THE C I E N C E O F H E A L T H PROMOTIOI

Underserved Populations; Medical Self-Care

Hispanic Women’s Breast and Cervical CancerKnowledge, Attitudes, and Screening BehaviorsAmelie G. Ramirez, DrPH; Lucina Suarez, PhD; Larry Laufrnan, EdD; Cristina Barroso, MPH;Patricia Chalela, MPH

Abstract

Purpo.se. This study examined breast and cervical cancer knowledge, attitudes, andscreening behaviors among d~fferent Hispanic populations in the United States.

Desi~. Data were collected from a random- digit dial telephone survey of 8903 Hispan-ic adult-s from eight U.S. sites. -Across sites, the av-erage respo-nse rate was E3%. -

Setting,. Data-were collected as part of the baseline asses-sment in a national Hispaniccancer c~ntrol and prevention intervention study.

Subjects. Analysis was restricted to 2239 Hispanic women aKe 40 and older who wereself-identified as either Central American (n = i74), Cuban (n~= 279), Mexican Ameri-can (n = 1550), or Puerto Rican (n = 236).

Meagures. A bilingual survey instrument was used to solicit information on age, edu-cation, income, health insuranc~ coverage, language use, U.S.-born status, knowle-dge ofscreeninkr guidelines, attitudes toward canceg, dnd screening participation. Differences inknowlea~i~ and attitudes across Hispanic groups were assessgd by ezther chi-sq~iare tests oranalysis-of Variance. Logistic regression mo- degs assessed the influence of knowledge andattitudes o- n screenin~ pa-rticipati- on. -

Re, u~!ts. The level~df know~ledKe of guidelines ranked from 58. 3 % (Mexican Americans)to 71.8% (Cubans) f~r mammo~Kra1~-hy, and from 4"1.1% (Puerto Ricans) to 55.6% bans) for Pap smear amon~ the ~d~fferknt Hisp- anic populations. Attitudes also varied, withMexicar,~ A~ericans and Puerto Ricans having more neKative or fa_talistic views of cancerthan C~:ban or Central Americans. Knowledge was szgn~ficantly related to age, education,income, language preference, and recent screening history-. Ovecall, attitudes -were not pre-d~ctzve of mammograph7 and Pap smear behavzor

Conclusions. F-actbr~ related tb mammography and Pap smear screeninK w~ry among........... hethe different Hispantc populatwns. L~mttat~ons ~nclude the cross-sect~onal-nature ~f t

study, self-reported measures of screening, and the limited assessment of attitudes. The dataand diversity Of Hispanic groups reinfdrce the position that ethno-r_e_gional characteristicsshould be c~arified and addressed in cancer scCeening promotion e~f6rts. The practical rela-tionships among knowledge, attitudes, and cancer screening are not altogether clear andrequire further research. (Am J Health Promot 2000; 14[5]:292-300.)

Key~Words: Cancer Screening, Mammography, Pap Smear, Hispanics, CancerScreening Behaviors, Cancer Knowledge andAttituc]es

Amelie G. Ramirez, DrPH, is Associate Professor of Medicine at Baylor College of Medicine,Deputy Director of the Chronic Disease Pre~-ention and Control Research Cent~ and AssociateDzrector for Community Research at the San Antonio Cancer Institute, San Antonio, Texas.Lucina Suarez, PhD, is at the Associateship.for Disease Control and Prevention.for the TexasDepartment of Health, Austin, Texas. Lari’y-Laufman, EdD, is Associate Prafess-or of Medi-cine, C:~istina Barroso, MPH, is a Research Coo(dinat~ and Patricia Chalela MPH, is Research Associate with the Chronic Disease Prevention and Control Research Cent~ BaylorCollege of Medicine, Houston, Texas.

Send reprint requests to Amelie G. Ramirez, DrPH, 8207 Callaghan Road, Suite 110, San Antonio,TX 78230.

This manuseript was submitted July 26, 1999; revisions were requested October 20, 1999; the manuscript wa,~ acceptedfor publication March 21, 2000.

Am J Health Pro~not 2000; 14(5) :292-300.Coto’right © 2000 by American Journal of Health Promotion, Inc.0890-1171/00/$5.00 + 0

INTRODUCTION

Hispanic/Latino women havesome of the lowest rates of healthscreening and health care utilizationin America. Howeve~, Hispanic wom-en experience significantly highercervical cancer incid~ence and mortal-ity than do non-Hispanic white wom-en.LZ Breast cancer !incidence is lowamong Hispanic wo~aaen comparedwith non-Hispanic white women,L-~-~

but a greater proportion of Hispanicbreast cancer patients experience alonger duration of ~,yrnptoms and aremore likely to die fiom the disease.~,s

The higher Hispanic cervical cancermortality rates and higher proportionof later-stage breast cancer diagnosisat least partially results from poorerscreening participation for these dis-eases.~ Hispanic women have consis-tently lower breast and cervical can-cer screening rates than non-Hispan-ic white women, regardless of riskStatus. 10--24

The relationship, between ethnicityand cancer outcornes is mediated bysocioeconomic stat~as, knowledge andattitudes, and access to medicalcare.2,2"~ Compared with non-Hispanicwhite women, Hispanic women morefrequently are poor, lack health in-surance, have fewer years of formaleducation, and have higher unem-ployment rates leading to inadequatemedical care. ]1,26-2!~ Hispanic womenalso often experience cultural andlanguage barriers ~:hat keep themfrom seeking health Care or cancer-related services and have limited

292 American Journal of Health Promotion

knowledge about cancer-related riskfactors and cancer screening proce-dures.3°-:~2 For many Hispanic wom-en, barriers include an inability tospeak English and feelings of fatal-ism.’~:~--~a However, among the differ-ent populations in the Hispanic com-munity at large, there has been nosystematic study of variation in breastand cervical cancer screening knowl-edge, attitudes, and behaviors.

In one study among rural, lowersocioeconomic Hispanic women,knowledge and attitudes about mam-mography (efficacy of the procedure,personal risk, fear of cancer and/ortreatment, fatalism, and cultural is-sues) were found to influence screen-ing decision-making and behavior.Other factors included issues relatedto participation (language, travel andaccess, time, cost, radiation exposure,and pain) and social concerns (rolemodeling, responsibility to self, re-sponsibility to others, influence offamily/friends, influence of doctors,and influence of society).:~7 In addi-tion, Hispanic women were morelikely to have medically inaccuratebreast cancer beliefs, such as consid-ering breast trauma and negative be-haviors (e.g., using illegal drugs) be risk factors, fearing that surgerymay cause cancer to spread, or be-lieving that mammograms are neces-sary only to evaluate breast lumps.Hispanics also were less likely toknow that symptoms such as breastlumps and bloody breast dischargecan indicate breast cancer.16,26,30,38

Although similarities exist amongthe various Hispanic groups, there iswide diversity in their demographicand cultural characteristics. Indeed,the Hispanic population is composedof many groups with differing histo-ries and other factors that can influ-ence cancer screening and relatedknowledge and attitudes. The lack ofwell-specified research on differentethno-regional Hispanic groups hasresulted in inadequate data on mam-mogram and Pap smear knowledge,attitudes, and behaviors for these in-dividual populations. In this study, weexamine group differences in mam-mogram and Pap smear knowledge,attitudes, and behaviors among fourHispanic populations. We also assessthe relationship of knowledge and at-

titudes to sociodemographic factorsand to Pap smear and mammogra-phy screening participation.

METHODS

DesignData for the study are derived

from a baseline assessment of variousHispanic populations, part of a multi-site cancer prevention and controldemonstration project funded by theNational Cancer Institute. The Na-tional Hispanic Leadership Initiativeon Cancer: En Acci6n study involvedeight locations across the UnitedStates, six intervention sites, and twocontrol sites. The eight En Acci6n re-search sites were selected because oftheir concentrated populations of thefour major Hispanic origin groups.At each site one group predomi-nates: Central Americans in SanFrancisco, California; Cubans in Mi-ami, Florida; Mexican Americans inBrownsville, Houston, Laredo, andSan Antonio, Texas, and San Diego,California; and Puerto Ricans inBrooklyn, New York. To assess base-line cancer screening practices, theOffice of Survey Research at the Uni-versity of Texas, Austin, conductedtelephone surveys among the Hispan-ic populations in the targeted areasfrom October 1993 to July 1994.

The survey instrument was de-signed using items from question-naires previously administered in theHealth Interview Survey)9 in the De-partment of Health and Human Ser-vices Behavioral Risk Factor Surveil-lance Survey (BRFSS),4° and our pre-vious research.41-4"~ A national panelof Hispanic experts in behavioral sci-ences and cancer prevention also re-viewed the questionnaire. The panelassessed the appropriateness of itemson ethnic demographics, cancerscreening practices, cancer knowl-edge, attitudes and beliefs, culturalbeliefs and practices, and other riskbehaviors that affect Hispanics’ par-ticipation in cancer prevention. Allitems were evaluated for cultural ac-ceptability and sensitivity. The surveyinstrument was pretested in San An-tonio and in San Francisco using aseparate sample of women similar tostudy participants. Minor changeswere made prior to implementation.

The questionnaire was translatedfrom English to Spanish and back-translated using well-establishedmethods to ensure accnracy and useof culturally appropriate words.

SampleAt each location the target area

was geographically defined by censustracts and zip codes. Lists of workingresidential telephone numbers withineach area were randomly sampled bycomputer. Approximately 92% ofHispanic households in the target ar-eas had telephones at the time of thesurvey. Within each site, stratifiedquota sampling was employed to ob-tain 300 subjects for each of four sex-age groups: males and females youn-ger and older than 40. Interviewscontinued until each cell of the sam-pling matrix was filled. These ageand sex quotas were set to allowcomparison among the different sec-tors of the Hispanic populationacross sites.

Interviewers used the ComputerAssisted Telephone Interview (CATI)system to administer the question-naire. All interviewers were bilingualand matched to the specific Hispanicgroup membership of each respon-dent. Interviewers underwent 9hours of training; 10% of their callswere validated; and throughout thesurvey, supervisors periodically moni-tored their telephone interviews. In-terviewers made a maximum of 12 at-tempts to reach each potential re-spondent. The Spanish language sur-vey took an average of 27 minutes toadminister, and the English versiontook an average of 24 minutes. Theaverage response rate was 83.0%, andthe average refusal rate across siteswas 3.6%. A total of 8903 Hispanicrespondents completed interviews, ofwhich 4716 were Hispanic womenage 18 and older. For this study, anal-ysis was restricted to 2239 women age40 years and older who were self-identified as Mexican American,Puerto Rican, Cuban American, orCentral American.

MeasuresVariables of interest for the pre-

sent analysis were age, education(greater or fewer than 12 years),household income, participation in a

May/June 2000, Vol. 14, No. 5 293

health care plan (insurance or othercoverage of costs), Spanish/Englishpreference based on a five-item lan-guage use scale, self-reported Hispan-ic-origin identity, U.S.-born status,knowledge of guidelines for bothmammogram and Pap smear exami-nations, attitudes toward cancer, andrecent rnammography and Pap smearparticipation. Recent mammographyand Pap smear screening was definedaccording to national guidelines; formammography, "recent" was if themammogram had been administeredin the previous 2 years; for Papsmear participation, "recent" was ifthe test had been administered inthe previous 3 years.

Regarding knowledge of mam-mography, women were asked if theyever heard of a mammogram; if so,they were asked how often theythought a woman age 50 and overshould have one. Based on their re-sponses, women were grouped intothree categories: those who had nev-er heard of a mammogram, thosewho had heard of a mammogrambut did not know the guidelines, andthose who knew the guidelines.Women were similarly grouped ontheir knowledge of the Pap smear(never heard of Pap smear, heard ofPap smear but did not know theguidefines, had knowledge of correctguidelines). Women were groupedaccord, ing to their age: 40 to 49, 50to 64, and 65 and older. Based onscreening rates and frequency distri-butions, educational attainment wasdivided into less than a high schooleducation and a high school educa-tion or greater. Household incomewas c~.tegorized as less than $10,000,$10,000 to $20,000, and more than$20,0O0.

Three items on a three-point Lik-err scale assessed women’s attitudestowarcl cancer. The first item, mea-suring beliefs regarding the successof cancer treatment, was stated as"Cancer can be cured" (agree = 1,disagree = 3, neither = 2). The sec-ond item, assessing attitudes towardpersonal resources to prevent cancer,was stated as "There is little that Ican d.o to prevent getting cancer"(agree = 3, disagree = 1, neither 2). The third item, tapping beliefsabout susceptibility to cancer, was

stated as "Compared to other peopleyour age, how likely are you to getcancer" (more likely = 3, equallylikely = 2, less likely = 1).

Language acculturation was mea-sured with a modified Cuellarscale.44,4-~ The five-point Likert scaleitems were language spoken, lan-guage read, language used to think,language used at home, and lan-guage used with friends. For eachwoman, scale item responses were to-taled to create an acculturation toEnglish use score. Scores rangedfrom 5 to 25; women with scores of11 or greater were considered mostlyEnglish users, and those vdth below11 were considered mostly Spanishusers. The Cronbach alpha reliabilityfor the modified acculturation scalewas .933.

AnalysesDifferences in proportions with

knowledge of guidelines across His-panic groups were assessed by chi-square tests. Differences in attitudestoward cancer across Hispanic groupswere assessed by both analysis of vari-ance (mean scores) and chi-squaretests (proportion who agree/dis-agree). Differences in proportions ofthose with knowledge of guidelinesand attitudes toward cancer acrossvarious sociodemographic character-istics were also tested with chi-squarestatistics.

Using the entire stud), sample, re-gardless of Hispanic group, logisticregression models were utilized to as-sess the influence of knowledge andattitudes on screening participationwhile controlling for socioeconomicfactors. Odds ratios (ORs), 95% con-fidence intervals (CI), and p-valueswere reported. All variahles excepthousehold income were included inthe logistic regression models.Household income was excluded be-cause 23.9% of the sample was un-able or unwilling to provide this in-formation. There was no significantvariation in the refusal to report in-come by Hispanic group. In the ini-tial models, all variables (age, educa-tion, insurance, English preference,U.S.-born status, knowledge, and atti-tudes) were included. Variables thatmet a p value of less than .25 wereincluded in a subsequent model. For

the final models, variables were elimi-nated if the p value was ~.05.

To evaluate whether differences inknowledge or attitud,e explained His-panic group differences in mammog-raphy or Pap smear behavior, logisticregression models were run withthree design variables representingHispanic groups (Central Americans,Puerto Ricans, and Cuban Ameri-cans, with Mexican ~Mnericans as thereferent) and all previously statistical-ly significant covariates. All analyseswere performed with Statistical Prod-uct and Service Solutions Version8.0.46

RESULTS

Table 1 shows the characteristicsof the study sample of Hispanic wom-en age 40 and older by ethnicity. Cu-ban women were more educated,older, and more likely to have healthinsurance than other groups. Mexi-can American and Puerto Ricanwomen were more likely to be En-glish users. Far more Mexican Ameri-can women were U.S. born than anyother group.

Substantial differences existed inthe level of knowledge about mam-mography and Pap smear guidelinesamong Hispanic groups. As shown inTable 2, the proportion of womenwho reported that they knew themammography guidelines was lowestamong Mexican Americans (58.3%)and highest among Cubans (71.8%).In addition, 4.8% of Mexican Ameri-can women said they had neverheard of mammography, nearly threetimes the proportion for CentralAmerican women (1.7%). Table shows that Cuban women also weremore likely to know the Pap smearguidelines than the other Hispanicgroups, while Pue:cto Ricans exhibit-ed the lowest level[ of knowledge.Among Cuban women, 55.6% indi-cated that they had knowledge of thePap test guidelines, as compared with41.1% for Puerto Rican women.Overall, women in all groups wereless likely to know the Pap smearguidelines than mammographyguidelines.

Table 3 reflects attitudes of thedifferent Hispanic groups towardcancer and its prevention and cure.

294 American Journal of Health Promotion

Table 1

Sociodemographic Characteristics of Study Sample

Variable

%Mexican % Central % Puerto % Cuban

American American Rican American(n = 1550) (n = 174) (n = 236) (n = 279)

Age40-49 32.3 30.5 35.6 12.550-64 32.5 36.2 39.4 28.065 + 35.2 33.3 25.0 59.5

Education12+ 25.0 29.9 24.3 48.7

income<$10,000 50.6 51.2 64.8 56.6$10,000-$20,000 30.1 27.2 14.8 26.5>$20,000 19.3 21.6 20.3 16.9

No health insurance 40.8 39.7 16.5 18.8English preference 34.7 18.4 38.1 11.8U.S.-born 40.5 2.3 5.1 1.1

More Mexican Americans (21.5%)and Puerto Ricans (21.2%) disagreedwith the notion that cancer is cur-able and believed that they weremore likely to get the disease (17.0%and 20.1%, respectively) than did Cu-bans and Central Americans. Mexi-can Americans displayed greater con-sistency in their negative and fatalis-tic view of cancer; they were themost likely to agree that little couldbe done to prevent the disease. In-deed, approximately 4 of every 10Mexican Americans in the survey hadthis attitude.

As shown in Table 4, knowledge ofmammography and Pap smear guide-lines was significantly related to age,education, income, and languagepreference. Knowledge of Pap smearguidelines was related to insurancecoverage, but knowledge of mam-mography guidelines was not. Nei-ther knowledge of Pap smear nor

Table 2

Knowledge of Mammography and Pap Smear, Guidelines, and Recent Mammogram and Pap Smear for Women 40 YearsOld and Older, in Percentages

Never Heard Heard but No Knowledge Knowledge RecentHispanicGroup n Mammogram Pap Smear Mammogram Pap Smear Mammogram Pap Smear Mammogram Pap Smear

MexicanAmerican 1548 4.8 11.7 36.9 35.8 58.3 52.5 53.6 63.0CentralAmerican 174 1.7 8.6 33.9 43.7 64.4 47.7 70.5 67.8Puerto Rican 236 2.1 17.8 31.8 41.1 66.1 41.1 61.7 67.5Cuban 277 2.9 4.9 25.3 39.8 71.8 55.6 70.5 69.0

Table 3

Attitudes Toward Cancer by Hispanic Group

Cancer Can Be Cured Little I Can Do to Prevent How Likely to Get Cancer

Hispanic Group Mean* SD % Disagree Meant SD % Agree Means SD % More Likely

Mexican American 1.58 0.8 21.5 1.91 0.9 39.5 1.93 0.6 17.0Central American 1.53 0.8 17.8 1.82 0.9 36.8 1.79 0.6 12.2Puerto Rican 1.57 0.8 21.2 1.84 0.9 33.5 1.96 0.7 20.1Cuban 1.44 0.7 15.2 1.85 0.9 34.3 1.84 0.6 11.6p value 0.07 0.19 0.47 0.02 0.01 0.03

* Where responses were scaled as agree = 1, neither = 2, disagree = 3.1 Where responses were scaled as agree = 3, neither = 2, disagree = 1.:l:Where responses were scaled as less likely = 1, equally likely = 2, more likely = 3.

May/June 2000, Vol. 14, No. 5 295

Table 4

Knowledge and Attitudes by Sociodemographic Characteristics*

Variable

% KnowMammography % Know Pap

Guidelines Guidelines% Disagree Cancer % Agree Little Can Be

Can Be Cured Done to Prevent

% More Likely to GetCompared With

Others

Age group40-49 64.9 60.5 22.4 37.5 20.450-64 64.1 57.1 22.4 38.3 18.465+ 55.7 38.8 17.0 38.2 10.9p value 0.00 0.00 0.011 0.947 0.000

Education<High school 58.3 46.1 21.1 41.1 16.2High school grad 68.7 64.4 18.8 30.0 16.5p value 0.00 0.00 0.213 0.00 0.892

Income<$10,000 58.2 45.3 20.1 41.6 16.2$10,000-$20,000 66.2 63.9 21.1 34.6 17.1>$20,000 71.4 64.4 23.5 27.4 19.1p value 0.00 0.00 0.421 0.00 0.51

InsuranceYes 61.6 48.8 19.3 36.2 15.0No 60.7 55.9 22.4 41.5 18.4p value 0.67 0.001 0.08 0.013 0.045

U.S.-bornYes 60.7 51.3 22.8 37.2 18.7No 61.6 51.4 19.5 38.4 15.3p value 0.698 0.977 0.077 0.597 0.056

English preferenceYes 67.2 60.5 20.7 31.0 19.2No 58.5 47.2 20.3 41.2 15.0p value 0.00 0.00 0.824 0.00 0.018

Recent mammogramYes 70.5 57.0 19.6 37.0 16.5No 48.8 43.9 21.5 39.4 16.2p value 0.00 0.00 0.27 0.236 0.861

Recent Pap smearYes 69.0 63.5 21.1 36.9 18.5No 47.2 30.7 18.9 39.6 12.4p value 0.00 0.00 0.214 0.201 0.00

* N may vary for each group.

mammography guidelines was relatedto U.S.-born status. Knowledge ofguidelines was strongly related to re-cent screening. This is especially trueof those reporting recent Pap smears;more than twice as many of thosewho had a recent Pap test (63.5%) those who had not (30.7%) knew theguidelines for the test.

Table 4 shows no consistent corre-lation between attitudes and sociode-mographic factors. For example,more of those earning over $20,000believe cancer cannot be cured thanthose in the <$10,000 income cate-gory. Yet 27.4% of those making over$20,000 believe little can be done toprevent cancer, well below the 41.6%

of lower income respondents whohold this view. Overall, attitudes werenot predictive of mammography andPap smear behavior. In addition,women who thought they were morelikely to get cancer had more oftenreceived a recent Pap smear. Amongrespondents, 18% of those who hada recent Pap test believed they weremore likely to get cancer as com-pared with 12.4% of those who hadnot had a recent test.

Results of multiple logistic regres-sion indicate that age, insurance, andknowledge of guidelines were theonly statistically significant predictorsof recent mammography use (Table5). Women who knew the guidelines

were 2.5 times more likely to havehad a recent mammogram. Educa-tion, English language use, and U.S.-born status were not related to mam-mography use. Additionally, attitudesas reflected by the three statements("cancer can be cured," "little canbe done to prevent," and "likely toget cancer") were unrelated to mam-mography beha~tor.

With regard to Pap smear behav-iors, multiple logistic regression re-sults show that age, education, insur-ance coverage, English preference,U.S.-born status, and knowledge ofguidelines were :all statistically signifi-cant predictors (Table 5). Womenwho knew the Pap smear guidelines

296 American Journal of Health Promotion

Table 5

Recent Mammogram and Pap Smear Logistic Regression for Women 40 Yearsand Older

Mammogram Pap Smear(N = 2046) (N = 2024)

Odds OddsVariable Ratio 95% CI Ratio 95% CI

Age40-49 1.00 --1 1.00 --1"50-64 1.52" 1.20-1.91 0.75 0.58-0.9765+ 1.23 0.96-1.58 0.42* 0.32-0.55

High school graduate 1.19 0.94-1.49 1.46"* 1.13-1.88Insurance 2.31 1.87-2.86 1.71" 1.36-2.16English preference 1.24 0.96-1.58 1.78* 1.36-2.34U.S.-born 0.87 0.69-1.11 0.62* 0.48-0.80Knowledge 2.58* 2.13-3.12 3.47* 2.83-4.26Cured 0.98 0.78-1.23 1.10 0.86-1.40Prevent 0.96 0.79-1.16 0.98 0.80-1.21More likely 1.01 0.78-1.30 1.42*** 1.07-1.89

1 Reference group.*p< 0.001; "*p< 0.01; ***p< 0.05.

Table 6

Recent Mammogram Logistic Regression for Women 40 Years and Older (N 2219)

Variable Odds Ratio 95% CI

Age40-49 1.00 --1-50-64 1.46* 1.17-1.8365+ 1.21 0.95-1.54

High School graduate 1.24** 1.00-1.53Insurance 2.33*** 1.89-2.87Knowledge 2.51"** 2.09-3.02Mexican American 1.00 --i"Central American 2,03*** 1,42-2,90Puerto Rican 1.07 0.79-1.44Cuban 1.49* 1.10-2.01

1 Reference group.* p < 0.01; ** p < 0.05; *** p < 0.001.

were more than three times morelikely to have had a recent Pap test.The only attitude predictive of Papsmear behavior was believing thatgetting cancer was more likely thanfor other people.

Tables 6 and 7 show the multiplelogistic regression results on impor-tance of sociodemographic andknowledge predictors to mammogra-phy and Pap smear use. Controllingfor knowledge of mammographyguidelines and important soeioeco-

nomic factors, Central Americanswere most likely to have had a recentmammogram (OR = 2.0), followedby Cuban Americans (OR = 1.5)when compared with Mexican Ameri-cans. With regard to Pap smear be-havior, group differences diminishedwhen controlling for guidelinesknowledge and sociodemographicfactors, although Central Americansand Cuban Americans still held aslight advantage in receiving a Papsmear (OR- 1.3).

DISCUSSION

The results of this study demon-strate considerable Hispanic groupdifferences in levels of knowledgeabout mammography and Pap smearscreening. In our sample, Cubanswere most likely to know both mam-mography and Pap smear guidelines.Mexican Americans were least likelyto have ever heard of mammography,to know mammography guidelines,or to have ever heard of Pap smear;Puerto Ricans were least likely toknow Pap smear guidelines. Al-though attitudes proved less predic-tive of screening, Mexican Americansand Puerto Ricans were more likelythan Central Americans or Cubans tothink they are likely to get cancerand to disagree with the idea thatcancer can be cured. Mexican Ameri-cans were also the most consistent intheir negative/fatalistic view of can-cer, since they were also the mostlikely to agree that there was littlethey could do to prevent cancer.

As has been shown in other stud-ies, knowledge of guidelines wasstrongly related to mammographyand Pap smear utilization in theseHispanic groups. Regardless of socialand economic factors, women whoknew the guidelines were far morelikely to have had a recent screeningmammogram or Pap smear. More-over, knowledge of the Pap smearguidelines largely explained thescreening level differences betweenHispanic groups. Controlling forknowledge and socioeconomic fac-tors, Central Americans were twice aslikely as other groups to have had arecent mammogram. However,knowledge of mammography guide-lines did not completely explain His-panic group differences in mammog-raphy screening. Why there are dif-ferences in the mediating effects ofknowledge on Pap smear and mam-mography is not clear. There may beunmeasured differences in availabilityof the Pap smear vs. mammography,or the effects may be due to a gener-ally lower level of knowledge aboutPap smear guidelines.

In general, attitudes were not pre-dictive of mammography and Papsmear behavior except for perceivedvulnerability. Women who thought

May/June 2000, Vol. 14, No. 5 297

Table 7

Recent Pap Smear Logistic Regression for Women 40 Years and Older (N 2025)

Variable Odds Ratio 95% CI

Age4O-49 1.00 --1.50-64 0.74* 0.57-0.9665 + 0.40** 0.30-0.53

High School graduate 1.36" 1.04-1.77Insurance 1.69** 1.33-2.15English preference 1.85** 1.40-2.45U.S.-born 0.66** 0.50-0.88Knowledge 3.45** 2.81-4.23More likely 1.44* 1.08-1.91Mexican American 1.00 --1-Central American 1.26 0.86-1.86Puerto Rican 0.99 0.69-1.41Cuban 1.32 0.93-1.88

1 Reference group.* p < 0.05; ** p < 0.001; *** p < 0.01.

they were more likely to get cancerwere more likely to have had a re-cent Pap smear. Other studies alsohave shown inconsistent results whenmeasnring attitudes and linking atti-tudes to cancer screening participa-tion. In a previous study of MexicanAmerican women, screening behavior(brea.,;t self-examination, clinicalbreast examination, Pap smear, andpelvic examination) was inversely as-sociated with anxiety about cancerwhen all other predictors were statis-tically controlled. However, knowl-edge of cancer was positively, ratherthan negatively, associated with anxi-ety about cancer. 47 Another studyfound knowledge variables and self-efficacy to be strongly related tobreast self-examination and colorec-tal cancer screening, but not relatedto Pap sn~ears and general cancerknowledge.,~r, In a study of factors as-soci~ted with women being classifiedas "lapsed" in follow-up care for ab-normal Pap tests, the classification ofpatients as lapsed was attributableneither to culturally based beliefsand attitudes nor to lack of knowl-edge and motivation.4s

Ea this study, the independent pre-dictors of Pap smear screening didnot completely overlap with those ofma~nmography. Education, Englishpre!~’erence, and U.S.-born status werestrongly predictive of Pap smear be-

havior but not mammography behav-ior. Having a belief that they were ata higher risk of cancer also predicteda recent Pap smear, but not a recentmammogram. In addition, knowledgeof Pap smear guidelines was generallylower than knowledge of mammogra-phy guidelines. These observationsmay be related to recurring attitudesamong Hispanic women regarding gy-necological screening. In a study ofbarriers and facilitating factors associ-ated with Pap smear use, Hispanicwomen were more concerned withembarrassment, use of cold or un-clean speculum, discomfort, and per-ceptions of disapproval by physiciansand male partners. 4~ In one study,Hispanic women who held certainmedically unaccepted beliefs (e.g.,having sex during menstruation) weresignificantly less likely to report hav-ing received a Pap smear within theprevious 3 years. Because cervical can-cer risk factors are related to sexualactivities, both cultural and moral is-sues may filter and influence knowl-edge and attitudes about Pap smearscreening among Hispanics. It hasbeen suggested that stressing the sex-ual transmission of cervical cancermight even discourage Hispanic wom-en from participating in screening.5°,5~

As shown in this and other studies,less-acculturated Hispanic womenhave less knowledge about Pap smears

and have lower cervical cancer screen-ing rates, and they may comprise thesubgroup that is at greatest risk ofpresenting with advanced-stage dis-ease.52-5-~ Thus in designing interven-tions for Hispanic women, those fo-cused on cervical cancer control mayrequire an increased sensitivity tothese cuhural attitudes.

The study has several limitationsthat need to be con~fidered. First, thecross-sectional nature of the studydoes not permit causal inferencesabout knowledge and screening be-havior. And even though the resultsof this study strongly indicate thatknowledge predicts mammographyand Pap smear screening, these re-sults should be intccpreted with cau-tion. It is not clear if one’s knowledgeinfluences screening behavior or ifgetting screened in~luences one’sknowledge. Second, few constructs ofattitude were measured, which mayexplain why attitudes were less predic-tive of screening participation amongthe study groups. Third, the data arebased on self-reports and may be sub-~ect to recall and desirability responsebias, in which the ’.~ubjects tend tooverestimate the frequency of screen-ing and underestimate fatalistic atti-tudes, trying to answer in the waythey think the interviewer would pre-fer. Finally, there ~re some biases asso-ciated with telephone survey methods,which were used i:n the present study.For instance, sampling householdswith telephones has been shown todemonstrate bias toward more fe-males, larger hou~’~eholds, and fewerfunctionally impai.red persons. Usinglisted numbers rather than randomdigit dialing can create a modest biastoward younger, healthier females liv-ing in smaller households.56 In addi-tion, the results ~aay not be generaliz-able to women without telephones.

In our study, mammography andPap smear knowledge, attitudes, andbehaviors varied among the differentHispanic populations. These data re-inforce the position that knowledgehas a strong impact on some popula-tions. Furthermore, these differences,as well as cultural, sociodemographic,and attitude vari~ations make clearthe heterogeneity of the Hispanicpopulation. Co~sequently, it is impor-tant for health professionals to seek

298 American Journal of Health Promotion

up-to-date information about the His-panic populations in order to tailorhealth educational messages appro-priately. In terms of knowledge, atti-tudes, and behaviors, as well as withother ethno-regional characteristics,both the differences and the similari-ties should be carefully considered. Itis clear that in developing strategiesto imp~-ove screening, health profes-sionals must first understand theknowledge and attitudes that affectthe specific population’s preventivebehaviors.

SO WHAT? Implications forHealth Promotion Practitionersand Researchers

This study shows that knowl-edge of screening guidelines variesconsiderably among Cuban, Cen-tral American, Puerto Rican, andMexican American women. Asshown in other studies, knowledgeof guidelines was strongly relatedto screening participation. Atti-tudes toward cancer were less pre-dictive of screening behavior butalso showed considerable Hispanicgroup variation. These findingssuggest that health promotionpractitioners shou|d recognize theheterogeneity of the Hispanicpopulation with regard to knowl-edge, attitudes, and behavior andtailor cancer control interventionsaccordingly. Health researchersshould refrain from the practiceof using "Hispanics" as an um-brella term to describe a singlepopulation or class. In all cases,the research sample should bespecifically identified, and the eth-no-regional characteristics ad-dressed and clarified.

Acknowledgments

This study was supported by gra~t U01 CA59379 fromthe National Cancer Institute. The authors wish to ex-press their thanks and appredation to the followingNHLIC: Ell Acci6n Co-Principal Investigators for theircontributions in the ad~ninistration of this study: JosiMarti, MD, Brooklyn Hospital Center; Brooklyn, NewYork; Eliseo J. Pg, rez-Stable, Md), Uuiversity of Califor-nia at San Frandsco, San Francisco, California; Grego-ry A. 7hlavera, MD, MPH, San Diego State University,San Diego, California; Edward Trapido, ScD, Universi-ty q[ Miami, Miami, Florida; and Roberto Villarreal,M1), MPH, University of Texas Health Science Centerat San Antonio, San Antonio, Texas. The authors alsowish to acknowledge the contribution of Dani Presswoodin the preparation of this manuscript.

References

1. Miller BA, Kolonel LN, Bernstein L, et al. Ra-cial/Ethnic Patterns of Cancer in the UnitedStates, 1988-1992. Bethesda, Maryland: Na-tional Cancer Institute (NIH 96-4104), 1996.

2~ Skaer TL, Robison LM, Sclar DA, et aL Can-cer screening determinants among hispanicwomen using migrant health clinics. J HealthCare Poor Underserved 1996;7(4) :338-54.

3. Ries LAG, Kosary CL, Hankey BE et al. SEERCancer Statistics Review, 1973-1995. Bethesda,Maryland: National Cancer Institute, 1998.

4. American Cancer Society. Cancer Facts andFignres. Atlanta, Georgia: American CancerSociety, 1997.

5. Bondy ML, Spitz MR, Halabi S, et al. Low in-cidence of familial breast cancer among His-panic women. Cancer Cause Control 1992;3(4):377-82.

6. Mayberry RM, Branch PT. Breast cancer riskfactors among Hispanic women. Ethnic Dis1994; 4(1):41-6.

7. Delgado DJ, Lin WY, Coffey M. The role ofHispanic race/ethnicity and poverty in breastcancer survival. Puerto Rico Health Sci J1995; 14(2):103-16.

8. RichardsonJL, Langholz B, Bernstein L, et al.Stage and delay in breast cancer diagnosis byrace, socioeconomic status, age, and year. Brit

J Cancer 1992;65(6):922-6.9. Gilliland FD, Hnnt WC, Key CR. Trends in

the survival of American Indian, Hispanic,and non-Hispanic white cancer patients inNew Mexico and Arizona, 1969-1994. Cancer1998;82 (9) :1769-83.

10. Wilcox LS, Mosher ’~VD. Factors associatedwith obtaining health screening among wom-en of reproductive age. Public Health Rep1993;108( 1):76-86.

11. Perez-Stable EJ, Marin G, Matin BV. Behavior-al risk factors: a comparison of Latlnos andnon-Latino whites in San Francisco. Am JPublic Health 1994;84(61:971-6.

12. Fernandez MA, Tor~olero-Ltma G, Gold RS.Mammography anti Pap test screening anmnglow-income foreign-born Hispanic women inUSA. Cadernos Saude Pnblica 1998;14(Suppl.3):133-47.Longman AJ, Saint-Germain MA, Modiauo M.Use of breast cancer screening by older his-panic women. Public Health Nnrs 1992;9(2):118-24.

14. Fox SA, Stein JA. Effect of physician-patientcommunication on mammography utilizationby different ethnic groups. Med Care 1991;29(11):1065-82.

15. Vernon SW, Vogel VG, Halabi S, et al. Breastcancer screening behaviors and attilndes inthree racial/ethnic groups. Cancer 1992;69( 1 ):165-74.

16. Hubbel FA, Chavez LR, Mishra SI, et al. Fromethnography to intervention: developing abreast cancer control program for Latinas. JNatl Cancer hast Monogr 1995;18:109-15.

17. Fnlton JP, Rakowski W, Jones AC. Determi-nants of breast cancer screening among in-ner-city Hispanic women in comparison withother inner-city women. Pnblic Health Rep1995; 110 (4) :476-82.

18. Stein JA, Fox SA, Mnrata PJ. Influence of eth-nicity, socioeconomic status, and psychologi-cal barriers on nse of mammography. JHealtb Soc Behav 1991;32:101-13.

19. Ramirez AG, McAlister A, Gallion K, et al.Targeting Hispanic populations: fimtre re-search and prevention strategies. EnvironHealth Perspect 1995;103(Suppl. 8):287-90.

20. Fox SA, Roetzheim RG. Screening mammog-raphy and older Hispanic women: current sta-tus and issnes. Cancer 1994;74(7):2028-33.

21. Salazar MK. Hispanic women’s beliefs about

¯ 13.

breast cancer and mammography. CancerNnrs 1996;19(6):437-46.

22. The National Cancer Institute Cancer Screen-ing Consortium for Underserved Women.Breast and cervical cancer screening amongunderserved wonlen: baseline survey resultsfrom six studies. Arch Faro Med 1995;4:617-24.

23. Kass BI, Weinick RM, Monheit AC. Racial andethnic differences in health. Rockville, Mary-land: Agency for Health Care Policy and Re-search, 1996. (AHCPR Publication No. 99-0001 .)

24. Bakemeier RF, Krcbs LU, Murphy JR, et al.Attltndes of colorado health professionals to-ward breast and cervical cancer screening inHispanic women. J Natl Cancer Inst Monogr1995;18:95-100.

25. Harlan LC, Bernslein AB, Kessler LG. Cervi-cal cancer screening: who is Ilot screened andwhy? Am .l Pnblic Health 1991 ;81 (7):885-91.

26. Chavez LR, Hubbell FA, McMuIlin JM, et ahUnderstanding kuowledge and attitudesabout breast cancer: a cultural analysis. ArchFaro Med 1995;4:145-52.

27. Caplan LS, Wells BL, Haynes S. Breast cancerscreening among older racial/ethnic minori-ties and whites: barriers to early detection. JGerontol 1992;47:101-10.

28. Saint-Germain M, Longman AJ. Breast cancerscreening among older Hispanic women:knowledge, attitudes, and practices. HealthEduc Q 1993;20(4):539-53.

29. Hubbel FA, Waitzkin H, Mishra SI, et al. Ac-cess to nledica] care for docnmented and un-documented Latinos in southern Californiacounty. WestJ Med 1991;154(4):415-7.

30. Morgan C, Park E, Cortes DE. Beliefs, knowl-edge, and behavior about cancer among ur-bau Hispanic women. J Natl Cancer lustMonogr 1995; 18:57-63.

screening in Mexican American wometl: tileeffects of acculturation. Am J Public Heahh1994;84(5):742-6.

32. Perez-Stable E.I , Otero-Sabogal RFS, McPheesJ, et al. Self-reported use of cancer screeningtests among Latinos and Anglos in a prepaidhealth plan. Arch Intern Med 1994;154(10):1073-80.

33. Stein JA, Fox SA. Language preference as auindicator of mammograplay use among His-panic women. J Natl Cancer lust 1990;82(21):1715-6.

34. Suarez L, Pulley L. Comparing accnltnrationscales and their relationship to cancer screen-ing among older Mexican-American women..]Natl Cancer lust Monogr 1995;18:41-7.

35. Carpenter V, Colv,,ell B. Cancer knowledge,self-efficacy, and cancer screening behaviorsamong Mexican-American women. J CancerEduc 1995;10(4):217-22.

36. Perez-Stable EJ, Sabogal E Otero-Sabogal R,et al. Misconceptions about cancer among La-tinos and Anglos. J Am Med Assoc 1992;268 (22) :3219-23.

37. Salazar MK. Hispanic women’s beliefs aboutbreast cancer and malllnlography. CancerNnrs 1996;19(6):437-46.

38. Hubbell FA, Chavez LR, Mishra SI, et al. Dif-fering beliefs about breast cancer among Lati-nas and Anglo women, WestJ Med 1996;164(5) :405-9.

39. US Bureau of the Census. National Health In-terview Survey, 1992 Supplement Booklet,Cancer Control. Washington, DC: US Depart-ment of Commerce, 1992.

40. Centers for Disease Control and Prevention.Behavioral Risk Factor Surveillance SystemQuestionuaires 1991-1992. http://www.cdc.gov/nccdph p/br fss/pd f-qnes/92brfss.pdf.

May/June 2000, Vol. 14, No. 5 299

41. Ramirez AG, McAlister AL. Mass media cam-paign: a su salud. Am J Prey Med 1988;17:608-21.

42. Ramirez AG, McAlister A, Gallion KJ, et al.Commtmi~ level cancer control in a Texasbarrio. Part I. Theoretical basis, implementa-tion, and process evaluation. J Natl Cancerlost Mnnogr 1995;18:117-22.

43. McAlister AL, Fernandez-Esquer ME, RamirezAG, et al. Community level cancer control ina Texa:~ barrio. Part I1. Base-line and prelimi-nary outcome findings. J Natl Cancer InstMonogr 1995;18:123-6.

44. Cnellar I, Harris LC, Jasso R. An accoltura-tion scale for Mexican American normal andclinica7 popnlations. HispanicJ Behav Sci1980;2(3):199-217.

45. Ramirez AG, CousinsJH, Santos Y,, et al. Amedia-based accnlturation scale for MexicanAmericans: application to public health edu-cation programs. Faro Community Health1986;9(3):63-71.

46. SPSS Inc. SPSS for Windows. Release 8.0.0 ed.Chicago, Illinois: SPSS, 1997.

47. Lobell M, Bay RC, Rhoads KV, et al. Barriersto cancer screening in Mexican-Americanwomen. Mayo Clio Proc 1998;73(4):301-8.

48. Hunt LM, de Voogd KB, Akana LL, et al. Ab-normal Pap screening among IVlexican Ameri-can women: impediments to receiving and re-porting follow-up care. Oncol Nurs Forum1998;25 (10) 1743-9.

49. Jennings KM. Getting a Pap smear: focusgroup responses of African American and La-tina women. Oncol Nurs Forum 1997;24(5):827-35.

50. Hnbbell FA, Chavez LR, Mishra SI, et al. Be-liefs about sexual behavior and other predic-tors of papanicolaou smear screening amongLatinas and Anglo women. Arch Intern Med1996; 156 (20) :2353-8.

51. Martinez RG, Chavez LR, Hubbell FA. Purityand passion: risk and morality in Latina ina-migrants’ and physicians’ beliefs abont cervi-

cal cancer. Med Anthropol 1997;17(4):337-62.

52. Suarez L, Roche RA, Nichols D, et al. Knowl-edge, behavio~; and fears concerning breastand cervical cancer among older low-incomeMexican-American women. Am J Prev Med1997;13(2):137-42.

53. Peragallo NP, Alba ML, Tow B. Cervical can-cer screening practices among Latino womenin Chicago. Public Health Nnrs 1997;14(4):251-5.

54. Polednak AP. Reported Pap test nse by His-panic women in Connecticut and Long Is-laud. Corm Med 1996;60(1):3-8.

55. Harmon MP, Castro FG, Coe K. Acculturationand cervical cancer: knowledge, beliefs, andbehaviors of Hispanic women. Women Health1996;24(3) :37-57.

56. Gilbert GH, Duncan RP, Knlley AM, et al.Evalnation of bias and logistics in a survey ofadnlts at increased risk for oral health decre-ments. J Public Health Dent 1997;57(1):48-58.

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