US cities partici-

pated in the study. Logistic regression was used to model adherence to recom-

mendations by screening type (cervical or breast cancer) and screening need

(needs to obtain initial screening, overdue for rescreening, up-to-date with

rescreening).

RESULTS. Predictors differed by type of screening and screening need. Women

who reported exposure to cancer education were more likely to have had a mam-

mogram and to be up-to-date with Pap smear screening than women without

such exposure. Women who were younger, had more than a sixth grade educa-

tion, and/or had children were more likely to have had a Pap smear. Older

women who had been in the US the longest were more likely to be overdue for a

Pap smear. Women with incomes $5000 to $7000 were more likely to have

obtained a mammogram. Regional differences were found with respect to mam-

mography screening and maintenance behaviors.

CONCLUSIONS. Exposure to cancer education is an important predictor of screen-

ings among uninsured urban Latina women. The potential of creating educa-

tional interventions that can increase screening rates among women who

evidence health disparities is encouraging. Recruitment strategies to reach

women in need of screenings are provided. Cancer 2007;110:1578–85. � 2007

American Cancer Society.

KEYWORDS: Latinas, cervical cancer, breast cancer, screening, health insurance.

L atina women experience an unequal burden of cervical and

breast cancer.1–4 They face numerous barriers to early screenings

such as lack of access to healthcare and culturally responsive pro-

grams, lack of transportation and childcare, and linguistic isolation

from information.5–9 As a result, these women do not obtain screen-

ing exams according to the timing recommended by the US Preven-

tive Task Force,10,11 and cancers are detected at more advanced

stages, when prognosis is more guarded.12–14 Consequently, Latinas

have a lower 5-year survivorship rate for breast cancer and a higher

mortality rate for cervical cancer compared with non-Latina

Whites.1,14,15

The authors thank Diana Jeffery, PhD, for insightand advice on the article, and Marta Sotomayor,DSW, for her support of this project. The helpfulcomments on earlier versions of this article pro-vided by Viviana Pitton, MEd, and Allison Grupski,MA, are acknowledged. Data collection was sup-ported by Cooperative Agreement U57/CCU310174-03 from the Centers for DiseaseControl and Prevention.

Address for reprints: Lydia P. Buki, PhD, Depart-ment of Kinesiology and Community Health, Uni-versity of Illinois, 224 Huff Hall, 1206 S. FourthSt., MC 588, Champaign, IL 61820; Fax: 217-333-2766; E-mail: buki@uiuc.edu

Received October 10, 2006; revision receivedMay 18, 2007; accepted May 23, 2007.

ª 2007 American Cancer SocietyDOI 10.1002/cncr.22929Published online 14 August 2007 in Wiley InterScience (www.interscience.wiley.com).

1578

Health insurance status and primary language

have been found to predict screening rates among

Latina women; these findings result from the use of

samples that are diverse with respect to these fac-

tors.16–26 A focus on uninsured and Spanish-speaking

Latinas, however, is warranted,27 as they comprise

a substantial proportion of the adult Latino/a

population (47% and 34%–50%, respectively).9,28

Among Latinos who are primarily Spanish-speaking,

61% do not have health insurance,9 placing them

at risk for nonadherence to screening recommenda-

tions.9,13,27,29

For uninsured women, different screening pre-

dictors may emerge. A few studies have examined

this population, with a focus on farmworkers.30 Find-

ings suggest that knowledge about screenings may

increase screening rates in that population,30 which

is consistent with data from Latina samples pooled

according to health insurance status and primary

language.19–26 However, to our knowledge, no study

has examined screening predictors among urban

populations without health insurance. Such an inves-

tigation is reasonable because the majority of Latinos

live in urban areas.31 Therefore, the purpose of this

study was to examine how demographic factors and

exposure to cancer education are related to cancer

screening in a large national community sample of

urban, Spanish-speaking Latina women without pri-

vate health insurance coverage.

Consistent with previous studies, we analyzed

cervical and breast cancer screening data separately,

as the predictors may differ from one another.5,32–37

Finally, we investigated predictors at 3 levels of

screening need: 1) needs to obtain initial screening

(ie, never screened); 2) overdue for rescreening (ie, a

time longer than that recommended by screening

guidelines has passed since the last screening exam);

or 3) up-to-date with rescreening (ie, will need a

maintenance repeat screening when it becomes due).

This is consistent with recent conceptualizations in

the literature that focus not only on factors that

affect initial screening but also on factors that can

help discriminate women who have had a recent

repeat screening versus those who are over-

due.26,32,34,38

Specifically, we sought to answer the following

research questions: 1) are the predictors of breast

and cervical cancer screening different?, and 2) do

screening predictors differ according to screening

need? Answers to these questions will further our

understanding of the context in which urban

women obtain screenings and may help optimize

interventions aimed at increasing their screening

rates.

MATERIALS AND METHODSParticipantsA total of 467 self-identified Latina women partici-

pated in the study. Data were collected at baseline as

part of a larger national project designed to increase

cervical and breast cancer screening rates among

medically underserved Latinas. We collected this

cross-sectional, purposeful sample at 4 sites across

the US, chosen because of their urban setting and

their sizable population of medically underserved

Latinas over the age of 40. The sites were: Dallas

(TX), Hartford (CT), Newark (NJ), and Washington

(DC). An additional outreach was conducted in

Washington DC during Minority Cancer Awareness

Week (MW), which was treated as a separate site

given that the recruitment strategy relied on radio

advertising rather than face-to-face outreach, poten-

tially resulting in samples that differed along demo-

graphic factors.

MeasuresA sociodemographic survey included 20 questions

about demographic characteristics (eg, age), cultural

variables (eg, country of origin), risk factors (eg, can-

cer history), and screening behaviors. Exposure to

cancer education was measured with the question

‘‘Have you ever attended an educational presentation

about the importance of early detection of breast

and cervical cancer?’’ A draft of the survey was

reviewed by 1 peer health worker (promotora de

salud) from each site and their feedback was incor-

porated into the final version. The questionnaire was

administered in Spanish and took approximately 10

minutes to complete.

ProcedureParticipants were recruited through community out-

reach efforts that included at least 1 promotora de

salud at each site. These promotoras were bilingual,

bicultural women who were trusted members of the

community and who tailored their culturally respon-

sive recruitment efforts to the needs of each local

site. The benefit of using promotoras to reach medi-

cally underserved populations has been estab-

lished.39,40 The promotora de salud in Dallas was

affiliated with a senior center and a local Catholic

church and she recruited participants mainly

through these organizations, at health fairs, and at

daylong Spanish language health conferences orga-

nized for the entire family. The promotora de salud

in Hartford was affiliated with a community health-

care organization and she recruited participants from

their pool of past patients, at health fairs, and

Predictors of Screening in Latina Women/Buki et al. 1579

through extensive door-to-door outreach in the com-

munity. The promotora de salud in Newark worked

at a community organization that provided social

services. Women at this site were recruited at the

waiting area of the organization, as well as through

media announcements and visits to senior housing

complexes. The area covered by the 2 promotoras de

salud in Washington DC included northern Virginia

and adjacent counties in Maryland as well. Outreach

at this site included recruitment at beauty salons,

churches, community clinics, Hispanic festivals,

laundromats, libraries, shopping malls, on the street,

and at the senior center with which 1 health pro-

moter was affiliated. The recruitment method was

different for MW than for the remainder of the DC

sample, as it relied heavily on radio announcements

made at a popular Spanish radio station in a con-

certed effort associated with Minority Cancer Aware-

ness Week. Women listening to the announcements

were provided with a toll-free telephone number to

call for participation in the program.

Promotoras administered the survey by reading

each question in person or over the phone and re-

cording each participant’s response. Participants

recruited in person also had the option of filling out

the questionnaire themselves. Participation in the

study was voluntary and without compensation. All

information obtained was kept confidential.

Data AnalysesLogistic regression was used to model women’s ad-

herence to screening recommendations for cervical

(Pap smear) and breast cancer (mammogram).

Because there were 3 sequential levels of the adher-

ence variables (needs to obtain initial screening,

overdue for rescreening, up-to-date with rescreen-

ing), we used continuation ratios to model 1)

whether a woman has or has not been screened for

cancer (ever vs never screened), and 2) whether a

woman is up-to-date or not with repeat screening

(up-to-date vs overdue repeat screening).41,42

On the basis of results from past studies con-

ducted with Latina samples,18,22,23,26,30,33,37,43–45 the

following predictors were considered: demographic

variables, exposure to cancer education, and interac-

tions among these variables. Demographic variables

were age, formal education (less than 6, 6, 7–11, 12,

more than 12 years completed), annual household

income ($0–1,500; 1,501–5,000; 5,001–7,000; 7,001–

10,000; 10,001–14,000; 14,001–25,000; more than

25,000), recruitment site (TX, CT, NJ, DC, MW),

country of origin (US, Mexico, Puerto Rico, South

America, Central America and the Caribbean, other),

proportion of life in US (.10, .25 and .43, which cor-

respond to the 25th, 50th, and 75th percentiles,

respectively), and having had a child. When parame-

ter estimates for levels of a variable were nearly

identical (or not statistically different), we forced

them to be equal, thus creating dichotomous cate-

gories. To deal with missing observations in the

data, most models were fit to the data 3 times: 1)

women with no missing observations, 2) women

with complete data for a particular model, and 3)

multiple imputation using an experimental imple-

ment for categorical variables using SAS v. 9.1 (Cary,

NC). These 3 methods yielded the same basic find-

ings; therefore, we report the analyses of women

who had complete data available for a particular

model. We believe this information is of the highest

quality because it is based on data provided by the

participants themselves.

RESULTSDescriptive InformationDemographic characteristics and participants’ cancer

screening behaviors are presented in Table 1. Partici-

pants’ ages ranged from 40 to 87 (M 5 53 years;

SD 5 11). Most women were born outside of the US

mainland (94%), including almost two-thirds from

Central America, the Caribbean, and South America.

Women born outside the US had lived in this coun-

try, on average, 14 years (SD 5 11 years), or just over

a quarter (27%) of their lives. The average household

income was $10,579 (SD 5 $6,601). Although 70% of

participants reported 6 or more years of formal edu-

cation, only 10% reported education beyond high

school. The majority of participants had children.

Just over one-third reported exposure to a presenta-

tion on the importance of early detection of cervical

or breast cancer. Time since last screening ranged

from 0–21 years and 0–22 years for Pap smear and

mammography screenings, respectively. The percent-

age of women who had never had a Pap smear or

were overdue for one was 61%; among women over

50, three-fourths had never had one or were overdue

for a mammogram. All participants reported having

no private health insurance coverage.

Cervical Cancer ScreeningEver versus never screenedA total of 427 women were used in modeling the

probability of a woman ever having had a Pap smear.

As shown in Table 2, which includes odds ratio (OR)

and 95% confidence interval (CI) data for all the

models, age, formal education, and having had a

child were the only statistically significant predictors.

This model provided a good representation of the

1580 CANCER October 1, 2007 / Volume 110 / Number 7

data (Hosmer-Lemeshow statistic 5 2.90, df 5 8,

P 5 .94). With respect to age, the odds that a woman

had a Pap smear were 1.47 times larger than the

odds for a woman 10 years older. The odds that a

woman had a Pap smear given that she completed at

least 6th grade were 1.94 times larger than the odds

for a woman with less than a 6th-grade education.

The odds that a woman had a Pap smear given that

she had a child were 1.69 times larger than the odds

for a woman who has never had a child.

Up-to-date versus overdue repeat screeningWe now turn to distinguishing between women who

needed a maintenance repeat screening as opposed

to a rescreening that is overdue. A relatively complex

logistic regression model was chosen that included

age (Wald chi-square 5 5.45, df 5 1, P 5 .02), pro-

portion of life in the US (Wald chi-square 5 5.87,

df 5 1, P 5 .01), cancer education (Wald chi-

square 5 4.53, df 5 1, P 5 .03), and the interaction

between age and proportion of life in the US (Wald

chi-square 5 5.39, df 5 1, P 5 .02). This model was fit

to 393 women with complete data on all variables and

provided a good representation of the data (Hosmer-

Lemeshow statistic 5 6.28, df 5 8, P 5 .62). The odds

that a woman with exposure to cancer education was

up-to-date with Pap smear screening were 1.60 times

larger than the odds for a woman without this expo-

sure. As shown in Figure 1, however, this probability

declined for older women as their proportion of time

lived in the US increased.

Breast Cancer ScreeningBecause the screening recommendation for yearly

mammograms applies to women 50 and older, only

women over this age were included in the analyses.

In addition to the 8 possible explanatory variables

used in the cervical cancer screening analyses,

TABLE 2Multivariate Logistic Regression Analysis of Cervical and BreastCancer Screening by Screening Need

Characteristic OR 95% CI

Cervical Cancer Screening

Ever vs never

Age (for 1 y increase), y 1.47 1.08–2.01

Formal education (�6 vs <6), y 1.94 1.69–8.40

Had child (vs no child) 1.69 1.04–7.87

Up-to-date vs overdue

Age (for 1-y increase), y 0.97 0.94–0.99

Proportion of life in US, % 0.02 0.00*–0.49

Had cancer education (vs none) 1.60 1.04–2.45

Age by proportion of life in US 1.06 1.01–1.12

Breast Cancer Screening

Ever vs never

Formal education (�6 vs <6), y 1.51 0.99–2.32

Income (5000–7000 vs <5000 or>7000), $ .32 0.15–0.69

Recruitment site (NJ/TX vs CT/DC/MW) 3.91 1.70–8.99

Had cancer education (vs none) 1.56 1.04–2.36

Education by cancer education

<6 y and had cancer education 6.07 1.66–22.18

�6 y and had cancer education 0.98 0.35–2.71

Up-to-date vs overdue

Recruitment site (CT vs NJ/TX/DC/MW) 7.71 2.41–24.59

Adherence with PAP (up-to-date/never vs overdue) 9.81 4.11–23.39

OR indicates odds ratio; 95% CI, 95% confidence interval; NJ/TX, Newark, New Jersey and Dallas,

Texas; CT/DC/MW Hartford, Connecticut, and Washington, District of Columbia, and Washington

DC during Minority Cancer Awareness Week.

* Actual value is 0.001.

TABLE 1Background Characteristics of Participants

Variable No. % Mean (SD)

Age, y

40–50 254 54.6 44.6 (3.3)

�51 211 45.4 62.6 (8.8)

Life in US, % 412 100 0.27 (0.19)

Income, $

<5000,>7000 380 86.2 11358 (6899)

5000–7000 54 13.8 5779 (523)

Formal education, y

<6 125 29.6 2.7 (1.8)

�6 297 70.4 10.2 (3.0)

Has children

Yes 384 90.8 —

No 39 9.2 —

Location

TX 78 16.7 —

CT 74 15.8 —

NJ 79 16.9 —

DC 129 27.6 —

MW 107 22.9 —

Country of origin

United States 23 5.3 —

Mexico 66 15.2 —

Puerto Rico 71 16.3 —

Central America & Caribbean 134 30.8 —

South America 141 32.4 —

Reported cancer education

Yes 152 34.5 —

No 288 65.5 —

Pap smear screening

Never 36 7.9 —

Overdue 242 53.1 —

Up-to-date 178 39.0 —

Mammography screening*

Never 60 28.6 —

Overdue 97 46.2 —

Up-to-date 53 25.2 —

TX indicates Dallas, Texas; CT, Hartford, Connecticut; NJ, Newark, New Jersey; DC, Washington, Dis-

trict of Columbia; MW, Washington DC during Minority Cancer Awareness Week.

* Mammography information provided for women older than 50 years of age.

Predictors of Screening in Latina Women/Buki et al. 1581

adherence with recommendations for cervical cancer

screening was added as an explanatory variable in

the logistic regressions for mammography, given its

potential association with breast cancer screening.46

Ever versus never screenedFormal education, income, recruitment site, cancer

education, and the interaction of formal education

and cancer education were statistically significant ex-

planatory variables for modeling the probability of

ever having been screened for breast cancer (n 5 184

women). This model showed good representation of

the data (Hosmer-Lemeshow statistic 5 5.53, df 5 7,

P 5 .60). The odds that a woman with $5,000 to

$7,000 had a mammogram were 9.85 times the odds

for a woman whose income was less than $5,000 or

more than $7,000. With respect to recruitment site,

the odds that a woman from NJ or TX had a mam-

mogram were 3.91 times the odds for a woman

recruited at other sites. For a woman with less than a

6th-grade education, the odds that she had a mam-

mogram given she had cancer education were

6.07 times the odds for a woman without cancer

education.

Up-to-date versus overdue repeat screeningRecruitment site (Wald chi-square 5 11.90, df 5 1,

P < .01) and adherence with cervical cancer screen-

ing (Wald chi-square 5 26.51, df 5 1, P < .01) were

retained in the final model fit to the 148 women who

were up-to-date or overdue for breast cancer screen-

ing. The only recruitment site that was different from

the others was CT; thus, in the final model we re-

stricted the parameter estimates for all the other sites

to be equal. This model provided a good fit to the

data (Hosmer-Lemeshow statistic 5 1.15, df 5 2,

P 5 .56). The odds that a woman from CT was up-to-

date with mammography were 7.71 times the odds

for a woman from another location. The odds of

being up-to-date with mammography for women

who were up-to-date with cervical cancer screening

or who have never had a Pap were 9.81 times the

odds for women who were overdue for cervical can-

cer screening. To aid in the interpretation of the

results that follows, predictors of screening by cancer

type and screening need are summarized in Table 3.

DISCUSSIONThe present study supports a growing body of

research suggesting that predictors of screening differ

by cancer type and screening need, and extends

these findings to a large national community sample

of urban Latina women without health insurance.

FIGURE 1. Probabilities of being up-to-date with Pap smear screening as a function of proportion of life in the US and age with a separate line for cancereducation.

TABLE 3Summary of Predictors in the Models by Screening Type and Need

Screening type

Screening need

Ever vs

no screening

Up-to-date with repeat

screening vs overdue

for repeat screening

Cervical cancer Age Age

screening Formal education Proportion of life in US

Children Cancer education

Age 3 proportion of life in US

Breast cancer

screening

Formal education Recruitment site

Income

Recruitment site

Cancer education

Formal education

3 cancer education

Adherence with Pap

smear screening

1582 CANCER October 1, 2007 / Volume 110 / Number 7

A key finding is that among this sample of Latinas

with numerous barriers to early screenings (eg, lack

of health insurance, low incomes, low levels of for-

mal education, linguistic barriers) cancer education

was associated not only with first-time mammog-

raphy screenings, but also with maintenance screen-

ing behaviors for cervical cancer. Because the

aforementioned screening barriers are not easily

changed, the possibility of creating educational inter-

ventions that increase screening rates for groups

experiencing health disparities is encouraging.

Similar to patterns found in pooled samples

including women with and without health insurance,

participants who were younger33,34 and had higher

levels of education33,34,37 were more likely to have

obtained a Pap smear. To our knowledge, the finding

that women with children were more likely to have

had a Pap smear is novel; however, there is evidence

in the literature that Latinas who are married are

more likely to have obtained this test.37 This is con-

sistent, as well, with reports from young Latinas that

they are taught not to get a Pap smear until they

have children.47 Most important, a unique finding in

the present study is that women with low levels of

formal education who had exposure to cancer educa-

tion were more likely to have obtained a mammo-

gram than those without this exposure. Unlike a Pap

smear, which women are likely to receive in conjunc-

tion with milestones such as pregnancy care, obtain-

ing a mammogram is a behavior adopted later in

life. Our findings suggest that women who are over

50 and who have less than a 6th-grade education

need to be educated about the importance of taking

up this behavior. We also found that participants

with incomes between $5,000 and $7,000 were more

likely to have had a mammogram than women in

other income ranges. This may reflect a unique pat-

tern among uninsured samples. Women with lower

incomes may qualify for low-fee screenings, whereas

women with higher incomes who do not qualify for

these services may be unable to cover the cost of the

exams on their own. It is also possible that women

with higher incomes have several part-time jobs that

limit their access to exams during working hours.

Models of maintenance behaviors yielded unique

predictors for each cancer type (see Table 3). The lit-

erature conveys that low-income Latinas are likely to

be underscreened for cervical cancer.22,43,48–50 In our

study with low-income participants, we found that

women who had exposure to cancer education were

more likely to be up-to-date with Pap smear screen-

ings than those who did not have this exposure. This

finding suggests that educational interventions have

the potential to increase regular Pap smear screen-

ings in this population. We also found that women

who were up-to-date with Pap smear screenings

were more likely to be up-to-date with mammog-

raphy; these women 1) make regular medical visits

and may be referred for mammography screening,

and 2) may value engaging in health promotion

behaviors. Conversely, the finding that not having

had a Pap smear predicts regular adherence with

mammography is counterintuitive. It is possible that

when older women enter the healthcare system they

are referred for mammograms but not Pap smears. A

lack of active referral for parallel screenings has been

documented in other studies51 and has implications

for healthcare delivery.

Finally, we found regional differences with

respect to mammography screening and mainte-

nance behaviors. Participants from NJ and TX were

more likely to have ever had a mammogram,

whereas women from CT were more likely to be up-

to-date with mammography screening. Women in NJ

and TX were older than women recruited at other

sites, which could account for a greater likelihood of

having obtained a mammogram at least once. Con-

versely, women from CT were recruited through a

community health clinic that provided access to

mammography services, and many of their partici-

pants were US citizens, which could account for

their higher rates of adherence to mammography

rescreening.

Contributions and Limitations of the StudyIn this investigation, we make a unique contribution

by 1) examining predictors of screening in a national

community sample of uninsured urban Latina

women, and 2) emphasizing factors that not only

predict having a screening, but also distinguish

between women who are overdue from those who

obtain on time rescreenings. There are limitations,

however, associated with the current study. Valida-

tion studies suggest that self-report screening data

may have been influenced by recall bias and tele-

scoping (eg, women may have reported that a

screening took place more recently than it had, parti-

cularly if more than 2 years had transpired since the

last screening).52 In addition, participants from NJ

and CT were recruited through a community health

center, which could have contributed to findings

related to higher mammography uptake and rescre-

ening, respectively. Finally, it is possible that women

who screened regularly were more likely to attend

educational presentations, rather than exposure to

cancer education influencing their screening beha-

viors. The direction of this relation should be

explored in future research.

Predictors of Screening in Latina Women/Buki et al. 1583

Implications for Intervention and Future ResearchOn the basis of our findings, for Pap smear screening

a priority population of women who are older, have

low levels of formal education, and/or do not have

children needs to be identified, as they are the least

likely to have been screened for cervical cancer.

In addition, older women who have spent the major-

ity of their lives in the US need to be identified as a

priority population for rescreening. For mammog-

raphy screening, we recommend recruiting women

through community-based outreach (eg, senior cen-

ters, churches, door-to-door, Spanish radio) rather

than through collaborations with community clinics,

where women are more likely to have been screened.

A priority population of women who have less than a

6th-grade education and have household incomes

under $5000 need to be given information about the

importance of mammography uptake and about

public assistance programs that can help them pay

for the exam. Also, it is necessary to find ways to

reach women with incomes over $7000. It is possible

that bringing a mammovan to the work site may act

as a facilitator to obtain rescreenings for women who

have several part-time jobs that do not offer health

insurance coverage or sick time to obtain preventive

exams. Our findings have implications for healthcare

providers as well, given that Pap smear screening

rates may be increased by identifying women in

need of this screening at the time they obtain a

mammogram and referring them for this exam.

To realize the promise of educational interven-

tions and close the gap in health disparities, models

of recruitment and information delivery in Spanish

need to be developed, evaluated, and subsequently

implemented widely. Although there is a growing lit-

erature of elements to be included in effective print

materials in Spanish for Latino/a audiences,53,54 we

know little about best practices in oral education.

Model curricula must be developed to increase

women’s abilities to obtain, process, and understand

basic health information and services needed with

respect to cervical and breast cancer. Research is

needed to discern which elements to include in these

presentations (eg, cancer causes, detection, treat-

ment) in order to optimize their effectiveness at

increasing women’s health literacy with respect to

these types of cancer.

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