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Language and Use of Cancer ScreeningServices among Border and Non-BorderHispanic Texas WomenLeticia E. Fernández & Alfonso MoralesPublished online: 03 Apr 2007.
To cite this article: Leticia E. Fernández & Alfonso Morales (2007) Language and Use of CancerScreening Services among Border and Non-Border Hispanic Texas Women, Ethnicity & Health, 12:3,245-263, DOI: 10.1080/13557850701235150
To link to this article: http://dx.doi.org/10.1080/13557850701235150
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Language and Use of CancerScreening Services among Border andNon-Border Hispanic Texas WomenLeticia E. Fernandez & Alfonso Morales
Objectives. Compared to other groups, Mexican American women screen less frequently
for cervical and breast cancer. The most significant barriers reported by previous
researchers include not having a usual source of care, lacking health insurance and
English-language difficulties. In this paper we document and examine the factors
associated with disparities in cancer screening between border and non-border residents
by language of interview (Spanish or English) among Texas Hispanic women. We
hypothesize that, controlling for socioeconomic and demographic characteristics, border
residents are more likely to utilize screening services than non-border residents because of
the greater presence of bilingual services in border counties.
Design. We follow the framework of the Behavioral Model for Vulnerable Populations
proposed by Gelberg et al. (Health Services Research, vol. 34, no. 6, pp. 1273�1302,
2000). This model conceptualizes use of health care as an outcome of the interplay of
predisposing, enabling and need factors and recognizes that vulnerable groups face
additional barriers to health care utilization. Data come from the 2000, 2002 and 2004
Texas Behavioral Risk Factor Surveillance surveys.
Results. Group differences in cancer screenings are explained largely by socioeconomic
characteristics and structural barriers to access. The significance of language of interview
and of border residence disappear after controlling for factors such as health insurance,
income and a usual source of care.
Conclusion. Women who selected to be interviewed in Spanish were less likely to report
age-appropriate cancer examinations, health insurance and a regular health care
provider than those who selected to be interviewed in English. Disparities in cancer
Correspondence to: Leticia Fernandez, 808 S. Glebe Road, Arlington, VA 22204, USA. Tel: �1 915 443 8415;
Email: [email protected]
ISSN 1355-7858 (print)/ISSN 1465-3419 (online) # 2007 Taylor & Francis
DOI: 10.1080/13557850701235150
Ethnicity and Health
Vol. 12, No. 3, June 2007, pp. 245�263
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screenings among vulnerable Hispanic populations could be reduced by promoting the
establishment of a regular health care provider.
Keywords: USA�Mexico Border; Hispanics; Cancer Screening; Pap Test; Mammogram
Objetivos. Comparadas con otros grupos, las mujeres Mexico Americanas se examinan
con menor frecuencia para detectar cancer cervical y del seno. Los obstaculos mas
importantes reportados en investigaciones previas incluyen el no tener un lugar usual
para servicios de salud, falta de seguro medico y dificultades con el idioma Ingles. En este
artıculo documentamos y examinamos los factores asociados con diferencias en el uso de
examenes de cancer entre mujeres Hispanas residentes de Texas en comunidades
fronterizas y no-fronterizas por idioma de la entrevista (Espanol o Ingles). Nuestra
hipotesis es que, entre mujeres con las mismas caracterısticas socioeconomicas y
demograficas, las residentes de la frontera tienen una probabilidad mas alta de hacerse
estos examenes que las residentes de comunidades no fronterizas debido a la mayor oferta
de servicios bilingues en condados fronterizos.
Diseno. Adoptamos la estructura del Modelo de Conducta para Poblaciones Vulnerables
propuesto por Gelberg et al. (Health Services Research, vol. 34, no. 6, pp. 1273�1302,
2000). Este modelo concibe el uso de servicios de salud como el resultado de la
interaccion de predisposicion, capacidad y necesidad, y reconoce que los grupos
vulnerables enfrentan barreras adicionales para usar servicios. Los datos fueron
obtenidos de la encuesta de Monitoreo de Conductas de Riesgo en Texas de los anos
2000, 2002 y 2004.
Resultados. Las diferencias en el uso de examenes de cancer se explican principalmente
por las caracterısticas socioeconomicas de las mujeres y las barreras estructurales al
acceso a los servicios. La importancia del idioma de la entrevista y de la residencia
en un condado fronterizo desaparecen cuando se toman en cuenta factores tales
como seguro medico, nivel de ingresos, y tener un lugar usual de servicios de
salud.
Conclusion. Las mujeres que eligieron ser entrevistadas en Espanol reportaron con
menor frecuencia que las que eligieron ser entrevistadas en Ingles el uso de examenes
de cancer apropiado para su edad, tener seguro medico y tener un lugar usual de
servicios de salud. Las diferencias en el uso de servicios de deteccion de cancer en la
poblacion Hispana vulnerable se podrıan reducir promoviendo el establecimiento de un
lugar usual de servicios de salud.
Palabras Clave: Frontera Mexico�EU; Hispanos; Examenes de Cancer; Prueba de
Papanicolaou; Mamografıa
246 L. E. Fernandez & A. Morales
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Introduction
Hispanic women have lower incidence and death rates from breast cancer than non-
Hispanic white women, but they have higher incidence and mortality rates from
invasive cervical cancer (O’Brien et al . 2003). Among the goals of Healthy People
2010 are to reduce mortality due to breast cancer by 20% (from 27.9 deaths per
100,000 women to 22.3) and the death rate due to cervical cancer by one-third (from
3.0 per 100,000 women to 2.0). Although the breast cancer death rate is already lower
for Hispanic women (16.8 per 100,000), this is the leading cause of cancer death
afflicting them. In terms of cervical cancer, death rates are about 30% higher among
Hispanic women than non-Hispanics (3.3 per 100,000 and 3.0, respectively). Mexican
immigrants, in particular, have a higher prevalence of human papilloma virus, which
has been associated with risks of cervical cancer (Healthy People 2010 2000;
Armstrong et al . 2002; ACS 2005).
While regular screenings could detect cancer at early stages, Hispanic women, and
in particular Mexican Americans, remain less likely to receive regular mammograms
and Pap smears than other groups, thus resulting in diagnosis at later stages (Hedeen
& White 2001; NWHIC 2003; Bazargan et al . 2004; Gorin & Heck 2005).
In this paper we examine the role of English-language proficiency on breast and
cervical cancer screenings among women in a large survey representative of Hispanic/
Latina Texas residents. About 83% of the Hispanic population in Texas is Mexican
American, compared to 66.9% nationwide (Pew Hispanic Center 2004; ACS 2005;
Gorin & Heck 2005). Therefore, when possible we refer to findings for this
population. Often, however, the country of origin is not specified in the research
literature, and we will use interchangeably the more general terms Hispanic or Latina.
The goals of this study are twofold: first, to document the extent of disparities in
Mexican Americans’ utilization of cancer screening services by language. Second, in
order to study the persistent association between language and health care disparities,
we study the factors associated with age-appropriate breast and cervical cancer
screenings in border and non-border counties in Texas. Our rationale is that border
populations are less likely to experience language barriers, thus providing a gauge of
the extent to which language difficulties may prevent use of cancer screening services.
Previous research suggests that no health insurance, no usual source of care and
lack of English-language proficiency are associated with reduced use of breast and
cervical cancer screenings among Mexican Americans (Parchman & Byrd 2001;
Fernandez-Esquer et al . 2003; Asamoa et al . 2004). Although not specific to Mexican
Americans, two hospital-based studies found that Hispanic women and non-English
speakers had their first mammography at a later age and were less likely to adhere to
timely exams than other groups (Blanchard et al . 2004; Colbert et al . 2004). In one of
these studies, differences in age at first mammogram between Hispanic and non-
Hispanic women disappeared after controlling for language, which was one of the
strongest predictors in their analysis (Colbert et al . 2004). The authors reported that
among English-speaking Latinas, the median age at first mammogram was 40.6 years,
Ethnicity & Health 247
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but Spanish-speaking Latinas began mammographic screenings much later, at a
median age of 49 years.
In contrast, two other studies based on large samples that included Hispanic
immigrants found that health insurance, having a usual source of care and citizenship
were more important than English-language proficiency in explaining their lower
utilization of Pap smears and mammograms (Carrasquillo & Pati 2004; De Alba et al .
2004).
A review of several studies assessing the impact of language as a barrier to health
care among Latinos in the USA found mixed evidence. While five of the nine studies
concluded that limited English proficiency was detrimental to health care access,
three studies reported weak or mixed findings and one study found no impact of
language on access (see Timmins 2002). The author concludes that while language
may not be the most significant barrier, limited English proficiency is a marker for
risk for limited access to health care and lower quality of care among Hispanics. Thus,
it may be that English-speaking Latinas are better able to obtain health information
and negotiate health care services. Alternatively, it has been suggested that language
use may be a proxy for cultural orientation and health beliefs that impact on cancer
screening practices among Mexican Americans (Lobell et al . 1998; Fernandez-Esquer
et al . 2003; McGarvey et al . 2003; Gorin & Heck 2005; McMullin et al . 2005).
Residence in a USA�Mexico border county provides an opportunity to examine
the extent to which access factors (i.e. language barriers, no health insurance, cost)
rather than cultural factors, make language a significant predictor of underutilization
of cancer screening services among Mexican American women. Although the USA�Mexico border is characterized by poverty and low rates of health insurance (Texas
Department of State Health Services 2000), residents on the border are more likely to
find health care providers who speak Spanish in low-cost community health clinics,
and they also have the alternative of crossing to Mexico for lower-cost health care and
pharmaceuticals. In this respect, there are broad variations in the estimates of the
extent and type of health care services accessed in Mexico. Most reports agree that
this is a well-established practice among border residents (most likely those with
documents to cross back and forth legally) who lack health insurance or feel more
comfortable interacting with the Mexican culture than navigating the US health care
system. Few of these studies, however, have examined the quality of health care and
whether it regularly includes preventive and screening services (Macias & Morales
2001; Ruiz-Beltran & Kamau 2001; Landeck & Garza 2002; Calvillo & Lal 2003;
Homedes & Ugalde 2003; Potter et al . 2003; Ortiz et al . 2004).
Hypothesis. If disparities in health care utilization between Spanish- and English-
speaking Latinas are due to access factors (language barriers, health insurance, cost),
then we would expect Spanish-speaking border residents to be more likely to use
cancer screening services than non-border residents with similar socioeconomic
characteristics. In contrast, it may be that border residence does not influence
utilization of screening services either because (a) the reason for reduced utilization
of cancer screening has cultural components not influenced by border residence; or
248 L. E. Fernandez & A. Morales
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(b) those who could potentially seek preventive care on the Mexican side may not do
so because of perceived or actual differences in quality of care in Mexico. We will not
be able to discern between these alternatives in this paper, but we hope to do so in
future research. The next section describes the data and methods used in this study;
Section 3 presents our findings; and Section 4 presents our conclusions.
Data and Methods
The Texas Behavioral Risk Factor Surveillance System is a telephone survey conducted
on a monthly basis (n�500) among randomly selected non-institutionalized Texas
residents 18 years of age and older. Respondents choose the language of the interview,
either English or Spanish. The survey collects data on demographic and socio-
economic characteristics as well as preventive health practices and various health risk
behaviors.
Information about screening for breast and cervical cancer was collected in 2000,
2002 and 2004. The American Cancer Society’s guidelines recommend screenings
starting no later than age 21; therefore, our analysis includes only Hispanic women in
the age range 21�64.
We follow the framework proposed by the revised Behavioral Model for Vulnerable
Populations (Gelberg et al . 2000). As is the case in the original model, the revised
model conceptualizes use of health care as an outcome determined by the interplay of
predisposing (socioeconomic) characteristics, enabling and need factor (Andersen
1968, 1995). Because vulnerable populations, such as low-income Hispanic women,
face additional barriers to health care we also include group-specific relevant variables
in each domain so as to tailor the model to the particular conditions of this group
(Gelberg et al . 2000). Thus, the independent variables included in the analysis are
discussed below and incorporate traditional and vulnerable domains.
Predisposing factors. Age, education, employment, language selected by the respon-
dent for the interview, marital status and self-assessment of mental health. Language
and mental health issues may be particularly relevant to recent Mexican immigrants
who not only may have difficulty understanding English, but also may be coping with
the stress associated with unfamiliar social settings and, in some cases, separation
from their kin.
We use language of the interview as an indicator of English-language proficiency
because there is no additional information about this variable in the dataset; however,
results should be interpreted with caution since it may be possible that some
respondents selected to be interviewed in Spanish even though they are proficient in
English.
Coding for mental health status was based on the question ‘Now thinking about
your mental health, which includes stress, depression, and problems with emotions,
for how many days during the past 30 days was your mental health not good?’ Those
who reported 14 or more days were coded as having frequent mental distress. This
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period has been used by clinical researchers and clinicians as a marker for clinical
depression and anxiety disorders (Milazzo-Sayre et al . 1997; CDC 1998, 2004).
Enabling factors. Factors included under this dimension are health insurance, having
a regular health care provider, household income, whether the respondent perceived
cost to be a barrier to health care in the past year and residence in a Texas�Mexico
border county. We also include an interaction term between language of interview
and border residence since our main hypothesis is that border residents proficient in
Spanish will have greater access to preventive care than both non-border residents
and to English-interviewed border residents.
The variable for household income was missing in 14% of the cases, and these were
concentrated among women interviewed in Spanish (25.5% compared to 6.1%
among women interviewed in English). Since this may be a marker for other issues,
such as limited knowledge of, or access to, household income, we coded it as an
additional category and included it in the analysis. Approaches to other variables
with missing data are described at the end of this section.
The border indicator was coded as ‘1’ for 15 Texas counties directly on the border
with Mexico (Brewster, Cameron, El Paso, Hidalgo, Hudspeth, Jeff Davis, Kinney,
Maverick, Presidio, Starr, Terrell, Val Verde, Webb, Willacy and Zapata). All other
counties are coded as ‘0’ (non-border).
Need factors. Include self-rated health status, whether physical health was impaired
for 10 or more of the last 30 days by illness or injury, and ever having been diagnosed
as diabetic. Self-rated health was measured with a 5-point scale (excellent to poor).
Physical impairment was coded based on answers to the question ‘Now thinking
about your physical health, which includes physical illness and injury, for how many
days during the past 30 days was your physical health not good?’ As a measure of risk
factors pertinent to the sample in this analysis we included ever having been
diagnosed with diabetes, which is a chronic condition disproportionately affecting
Hispanics of Mexican origin or descent (NWHIC 2003). Those reporting gestational
diabetes were also included in this group because it has been reported that, regardless
of race or ethnicity, about half of the women who develop gestational diabetes have
the disease within 20 years (Kieffer 2000; NWHIC 2004).
The outcomes used to measure access to preventive health care are binary and refer
to whether women reported age-appropriate utilization of three specific cancer
screening exams as recommended by the American Cancer Society (ACS 2004):
a. Pap smear (coded as 1 if respondent age 21�29 had one within the past year or
respondent age 30�64 had one within the last three years; coded 0 otherwise).
b. Clinical breast examination (coded as 1 if respondent age 21�39 had one within
the last three years or if respondent age 40�64 had one within the past year; 0
otherwise).
c. Mammogram among women age 40�64 (coded as 1 if respondent had one in the
last two years; 0 otherwise).
250 L. E. Fernandez & A. Morales
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Two challenges to the analysis arise from missing data and to information not
collected by the survey. Specifically, we identified three variables in the analysis (in
addition to household income mentioned above) for which over 4% of the cases were
missing: self-assessed mental health had 106 cases with missing information (4.3%);
self-assessed physical health had 120 cases (4.9%); and having a regular health care
provider had 352 cases with missing information (14.4%). To assess the impact of
these cases on our results, we did the analysis using three approaches: excluding cases
with missing data, including all cases by coding them as an additional category for
each of the three variables identified, and imputing values using the Stata function,
which predicts the missing value by a regression that includes demographic,
socioeconomic and health characteristics available in the model. Our results were
robust to the different specifications, and we present those obtained using imputed
values. The alternative analyses are available from the main author upon request.
Variables that were not available, but would be relevant to this study include
information about the degree of English-language proficiency, bilingualism, place of
birth or time residing in the USA, beliefs about preventive care and availability of
social networks. In addition, the location of the health care provider was not
available, and the information about usual place of care was not asked every year. We
can only speculate that some of the border residents access health care on the
Mexican side of the border as other researchers have reported (Landeck & Garza
2002; Ortiz et al . 2004).
Hispanic ethnicity was identified by responses to ‘Are you of Spanish or Hispanic
origin?’ In total, there were 2,445 Hispanic women ages 21�64, of which 2,399 are
included in the analysis after imputations to the predictors; no imputations were
done for the dependent variables.
The analysis is divided into two parts, both carried out using the survey feature in
Stata (v. 8) to take into account the complex multistage cluster sampling design of the
survey and compute correct standard errors (Coughlin et al . 2003). In the first part
we present weighted descriptive statistics showing predisposing, enabling and need
characteristics by language of the interview. In the second part we use logistic
regression to examine the association between individual characteristics and
adherence to cancer screening recommendations in each of the binary outcomes of
interest. Coefficients are expressed as odds ratios in Table 3 and confidence intervals
are reported in parentheses. In order to address issues of multicollinearity, we
computed Pearson correlation coefficients between all pairs of variables. We did not
find collinearity issues among the independent variables included in the models.
Findings
Although the main analysis includes only Hispanic women in the age range 21�64, in
Table 1, for the purpose of comparison with national statistics, we show rates of
screening for all Hispanic women in the sample, ages 18 and older (ACS 2005).
Disparities in rates of Pap smears between Hispanics in Texas, mostly Mexican
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Americans, and Hispanics nationwide are relatively small (79.7% vs 83.4%,
respectively); however, there are large differences for mammograms and clinical
breast examinations. Only 48% of Texas Latinas ages 40 and older reported having a
clinical breast exam in the past year compared to 65% nationwide. Similarly, only
47% of Texas Latinas, compared to 65% nationwide, had a mammogram in the past
year.
Note that the women who selected to be interviewed in Spanish and those who
are border residents are at a particular disadvantage. Both interviewing in Spanish
and border residency seem to be associated with lower utilization of screening
services. This is not consistent with our hypothesis that Spanish-speaking Latinas
may have greater access to cancer screenings if they live in a border county than
Table 1 Cancer Screening Utilization by Language Selected by Respondent: Texas BRFSS
2000�2004 and National BRFSS 2000
Texas Hispanic/interviewed in
English
Texas Hispanic/interviewed in
Spanish
All TexasHispanic
women insample
US Hispanica
Cervical cancer screening:Percent of women reportingPap smear within the pastthree years (ages 18� withno hysterectomy)**
81.4(n�1,230)
77.9(n�972)
79.7(n�2,286)
83.4
Resident of border county 77.4(n�317)
77.5(n�351)
77.5(n�691)
�
Resident of non-bordercounty**
83.0(n�906)
78.4(n�598)
80.9(n�1,565)
�
Breast cancer screening:Percent of women reportingclinical breast exam withinthe past year (ages 40�)**
56.4(n�701)
39.4(n�512)
48.2(n�1,266)
65.1
Resident of border county** 55.8(n�205)
35.4(n�247)
44.4(n�465)
�
Resident of non-bordercounty**
56.4(n�492)
43.4(n�249)
50.6(n�781)
�
Percent of women reporting amammogram within the pastyear (ages 40�)**
52.4(n�707)
40.8(n�516)
46.5(n�1,276)
65.4
Resident of border county** 48.9(n�207)
36.4(n�247)
41.9(n�467)
�
Resident of non-bordercounty**
53.2(n�496)
45.0(n�253)
49.1(n�789)
�
Note : Comparisons based on weighted data; unweighted sample size shown in parentheses in each cell.aNational data come from CDC’s Behavioral Risk Factor Surveillance System public use data files for year 2000.
Source : ACS (2005).
**p B0.05 for Pearson’s Chi-square test of homogeneity between groups.
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non-border residents. However, these figures are not adjusted for educational or
age differences.
Further evidence of large demographic and socioeconomic disparities between
Hispanic women interviewed in English and Spanish is shown in Table 2. Women
who chose to be interviewed in Spanish were younger, less likely to have completed
high school or be employed, and more likely to be a homemaker than Hispanic
women interviewed in English. Surprisingly, there were no significant differences in
terms of the proportion reporting frequent mental distress, but this could also be
associated with differences in age distribution.
Disparities associated with enabling factors were also striking. Only 27% of the
women who selected to be interviewed in Spanish had health insurance, a similar
proportion said that cost prevented them from accessing health care in the past 12
months, 40% reported having a regular health care provider and only 6% reported
annual household incomes of $35,000 or higher. In comparison, Hispanic women
who chose to be interviewed in English were 2.6 times more likely to have health
insurance (70.7%) and twice as likely to have a person they think of as their health
care provider (83.4%). Although annual household income was significantly higher
for these women, the proportion who reported that cost was a barrier to health care
was similar to that reported by women interviewed in Spanish (24.2 and 28.1%,
respectively). Because of the large proportion of cases with missing income
information among women interviewed in Spanish, we coded these as a separate
income category in the analysis.
In terms of health, the women who selected to be interviewed in Spanish were
more likely to rate their health as fair and less likely to rate it as good or better than
those interviewed in English. A similar proportion in each group, however, rated their
health as poor (4.5% of respondents in English and 5.3% of respondents in Spanish).
In general self-reported health measures are considered reliable predictors of health
status and mortality risks (Idler & Benyamini 1997). Among Hispanics, however,
studies suggest that recent (less acculturated) immigrants tend to be healthier but
more likely to rate their health as fair or poor than their more acculturated and US-
born counterparts (Hummer et al . 2000; Finch et al . 2002). This is consistent with
the fact that women interviewed in English were more likely to report 10 or more
days in which their physical health was not good (15.4%) compared to those
interviewed in Spanish (10.8%), and with similar rates of respondents in each group
ever diagnosed with diabetes (9.3 and 10.8%, respectively).
In sum, the Latinas interviewed in Spanish were less likely to have utilized cancer
screening services, particularly mammograms and clinical breast examinations. They
were also younger, less likely to be in the labor force, and at educational and
economic disadvantage than those interviewed in English. In terms of health status,
although Spanish interviewees did rate their general health lower, there were no
significant differences in rates of mental health or ever having been diagnosed with
diabetes, and physical health impairment was more frequent among English
interviewees. Next, we turn to the study of whether and to what extent use of
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Table 2 Predisposing, Enabling and Need Factors, Texas Latinas Ages 21�64 in BRFSS
2000, 2002 and 2004
VARIABLES Hispanic/in English(n�1,379)
Hispanic/in Spanish(n�1,020)
PREDISPOSING CHARACTERISTICS: Traditional/vulnerable (%)Age group:**
21�29 30.1 27.530�39 27.2 33.540�49 22.3 26.650�64 20.4 12.3
Schooling:**Less than high school 20.3 70.3High school graduate/GED or some college 60.8 22.8Bachelor’s degree or higher 18.9 6.8
Employment status:**Employed 61.0 40.8Homemaker 16.4 45.9Student 4.0 2.1Unemployed 9.6 7.8Retired or unable to work 8.9 3.5
Married or cohabiting** 67.4 76.9Reported 14� days of impaired mental health in last 30 days 11.3 9.9
ENABLING FACTORS: Traditional/vulnerable (%)Currently has health insurancea** 70.7 27.1Has a usual health care provider or personal doctorb** 83.4 40.0Cost prevented access to health care in last 12 months 24.2 28.1
Household income per year:**No answer/don’t know 6.1 25.5B$15,000 15.3 29.2$25,000 to less than $35,000 23.4 29.2$25,000 to less than $35,000 16.3 10.2$35,000 or more 38.9 5.9
Resident of a border county** 23.2 29.8
NEED FACTORS: Traditional/vulnerable (%)Self-rated general health as:**
Excellent, very good or good 79.7 56.7Fair 15.8 38.0Poor 4.5 5.3
Reported 10� days of impaired physical health in last 30 daysc** 15.4 10.8Ever diagnosed with diabetes (includes gestational diabetes) 9.3 10.8
Note : Comparisons based on weighted data; unweighted number of cases is shown in parentheses in heading.a‘Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or
government plans such as Medicare?’b‘Do you have one person you think of as your personal doctor or health care provider?’
**p B0.05 for Pearson’s Chi-square test of homogeneity between groups.
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cancer screening services are explained by predisposing, enabling and/or need factors,
and the role played by language and county of residence.
Factors Associated with Utilization of Cancer Screening Services
Table 3 shows the exponentiated coefficients (odds ratios) resulting from the logistic
regressions that examine the factors associated with having age-appropriate Pap
smears, clinical breast exams and mammograms in adherence with the guidelines by
the American Cancer Society (ACS). The main findings are:
(a) Predisposing factors. Demographic differences, in particular age and marital/
cohabitation status contribute significantly toward explaining the variation in use of
cancer screening services among Hispanic women. In fact, after controlling for these
factors, education remains a significant explanatory variable only for clinical breast
exams. Note, however, language of the interview remains associated with a lower
likelihood of having each screening exam even after controlling for age and
educational differences.
(b) Enabling factors. Once enabling factors are taken into account, language and
border residence do not contribute toward explaining the variation in use of
screening services among Texas Mexican Americans. In fact, enabling factors explain
a significant proportion of the variation in use of each of the cancer screening services
examined. In particular, health insurance and having a regular health care provider
have the larger impact. Having a regular health care provider doubles the odds of
accessing each of the screening services. Health insurance also plays a significant role
in the odds of having timely mammograms, and to a lesser extent in clinical breast
exams, but not in Pap smears.
As expected, low income is associated with a lower likelihood of having timely
cancer screenings; and the group of women who did not report household income
were significantly less likely to have screening exams than those in households
reporting annual incomes of $35,000 or higher. In addition, women who said that
cost prevented them from accessing health care in the past year were significantly less
likely to have timely Pap smears and clinical breast exams.
(c) Need factors. Need factors made only a modest contribution to the models after
taking into account predisposing and enabling factors. Latinas who assessed their
health as fair or poor were significantly less likely to report timely mammograms, but
not other exams. Other variables in this dimension, such as ever having been
diagnosed with diabetes, were not significant.
In sum, our findings strongly suggest that disparities in cancer screening utilization
are largely explained by access factors. Increased age-appropriate cancer screenings
could be achieved among Latinas who selected to be interviewed in Spanish if they
had a regular health care provider or health insurance. Our findings are consistent
with two recent reports indicating that among Hispanics, individuals from Mexican
origin or descent are least likely to have health insurance and a usual source of care,
Ethnicity & Health 255
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Table 3 Logistic Regression of Factors Associated with Adherence to Cancer Screening Guidelinesa among Texas Latinas, TXBRFSS 2000�2004*Coefficients Presented as Odds Ratios, Confidence Intervals in Parentheses
Pap smearsb Expb (Robust Std. Err.) Clinical breast exam Expb (Robust Std. Err.) Mammogram within the past two yearsc Expb
(Robust Std. Err.)
(a)
Predisposing
charact.
(b)
�Enabling
factors
(c)
�Perceived
need
(d)
Predisposing
charact.
(e)
�Enabling
factors
(f)
�Perceived
need
(g)
Predisposing
charact.
(h)
�Enabling
factors
(i)
�Perceived
need
Sociodemographic (predisposing) characteristics:
Age group:
21�29 0.397**
(0.293, 0.538)
0.422**
(0.307, 0.579)
0.416**
(0.300, 0.575)
2.119**
(1.639, 2.740)
2.524**
(1.901, 3.352)
2.452**
(1.822, 3.300)
30�39 1.463**
(1.037, 2.062)
1.535**
(1.077, 2.188)
1.528**
(1.064, 2.193)
2.941**
(2.284, 3.787)
3.276**
(2.527, 4.248)
3.215**
(2.469, 4.186)
40�49 1.000 1.000 1.000 1.000 1.000 1.000 0.412**
(0.297, 0.572)
0.457**
(0.324, 0.643)
0.455**
(0.321, 0.646)
50�64 1.000 1.000 1.000
Education:
High school 0.811
(0.590, 1.114)
0.920
(0.663, 1.277)
0.920
(0.663, 1.276)
0.784*
(0.610, 1.008)
0.904
(0.695, 1.175)
0.899
(0.691, 1.170)
0.728
(0.480, 1.104)
0.950
(0.604, 1.495)
0.944
(0.598, 1.490)
High school graduate/GED/some
college
1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Bachelor’s degree or higher 1.074
(0.696, 1.656)
0.867
(0.568, 1.323)
0.867
(0.570, 1.318)
1.326*
(0.949, 1.851)
1.133
(0.805, 1.595)
1.115
(0.792, 1.570)
1.127
(0.694, 1.829)
0.992
(0.606, 1.624)
0.964
(0.585, 1.589)
Currently employed 0.936
(0.712, 1.230)
0.818
(0.612, 1.092)
0.804
(0.606, 1.066)
0.933
(0.749, 1.162)
0.823
(0.656, 1.034)
0.817
(0.650, 1.026)
0.981
(0.705, 1.366)
0.878
(0.616, 1.250)
0.846
(0.591, 1.213)
Interviewed in Spanish 0.732**
(0.537, 0.998)
1.109
(0.749, 1.642)
1.093
(0.733, 1.628)
0.489**
(0.383, 0.624)
0.813
(0.587, 1.126)
0.829
(0.594, 1.156)
0.660**
(0.442, 0.986)
0.942
(0.561, 1.582)
1.042
(0.610, 1.780)
Married or cohabiting 1.675**
(1.269, 2.212)
1.434*
(1.059, 1.942)
1.429**
(1.058, 1.931)
1.485**
(1.174, 1.879)
1.284**
(0.997, 1.654)
1.297**
(1.010, 1.666)
1.120
(0.788, 1.591)
0.968
(0.664, 1.413)
0.959
(0.659, 1.395)
14� days impaired mental health in
last 30 days
0.878
(0.579, 1.333)
0.961
(0.610, 1.515)
0.978
(0.611, 1.565)
1.146
(0.804, 1.634)
1.204
(0.848, 1.711)
1.291
(0.892, 1.869)
0.724
(0.436, 1.202)
0.684
(0.404, 1.159)
0.687
(0.400, 1.178)
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Table 3 (Continued )
Pap smearsb Expb (Robust Std. Err.) Clinical breast exam Expb (Robust Std. Err.) Mammogram within the past two yearsc Expb
(Robust Std. Err.)
(a)
Predisposing
charact.
(b)
�Enabling
factors
(c)
�Perceived
need
(d)
Predisposing
charact.
(e)
�Enabling
factors
(f)
�Perceived
need
(g)
Predisposing
charact.
(h)
�Enabling
factors
(i)
�Perceived
need
Enabling factors:
Has health insurance 1.250
(0.888, 1.759)
1.249
(0.887, 1.758)
1.325**
(1.011, 1.737)
1.340**
(1.023, 1.755)
1.876**
(1.241, 2.834)
1.898**
(1.256, 2.870)
Has usual source of care 1.903**
(1.398, 2.591)
1.941**
(1.421, 2.652)
2.005**
(1.526, 2.633)
2.014**
(1.528, 2.653)
2.140**
(1.431, 3.199)
2.122**
(1.407, 3.200)
Household income
Don’t know/no response 0.500**
(0.295, 0.848)
0.500**
(0.295, 0.847)
0.558**
(0.372, 0.839)
0.575**
(0.383, 0.864)
0.841
(0.457, 1.548)
0.909
(0.494, 1.671)
Under $15,000 0.524**
(0.318, 0.863)
0.525**
(0.318, 0.866)
0.645**
(0.439, 0.947)
0.673**
(0.458, 0.990)
0.749
(0.426, 1.319)
0.801
(0.448, 1.433)
$15,000 to less than $25,000 0.638*
(0.401, 1.017)
0.649*
(0.408, 1.033)
0.841
(0.588, 1.203)
0.849
(0.594, 1.215)
1.100
(0.636, 1.904)
1.123
(0.652, 1.934)
$25,000 to less than $35,000 0.544**
(0.327, 0.905)
0.548**
(0.330, 0.911)
0.660**
(0.441, 0.987)
0.666**
(0.447, 0.992)
0.963
(0.535, 1.733)
0.984
(0.549, 1.762)
$35,000 or more 1.000 1.000 1.000 1.000 1.000 1.000
(Enabling factors, continued)
Cost prevented access to health care
in last 12 months
0.590**
(0.436, 0.798)
0.587**
(0.433, 0.796)
0.683**
(0.528, 0.885)
0.703**
(0.541, 0.913)
0.789
(0.526, 1.183)
0.803
(0.533, 1.212)
Resident of a border county 0.845
(0.551, 1.297)
0.844
(0.550, 1.295)
1.086
(0.772, 1.527)
1.091
(0.775, 1.536)
1.035
(0.655, 1.637)
1.005
(0.634, 1.592)
Interaction term: Spanish�border
resident
1.322
(0.736, 2.375)
1.309
(0.727, 2.355)
0.856
(0.532, 1.379)
0.846
(0.524, 1.366)
1.347
(0.663, 2.735)
1.440
(0.710, 2.920)
Need factor:
Self-assessed health as fair or poor 1.100
(0.798, 1.517)
0.862
(0.663, 1.122)
0.591**
(0.399, 0.876)
Eth
nicity
&H
ealth
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Table 3 (Continued )
Pap smearsb Expb (Robust Std. Err.) Clinical breast exam Expb (Robust Std. Err.) Mammogram within the past two yearsc Expb
(Robust Std. Err.)
(a)
Predisposing
charact.
(b)
�Enabling
factors
(c)
�Perceived
need
(d)
Predisposing
charact.
(e)
�Enabling
factors
(f)
�Perceived
need
(g)
Predisposing
charact.
(h)
�Enabling
factors
(i)
�Perceived
need
10� days of impaired physical
health in last 30 days
0.854
(0.545, 1.339)
0.847
(0.593, 1.211)
1.423
(0.905, 2.238)
Ever diagnosed with diabetes
(including during pregnancy)
0.819
(0.509, 1.317)
1.303
(0.856, 1.981)
1.382
(0.841, 2.272)
Log pseudo-likelihood �1,031.890 �988.149 �987.151 �1,481.724 �1,425.603 �1,422.397 �647.314 �616.320 �610.413
Nagelkerke R2 0.0922 0.1513 0.1524 0.0950 0.1421 0.1447 0.0730 0.1325 0.1435
% of correctly predictedd 78.1 78.3 78.3 66.4 69.4 68.4 63.9 67.0 65.8
Unweighted sample size n�2,023 n�2,399 n�1,018
aThe American Cancer Society recommends screening for cervical cancer annually starting no later than age 21. Starting at age 30, women who have had three consecutive
normal Pap smears may be screened every three years. Clinical breast exams (CBE) are recommended every three years for women 21�39 and every year for women 40 and
older. Mammograms are recommended annually starting at age 40 (ACS 2004).bOnly women who have not had a hysterectomy are included in this part of the analysis.cOnly women aged 40�64 are included in this part of the analysis.dThe cut value is 0.500.
**p 50.05; *p B0.10.
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and most likely to experience unmet medical need because of cost (Freeman &
Lethbridge-Cejku 2006; Roberts 2006).
Based on findings from earlier research, we expected to find that women in border
counties and interviewed in Spanish would be more likely to access screening services
than their non-border counterparts because of the bilingual environment and,
perhaps, lower cost of services across the border. We did not find evidence of this.
However, much work remains to understand the barriers that prevent Spanish-
speaking Mexican Americans from establishing a regular health care provider, as well
as the type of services that are in fact accessed on the Mexican side of the border, and
the health outcomes associated with such services.
Conclusions
We found no significant differences in utilization of cancer screening services by
language of the interview or border residence among women with similar health
insurance status, income and usual source of care. That is, we find that the reason
border residents and those interviewed in Spanish are less likely to have timely cancer
screenings is that they are more likely to lack a usual source of care and health
insurance than non-border residents and those interviewed in English. Having a
usual source of care, in particular, doubles the odds of utilization of cancer screening
services.
A discouraging finding is that younger Hispanic women in Texas are less likely to
adhere to the recommended guidelines for Pap smears than older cohorts. Similarly,
women in the age group 40�49 are less likely to have mammograms than their older
counterparts. These findings suggest the need for targeted interventions that promote
the establishment of a usual health care provider to reduce language, regional
(border/non-border) and age disparities in Pap smears, mammograms and clinical
breast exams among Hispanic women.
Two limitations to this study bear repeating since both may bias upward the
outcomes of interest in this study. First, the data were collected through phone
surveys. Women with no access to phone services may have increased difficulties in
accessing health care compared to those who were included in the study; in
particular, recent immigrants may be more likely to lack a constant phone service
compared to more established populations. Second, other studies have found that
immigrants tend to overreport use of screening services compared to US-born
populations, so that the extent of disparities would be further obscured (McPhee
et al . 2002).
This study suggests new and important avenues for future research. Our work
affirms the importance of structural factors, but we know that access variables, such
as having a regular source of care, may be influenced by both socioeconomic and
cultural perceptions of health care needs. In this regard there is a growing body of
research suggesting that a non-trivial proportion of low-income border residents
cross the border to receive physician services. Future research needs to identify the
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types of services that are accessed on the Mexican side of the border by low-income
US residents, as well as the extent to which providers of these services are perceived as
regular sources of care by their patients.
Since prevention draws from health care socialization and relationships with
medical professionals we also need further research on how respondents define a
‘regular health care provider’ or ‘a usual source of care’. This variable may be well
specified for some populations, but new immigrants may think of these terms
differently than assimilated immigrants or the general population.
Furthermore, health care resocialization should become a subject of further
research. Resocialization research would investigate immigrants’ health-related
system of ideas and behavior and understand how these relate to health care
practices in the USA. From research of this type we could identify attitudes and
behaviors that hinder utilization of preventive health care and learn how different
immigrant populations organize their relationship to health care providers. Under-
standing health care resocialization processes could be important to designing
effective health care interventions among new immigrants.
Acknowledgements
This research was completed with the support of the University of Texas at Austin
Population Research Center, where the first author was appointed as an NICHD
Postdoctoral Fellow. The authors thank Theresa Byrd, Josiah Heyman, Afredo
Cuevas, Michel Guillot and members of the University of Wisconsin FEMSEM for
their helpful comments on an earlier version, and Thy Minh Vo for her research
assistance.
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