Use of Cancer Screening Practices by Hispanic Women: Analyses by Subgroup

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<ul><li><p>Preventive Medicine 29, 466477 (1999)Article ID pmed.1999.0566, available online at on</p><p>Use of Cancer Screening Practices by Hispanic Women:Analyses by Subgroup</p><p>Ruth E. Zambrana, Ph.D.,*,1 Nancy Breen, Ph.D., Sarah A. Fox, Ed.D., andMary Lou Gutierrez-Mohamed, Ph.D.</p><p>030; Applied Research Program, Division of Cancer Controlal Institutes of Health, Bethesda, Maryland 20892;</p><p>Rand Corporation, Santa Monica, California 90407-2138;r</p><p>O Hcer dcli nam oine nior ttor</p><p>MsiotheonstuAman E</p><p>Rcatscr Hispanic2 women are to increase to 60% thosebe mres ea u etai otheyea minaingbre</p><p>nhabreanha</p><p>Cpriren</p><p>1</p><p>dreParPar*Social Work Program, George Mason University, Fairfax, Virginia 22and Population Sciences, National Cancer Institute, Nation</p><p>Department of Medicine, University of California, Los Angeles, andand Jackson Heart Study, Jackson State Unive</p><p>Oubjectives. This study compares the use of three can- ofscreening practices (Pap smear, mammogram, and un</p><p>nical breast examination) 3 years prior to interview seong five subgroups of Hispanic women, and exam- prs whether sociodemographic; access; health behav- ve, perception, and knowledge; and acculturation fac- das predict screening practices for any subgroup. andethods. Descriptive and multiple logistic regres- K</p><p>n analyses were conducted with data pooled from ina1990 and 1992 National Health Interview Surveys</p><p>women who reported that they were Hispanic. Thedy sample includes 2,391 respondents: 668 Mexican-erican, 537 Mexican, 332 Puerto Rican, 143 Cuban,</p><p>d 711 other Hispanic women.esults. Subgroup profiles reveal differences in edu- tenion, health insurance, use of English language, and ingeening use. Mexican women were the least likely to forscreened with any procedure. Logistic regression woults for each screening practice show that having brsual source of care was a positive predictor for ob- thning each of the three screening practices within pr</p><p>last 3 years. Being married, being more than 50 recrs of age, and having knowledge of breast self-exam- wotion were all predictors of having a Pap smear. Hav-</p><p>comhealth insurance and ever having had a clinicalByast examination and Pap smear were predictors ofpaving a mammography, while age, knowledge ofa mast self-examination, ever having had a Pap smearscred mammogram, and being a nonsmoker all predictedwomving a clinical breast examination.theonclusions. We conclude that access factors and</p><p>or screening are more strongly associated with cur-t screening than are language and ethnic factors. 2 </p><p>of HTo whom correspondence and requests for reprints should be ad- Sou</p><p>andssed to the current address at University of Maryland Collegek, Department of Women's Studies, 2101 Woods Hall, College self-</p><p>usedk, Maryland 20742. E-mail:</p><p>466en aged 50 and older who have received a clinicalast examination (CBE) and a mammogram withinpast 12 years, and to increase to at least 95% theportion of women aged 18 and older who have evereived a Pap smear [3]. In 1987, 13% of Hispanic</p><p>en reported having a mammogram in the past yearpared with 18% of non-Hispanic white women [4].1992, rates for every group had doubled and His-ic women were as likely as other groups to have hadammogram in the previous year. Despite increasedsity, Jackson, Mississippi 39216-4506</p><p>r data confirm that a disproportionate percentageispanic women are low income and at risk of beingerscreened. Our findings from a nationally repre-tative sample of Hispanics have implications forvider practices, ethnic-specific community inter-tions, and future development of measures anda collection approaches. q 1999 American Health FoundationAcademic Press</p><p>ey Words: cancer screening; women's health; Lat-; ethnicity.</p><p>INTRODUCTION</p><p>arly detection of breast and cervical cancer is consis-t with national objectives to promote cancer screen-behaviors [1,2]. The Healthy People 2000 Objectivesening among all women, low-income women,en over 65, and Hispanic women still remain at</p><p>greatest risk of not being screened [5].</p><p>Hispanic women and Latino women are used to refer to womenispanic origin from Mexico, Puerto Rico, Cuba, and Central andth America. The designation Hispanic is a federal designation,is used in national and state reporting systems. Latino is adesignated term by members of different groups. Hispanic isin this paper without preference or prejudice.</p><p>0091-7435/99 $30.00Copyright q 1999 by American Health Foundation and Academic Press</p><p>All rights of reproduction in any form reserved.</p></li><li><p>CANCER SCREENING USE BY HISPANIC WOMEN 467</p><p>Hispanics, who constitute nearly 11% of the U.S. pop- rates decline with increasing age. Higher levels of edu-cation are associated with more mammography screen-ulation, represent regional and socioeconomically dis-ing [23,24]. These patterns are similar for Hispanictinct subgroups3 [610]. In 1990, the Hispanic popula-women. Hispanic women who are older than 65 yearstion consisted of Mexican-origin (63%), Puerto Ricanof age, less educated, or poor are less likely to use mam-(11%), Cuban (5%), Central and South American (14%),mography [25]. Stein et al. found that for Hispanicand Other Hispanic (8%).4 Hispanics are geographicallywomen, financial indicators, primarily lack of insur-concentrated in five states: California (34%), Texasance, reduced use of mammography more than cultural(19%), Florida (7%), New York (10%), and Illinois (4%)differences [26]. A recent study on access to health care[8]. Hispanic women currently represent more than 9%found that health insurance coverage was higher forof the total female U.S. population, and are expectedEngto increase to more than 15% by the year 2020 [6].porHispanic women are younger, have lower median an-</p><p>gnuuorigpamfamaofeCulilienofeexaAby</p><p>Hnnit]origmeenomaInmwosdu].sigHHdwit</p><p>cerhtalnHieciarea PtTh</p><p>risman</p><p>FS thig arie dan h[18 a</p><p>ise3</p><p>whonat</p><p>T4</p><p>are stof C</p><p>iden spspanhial earnings, and are more likely to be unemployedyoemployed in low-wage, service-sector jobs than His-ornic men or non-Hispanic women [8,11]. Data on 1993woily income by Hispanic subgroup reveal that 37%hePuerto Ricans, 30% of Mexican-Americans, 18% ofagbans, and approximately 23% of Other Hispanic fam-ons were below the poverty level compared with 7.6%banon-Hispanic white families [12]. The rationale forMmining Hispanics by subgroups is strongly argued</p><p>several authors [710]. For example, Massey states,lowispanics do not comprise a single coherent commu-cay. Rather, they are a disparate collection of national30gin groups with heterogeneous experiences of settle-ednt, immigration, political participation, and eco-mic incorporation into the United States [9], p. 454.yethis paper, we compare five subgroups of Hispanicofmen on their use of three cancer screening proce-Hires (Pap smear, mammogram, and CBE) and test for[1nificant predictors of screening practices.(Nispanic women tend to be younger when diagnosedhah breast or cervical cancer, present with these can-vids at later stages of diagnosis, and have higher mor-toity rates than non-Hispanic white women [1316].ciaspanic women are less likely to have visited a physi-dun in the last year, to have had a mammogram andscap smear, and to know cancer warning signs [17].dee underlying factors that place Hispanic women atbyk are low-income status, lack of access to health care,wod institutional barriers [1830].</p><p>creening is positively associated with younger age, caher income, greater educational level, being mar- hed, health insurance, having a usual source of care, ited knowledge and use of prior cancer screening tests lic25]. Among U.S. women, Pap smear screening gu</p><p>itof</p><p>Subgroup is used throughout the paper to refer to individualsself-report Hispanic ethnicity and identify with a particular</p><p>ional origin such as Mexican-American or Puerto Rican.5The Census Bureau definition of persons of Other Hispanic origin</p><p>those whose origins are Spain, the Spanish-speaking countries mutoentral and South America, or the Dominican Republic, or persons</p><p>tifying themselves generally as Spanish, Spanish-American, His- Hilesic, Hispano, or Latino.lish-speaking women of Mexican origin who re-ted a family income above the poverty level, hadher levels of education, were employed, and werenger, as compared with Spanish-speaking Mexican-in women [27]. Puerto Rican and Mexican-originen, aged 50 to 64, had the lowest percentage of</p><p>lth insurance coverage. While 95.8% of all womend 65 and older report having Medicare coverage,y 88.1% of Mexican-American women, 86.5% of Cu-</p><p>women, and 77.4% of Puerto Rican women havedicare coverage5 [23].lthough the preponderance of evidence shows thatsocioeconomic status is an important predictor of</p><p>cer screening practices among Hispanic women [22, screening is most strongly associated with knowl-e of screening, prior screening, and physician recom-ndation for a screening [3140]. Hispanic women 40rs of age and older are less likely to have knowledge</p><p>ammography (31.6%) or CBE (13.4%) than non-panic white women (12.2 and 7.9%, respectively)Analyses of 1992 National Health Interview SurveyIS) data found that women 50 years and older whoreceived other preventive services from their pro-</p><p>ers, such as CBE and mammogram, were more likelyave had a Pap smear in the last 3 years [41]. Physi-s not recommending a Pap smear or mammogramto cost of tests, women's lack of knowledge aboutening tests, or lack of health insurance are strong</p><p>erminants of cancer screening underutilizationelderly women, low-income women, and Hispanic</p><p>en [3640].or Hispanic women, acculturation, income, and edu-ion are three interrelated factors associated withlth behaviors [10,17,4247]. Although there is lim-consensus on how to measure acculturation in pub-ealth, agreement exists on two points: English lan-ge use is a principal marker of acculturation, andassociated with country of birth, completed years</p><p>ducation, and number of years in the United States</p><p>o receive Medicare and social security entitlement, individualst work a total of 5 years in a job where contributions are madehe government. The lower rates of Medicare coverage amonganic women are a reflection of immigration at later ages andlikelihood of participation in the above-ground economy.</p></li><li><p>468 ZAMBRANA ET AL.</p><p>METHOD[47]. Less acculturated Hispanics are often character-ized by limited education, low literacy levels, and useof Spanish language, compared with their more accul- Data from the 1990 and 1992 NHISs were pooledturated counterparts. These attributes are, in turn,lin bels dvid uan oan eha</p><p>Bpra 9fou Tmo aEnwo nnot epriscr pprileaHi cdu eansub s</p><p>Tgroityind Denc ahigwoistredtoscr tgu rUn Ieco csta rind ncon ,couHi $</p><p>W olatun ccanan rna gdemabl sbellatsubtoked to decreased access to health services, lower lev- suof health knowledge, less communication with pro- aners [28,4750], and less likelihood to use preventive cad primary care services, to have annual Pap smears, pod, for those over 50 years of age, to report ever having thd a mammogram [5154]. weased on factors associated with cancer screening sisctices for Hispanic women reported in the literature, 19r questions were posed: (a) Are Hispanic women withre education, a usual source of care, and who speak ofglish more likely to be screened than less educated insmen, without a usual a source of care and who are tio</p><p>English speaking? (b) Are Hispanic women with thor screening more likely to have had more recent meeening procedures than Hispanic women without Suor screening? (c) Are Mexican women, who have the incst education and lowest income, least likely of all 18spanic groups to have had recent screening proce- acres? (d) Are Cuban women, who have more education prd higher income, most likely to be screened of all (53groups? Hio analyze cancer screening practices among sub-ups of Hispanic women, we employ a social inequal-</p><p>Memodel. This paradigm proposes that low-incomeividuals are more exposed to risk factors and experi-e more barriers in the health care system than prher-income individuals [55,56]. For Hispanic 18men, the model posits that socioeconomic character- ingics, including income, education, and literacy levels, weuce both knowledge of health practices and access Wehealth care services which, in turn, make cancer screening less likely. Acculturation, measured by lan- toage use, place of birth, and length of time in the vaited States, mediates the relationship between socio-nomic status and screening practices. In contrast to sondard models of health care utilization that focus on peividual behaviors exclusive of socioenvironmental tiostraints, the social inequality model takes into ac- 49nt how social, cultural, and economic context shape com</p><p>spanic women's use of cancer screening [57]. (,e pooled 2 years of nationally representative popu- vs</p><p>ion samples from the NHIS. This afforded us a vsique opportunity to examine the use of preventive ancer screening practices for total Hispanic women aid</p><p>d by subgroup. In this paper, we present the first cational estimates of cancer screening rates and socio- ed</p><p>ographic, access, and other health behavior vari- staes for total Hispanic women and by subgroup. We Reieve that these new estimates will be useful in formu- 5 (ing more effective targeted objectives for Hispanic int</p><p>1 5groups for the Year 2010 Healthy People Objectives.increase the statistical power to analyze the fivegroups. These data included comparable questionsshowed similar screening rates for all women. Be-</p><p>se the 1990 sample constituted 70% of the totalled sample and the 1992 sample constituted 30% oftotal pooled sample (1,667 in 1990 and 724 in 1992),adjusted the sample weights in the combined analy-by multiplying them by the factors 0.7 and 0.3 in0 and 1992, respectively.he NHIS is a continuing annual nationwide surveypproximately 49,000 households of the civilian non-titutionalized population of the United States. Ques-s on cancer screening practices were included inHealth Promotion and Disease Prevention Supple-</p><p>nt of the 1990 survey and in the Cancer Controlplement of the 1992 survey. The study sample</p><p>ludes 2,391 adult female Hispanic respondents,years of age and older. Hispanics were groupedording to self-reported ethnic identification intocoded categories: Mexican-American (668), Mexican7), Puerto Rican (332), Cuban (143), and Otherpanic (711).</p><p>asures and Analyses</p><p>ependent variables include three cancer screeningctices: Pap smear, mammogram, and CBE. Womenyears of age and older were asked questions regard-Pap smears and women 35 years of age and older</p><p>re asked questions regarding mammogram and CBE.constructed dichotomous dependent variables for</p><p>eening: a woman was either screened 3 years priorhe interview or she was not. This yielded comparableiables for the three screening practices.ndependent variables are grouped into measures ofioeconomic status; access to health services; healthceptions, behavior, and knowledge; and accultura-. Socioeconomic variables include age (1834,35and 501), education...</p></li></ul>


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