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Preventive Medicine 42

Hispanic acculturation and utilization of cervical cancer screening in the US

Mona Shah, Kangmin Zhu *, Hongyu Wu, John Potter

United States Military Cancer Institute, Walter Reed Army Medical Center, Building 1, Suite E-111, 6900 Georgia Avenue, NW, Washington, DC 20307-5001, USA

Available online 16 November 2005

Abstract

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.

D 2005 Published by Elsevier Inc.

Keywords: Hispanics; Women; Cervical Cancer; Screening; Acculturation

Introduction

The mortality and incidence rates from cervical cancer are

higher among Hispanic women than non-Hispanic women in

the United States (Centers for Disease Control and Prevention,

2002). However, Hispanic women are less likely to utilize

Papanicolau (Pap) smears compared to non-Hispanic Blacks

and Whites (Coughlin and Uhler, 2002). The CDC reported

that in 1998 the prevalence of Pap testing within the preceding

3 years was 80% for non-Hispanic white women, 83% for non-

Hispanic black women, but only 74% for Hispanic women

(Coughlin and Uhler, 2002).

One of the factors that may influence cervical cancer

screening use by Hispanics is acculturation, a process whereby

one whose learning was in one culture then adopts attitudes,

values, and behaviors of another culture (Suarez, 1994). The

1982–1984 Hispanic Health and Nutrition Examination

Survey (HHANES) showed that acculturation was associated

with Pap smear screening (Solis et al., 1990). However, to our

0091-7435/$ - see front matter D 2005 Published by Elsevier Inc.

doi:10.1016/j.ypmed.2005.10.002

* Corresponding author. Fax: +1 202 782 5833.

E-mail address: kangmin.zhu@na.amedd.army.mil (K. Zhu).

best knowledge, there have been no large population-based

studies that further examine the acculturation/cervical cancer

screening relationship since that study during which there have

been national efforts in increasing cervical cancer screening

(Centers for Disease Control and Prevention, 2005). The

purpose of this paper was to examine the relationship between

acculturation and Pap smear utilization in a population-based

sample of Hispanic women in the United States.

Methods

The data for our analyses were collected in the National Health

Interview Survey (NHIS) in 2000, which used a sampling plan based on

a multistage area probability design that permitted a representative sampling

of households. Black and Hispanic/Latino populations were over-sampled to

increase the precision of estimates for those subgroups (National Center for

Health Statistics, 2002). Our analyses were restricted to women between the

age of 21 and 70 (the aged range recommended for cervical cancer

screening based on the most recent American Cancer Society guidelines

(Early detection of cervical cancer, 2002)) who self-identified themselves as

Hispanic and reported that they never were diagnosed with cervical cancer.

Women with a hysterectomy were excluded because the cervix may have

been removed.

Data were collected through in-person telephone interviews. Hispanic

acculturation was defined based on a series of questions on language usage,

(2006) 146 – 149

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M. Shah et al. / Preventive Medicine 42 (2006) 146–149 147

both in childhood and adult. Respondents were asked to name the language in

which they generally spoke and the language that they were better able to read.

They were also asked to name the language they usually used when speaking at

home, when talking with friends, while thinking, when watching television, and

when listening to radio programs. We used the acculturation scale based on the

revised Marin and Marin Short Acculturation Scale (Marin and Marin, 1991),

for which the answers to the language questions were summed constituting a

score. The score was evenly divided into three groups or a tertilesa depending

on their summed score. The lowest tertile represents low acculturation; the

middle is moderate and the highest represents high acculturation. Pap smear

utilization was determined by whether they had ever had a Pap smear; those

who responded positively were then asked when they had their most recent

examination.

We used the logistic regression method in data analysis. Odds ratios and

95% confidence intervals were adjusted for demographic factors and other

potential confounding variables that were based on their relationship to the use

of Pap smear in the past 3 years and the acculturation levels in women who had

a Pap smear in the last 3 years.

Results

Table 1 shows the distribution of demographic variables.

Higher acculturated individuals tended to be younger then their

Table 1

Acculturation level by sample characteristics for Hispanic women in the United St

Variable

Low

N %

Age category (years)

21–39 392 57.73

40–49 149 21.94

50–59 68 10.01

60–70 70 10.31

Marital status

Married or living with partner 455 67.01

Widowed 43 6.33

Divorced or separated 93 13.70

Never married 87 12.81

Missing marital status 1 0.15

Education

Less than high school 519 76.44

High school education 92 13.55

1 to 3 years college 39 5.74

College degree through some post-grad work 18 2.65

Missing education 11 1.62

Family income

$20,000 or more 290 42.71

Less than $20,000 353 51.99

Missing family income 36 5.30

Ratio of family income to poverty thresholda

Under 0.99 213 31.37

1 to 1.99 217 31.96

2 to 2.99 65 9.57

3 to 3.99 16 2.36

4 to 4.99 7 1.03

5 and over 161 23.71

a Published 1999 poverty thresholds from the Census Bureau are used in these ca

status and vary by size of family and age of members. The family/poverty thres

representing a poorer family condition.

lower acculturated counterparts. The proportion of women who

were married or living with a partner decreased with increasing

acculturation level. Only 19% of higher acculturated women

had an education lower than high school compared to 76.4% in

lower acculturation women. Lower acculturated women were

more likely to have a family income below $20,000 and live in

a household with a family income/poverty threshold ratio

(family income divided by the poverty threshold from the U.S.

Census Bureau) of under 0.99.

Odds ratios and 95% confidence intervals for the relation-

ship between acculturation and cervical cancer screening are

presented in Table 2. Univariate analysis without adjustment

for potential confounders showed that acculturation level was

inversely correlated with no Pap smear for each defined

period. Similar results were found when adjusting for

demographic variables. When other factors in addition to

demographic variables were adjusted for, higher acculturated

women were less likely to never have had a Pap smear than

lower acculturated women (OR = 0.51; 95% CI, 0.29–0.89).

The other OR estimates included or were close to one when no

ates, 2000

Acculturation level

Moderate High Total

N % N % N %

470 60.57 465 68.28 1418 61.47

167 21.52 131 19.24 485 21.02

84 10.82 53 7.78 228 9.88

55 7.09 32 4.70 176 7.63

437 56.31 370 54.33 1364 59.12

26 3.35 17 2.50 93 4.03

150 19.33 136 19.97 405 17.56

161 20.75 156 22.91 438 18.99

2 0.26 2 0.29 7 0.30

302 38.92 129 18.94 1024 44.39

192 24.74 216 31.72 522 22.63

196 25.26 232 34.07 503 21.80

86 11.08 102 14.98 230 9.97

0 0.00 2 0.29 28 1.21

459 59.15 484 71.07 1320 57.22

284 36.60 173 25.40 871 37.75

33 4.25 24 3.53 116 5.03

169 21.78 97 14.24 515 22.32

193 24.87 125 18.36 560 24.27

119 15.34 118 17.33 323 14.00

55 7.09 74 10.87 153 6.63

39 5.03 56 8.22 108 4.68

201 25.90 211 30.98 648 28.09

lculations. Poverty thresholds are the dollar amounts used to determine poverty

hold ratio is the family income divided by the threshold with a lower value

Table 2

Odds ratios (95% confidence intervals) of having never had a pap smear, not having a pap smear within past 3 years and past year by acculturation level: United

States, 2000

Never had a Pap smeara No Pap smear within past 3 yearsa No Pap smear within past yeara

Number of

observations

OR (95% CI) P value

for trend

Number of

observations

OR (95% CI) P value

for trend

Number of

observations

OR (95% CI) P value

for trend

Univariate

Low acculturation 147 1.00 218 1.00 341 1.00

Moderate acculturation 106 0.70 (0.52–0.94) 163 0.64 (0.50–0.82) 330 0.80 (0.65–1.00)

High acculturation 46 0.24 (0.16–0.37) <0.001 96 0.36 (0.27–0.48) <0.001 241 0.58 (0.47–0.73) <0.001

Adjusted for sociodemographic factorsb

Low acculturation 147 1.00 218 1.00 341 1.00

Moderate acculturation 106 0.61 (0.43–0.86) 163 0.61 (0.46–0.81) 330 0.84 (0.67–1.06)

High acculturation 46 0.19 (0.12–0.31) <0.001 96 0.35 (0.25–0.49) <0.001 241 0.65 (0.50–0.84) 0.001

Adjusted for sociodemographic and other factorsc

Low acculturation 147 1.00 218 1.00 341 1.00

Moderate acculturation 106 0.86 (0.58–1.27) 163 0.83 (0.61–1.13) 330 1.12 (0.87–1.43)

High acculturation 46 0.51 (0.29–0.89) <0.001 96 0.73 (0.49–1.08) 0.104 241 1.07 (0.80–1.45) 0.648

a The total numbers of low, moderate, and highly acculturated women were 642, 758, and 664 when having never had a Pap smear was the outcome. The

corresponding numbers were 631, 757, and 662 when no Pap smear within the past 3 years or within the past year was the outcome.b Adjusted for age, marital status, family income, education, and ratio of family income to poverty threshold.c Adjusted for demographic variables, smoking status, alcohol consumption, amount of vigorous exercise a week, ever having the chicken pox, visiting a general

physician in the last 12 months, had the hepatitis B vaccine, ever donated blood, ever been tested for HIV, ever used birth control pills, ever given birth to a live baby,

ever heard of genetic testing for cancer, and personal thoughts on risk of getting cancer in the future.

M. Shah et al. / Preventive Medicine 42 (2006) 146–149148

Pap smear within the past 1 or 3 years was used as the

outcome.

Discussion

Our analyses unveiled differences in cervical cancer

screening patterns among the different acculturation levels

in Hispanic women. Lower acculturated women were less

likely to have had a Pap smear ever, in the past 3 years,

and in the past year. These results are consistent with those

from some previous studies that demonstrated a correlation

between acculturation and cancer screening in Hispanic

women (Suarez, 1994). Awareness and knowledge underlie

appropriate beliefs and attitudes toward cancer screening.

Language and cultural barriers in lower acculturated women

may prevent the establishment of appropriate beliefs, thus

relevant actions in seeking Pap smear tests cannot be taken

(Fernandez-Esquer et al., 2003).

Our analyses showed that acculturation seemed not related

to the use of Pap smear in the preceding year (the odds ratio

of Pap smear screening approached one) when adjusting for

all potential confounders. We tested the effects of these

factors on the odds ratio estimates by taking each of them out

of the model and found that having visited a general

physician in the same time period had the greatest effects

on the odds ratio estimates, the odds ratio of Pap smear

screening approached one when excluded. Visiting a doctor

might be highly related to the acculturation/Pap smear

association. In fact, a Pap smear may be recommended when

a woman visits her doctor. The under use of cervical

screening may partly result from a lower frequency of visiting

a doctor in Hispanic women.

There were several limitations to our study. The question-

naire was self-reported so the data obtained might not be

completely accurate. This may be particularly true for a study

on acculturation because people with different acculturation

levels have different language abilities and different compre-

hension of health-related questions. However, studies have

showed that there are yea-saying tendencies (when person

being surveyed responds affirmatively or agrees to please the

interviewer) in Hispanic people (Aday et al., 1980). This may

be more likely for less acculturated Hispanic individuals. If this

were true, the association identified in this study would be

diluted because cancer screening may be overestimated in this

group of people. The other potential limitation of this study is

the inability to distinguish Hispanic groups. Hispanic people

encompass diverse communities. These communities may vary

in language ability and culture, which may lead to different

understanding of health-related issues. If the distribution of the

communities varies according to acculturation levels in this

study, the results might have been influenced. We are unable to

assess this possibility because of lack of the information on

Hispanic origins.

In conclusion, our findings suggest that lower acculturated

women have barriers to using Pap smears. These results

reinforce the need to address acculturation for increasing

cervical cancer screening in the Hispanic population.

Acknowledgments

We would like to thank Dr. David Berrigan from the

Division of Cancer Control and Population Sciences National

Cancer Institute for his assistance on this study and Reena Shah

for her comments on the manuscript.

M. Shah et al. / Preventive Medicine 42 (2006) 146–149 149

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