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ONCOLOGY

Understanding barriers to cervical cancer

screening among Hispanic women
Luisa Watts, BA; Naima Joseph, MS; Amanda Velazquez, BA; Marisa Gonzalez, MD; Elizabeth Munro, MD;
Alona Muzikansky, MA; Jose A. Rauh-Hain, MD; Marcela G. del Carmen, MD, MPH
OBJECTIVE: We investigated issues affecting Papanicolaou smear

screening access, health services utilization, acculturation, social networking, and media venues most conducive to acquiring health information among Hispanics.
STUDY DESIGN: Self-identified Hispanics were surveyed. Participants

were stratified based on age, time living in the United States, and Papanicolaou screening frequency.
RESULTS: Of 318 participants, Hispanics aged 30 years or older and

living in the United States less than 5 years prefer speaking Spanish.
Women with 5 or more lifetime Papanicolaou smears were 1.610 times

more likely to have lived in the United States 5 or more years, 1.706
times more likely to speak a second language, and 1.712 times less
likely to need a translator during their health care encounter.
CONCLUSION: Age and years living in the United States may be

independent risk factors for participation in Papanicolaou screening programs. Social difficulties inherent to acculturation inform
health behavior and translate to health disparity among Hispanics.
Our results may help design federally funded and community-level
programs.
Key words: cervical cancer screening, disparities, Hispanics

Cite this article as: Watts L, Joseph N, Velazquez A, et al. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol
2009;201:199.e1-8.

ince the institution of Papanicolaou

screening program, both the incidence and mortality of cervical cancer in
the United States have steadily declined.1
Although the decline in incidence and
mortality rates of cervical cancer in the
United States have occurred across all racial and ethnic groups, significant disparities in these rates continue to exist.1
Hispanic women in the United States
shoulder a disproportionate burden,
both in rates of incidence and mortality
from cervical cancer. According to the
Surveillance, Epidemiology, and End

From the Division of Gynecologic Oncology,

Department of Obstetrics and Gynecology
(Ms Watts, Ms Joseph, Ms Velzquez, and Drs
Gonzalez, Munro, Raugh-Hain, and del
Carmen), and the Department of
Biostatistics (Ms Muzikansky),
Massachusetts General Hospital, Harvard
Medical School, Boston, MA.
Received Jan. 30, 2009; revised April 10,
2009; accepted May 12, 2009.
Reprints: Marcela G. del Carmen, MD, MPH,
55 Fruit St., Yawkey 9E, Boston, MA 02114.
mdelcarmen@partners.org.
0002-9378/$36.00
2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2009.05.014

Results database, Hispanic women are

diagnosed with cervical cancer twice as
often as non-Hispanic white women.1
The average annual cervical cancer mortality rate from 2000 to 2004 for Hispanic
women in the United States was reported
to be 1.5 times greater than that for nonHispanic white women.1
Several factors may account for the
observed disparity in cervical cancer incidence and mortality among Hispanic
women in the United States, as compared with these rates among non-Hispanic white women. These factors include differences in screening and
follow-up rates and practices, treatment,
behavioral risk factors, and potentially
underlying biological variations. Although this disparity in cervical cancer
incidence and rate is not uniquely shouldered by Hispanic women in the United
States and also affects African American
and American Indian/Alaskan Native
and Asian-American/Pacific Islander
women, Hispanic women represent a
special group with certain unique needs.
These needs include language proficiency, cultural preferences, legal status,
and social networking. Hispanics represent the fastest growing minority group
in the United States, with an estimated

41 million Hispanics currently living

in this country (14% of the total
population).2
It is estimated that by the year 2050,
102.6 million Hispanics will live in the
United States, comprising 24% of the total population.2 As Hispanics become a
growing segment of the US population,
this continued disparity may have a significant impact on their communitys infrastructure secondary to increased morbidity and mortality rates from an
entirely preventable malignancy.2 The
growing number of Hispanics in the
United States and their disparity across
many disease spectra, including cervical
cancer, will result in a continued burden
to the US health care system.
The factors that may play a role in Hispanic womens cervical cancer screening
and treatment need to be elucidated to
better design program and create opportunities that will lead to the resolution of
the disparity that currently exists. To
better understand the factors that have
an impact on cervical cancer screening
and care among Hispanics in the United
States, we conducted a large-scale survey
study, in which self-identified Hispanic
women were directly asked about issues
affecting their access of Papanicolaou

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smear screening programs and utilization of general health care services as well
as their acculturation, social networking,
and media venues most conducive to acquiring health care information in their
community.

M ATERIALS AND M ETHODS

Study population and design
Using radio, newspaper, and web-based
announcements, self-identified Hispanic women in the Boston area, aged
18-99 years, were invited to participate
in a written survey. The study accrued
participants from Aug. 1, 2007, through
June 15, 2008. Hispanic ethnicity was defined according to the categories listed in
the US Census 2000. These included
Mexican, Mexican-American, Chicano,
Puerto Rican, Cuban, or other Spanish/Hispanic or Hispanic ethnicity. This
means study participants were originally
or directly descending from Spain, a
Spanish-speaking part of Central or
South America, or the Dominican
Republic.
Based on the federal governments distinction between race and ethnicity as 2
separate concepts, we used the US Census 2000 definitions of race and ethnicity
for consistency and future comparisons.
To minimize any confusion over the 2
terms and to avoid Hispanics over-selecting other as their race, we placed
the question on race after a brief explanation that to qualify for study participation, the respondent had to be of Hispanic origin or ethnicity, as defined in
previous text.
The survey was available in both Spanish and English, either in hard copy or on
the web. The survey was comprised of 7
different sections and included a total of
121 questions. There was no identifying
information collected. The questions
and instructions for the survey were
written using language that would be understandable with a fourth-grade level of
education. Participants with limited literacy were offered the opportunity to
have the survey read to them for completion. The survey was designed using
questions from the cancer control supplement of the National Health Interview Survey, the US Census 2000 survey,
199.e2

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and questions from other published
sources in the literature.3-5
Some questions were modified by the
study investigators to collect more detailed information or improve question
readability. The survey was pretested
during a series of 4 focus group sessions
among women eligible for participation
but not included in the study. The instrument included questions on demographics, health utilization, acculturation, knowledge, and behavior. The
study was reviewed and approved by the
institutional review board of the Dana
Farber Harvard Cancer Center.

Study variables
The survey instrument included 7 sections collecting information pertinent to
the respondents demographic background, current socioeconomic situation, venues through which new information is acquired, health utilization,
acculturation, knowledge and access to
screening programs, and reproductive
history and behaviors. Acculturation
questions included inquiries into the respondents perception that others in
their community and in the health care
system could relate to them in their language and cultural paradigm.
Respondents were also asked specific
questions about their basic knowledge,
access to services, and screening practices including Papanicolaou smears,
mammography, and colonoscopy. Finally, women were asked about their reproductive history and behavior, focusing on those practices placing them at
increased risk of acquiring sexually
transmitted infections.
The demographic section in the survey
collected detailed information on the respondents country of origin, religious
background and current practices, marital status, primary and preferred spoken
and written language, and education
level. The section on current socioeconomic status collected data on the respondents present employment status,
annual income, legal status, and health
insurance coverage. Respondents were
also asked detailed questions about how
they learn new information, including
their use of radio, television, newspaper,
and computer media venues. These

American Journal of Obstetrics & Gynecology AUGUST 2009

questions detailed the participants language preference when using these venues as well as the time of day they were
more likely to access them. The health
utilization section collected information
on the womens access and use of basic
health maintenance, screening, and
emergency room services.

Statistical analysis
Comparisons were made within the respondents group. Participants were
stratified on the basis of age, the length of
time living in the United States, and Papanicolaou smear screening frequency.
For example, respondents were asked
how long they had lived in the United
States, and the responses were categorized into less than 5 years or 5 years or
longer.
The responses were also analyzed
based on the study participants age. Age
30 years was chosen, given that studies
have shown herpes papillomavirus prevalence and cervical cancer incidence are a
function of a womans age.6,7 Women
older than 30 years of age have been
shown to have a greater risk for developing high-grade lesions and cancer.6,7
The decision made to stratify based on
lifetime Papanicolaou smears was made
up front and before the study was initiated. For each question analyzed, nonresponses were excluded. Descriptive statistics, such as frequencies and means,
were provided for all the data. Two-sample Student t test and Pearson 2 statistics were used to analyze continuous and
categorical outcomes, respectively.
Logistic regression models fit to provide odds ratios (confidence interval) for
outcomes of interest such as the influence of socioeconomic status and social
networking on Papanicolaou smear
screening practices among respondents.
Multiple models were constructed to
better explain more complex patterns of
association between covariates of interest and a set of outcome variables. Response rates for all questions were assessed and analyzed to determine the
existence of potential source of bias.
All computations were done using SAS
statistical software (SAS Institute, Cary,
NC).

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TABLE 1

Demographic characteristics of survey respondents

Characteristics

na

Percentageb (%)

Religious behavior

.....................................................................................................................................................................................................................................

Nonpracticing

76

25

156

51

72

24

.....................................................................................................................................................................................................................................

Practicing Catholic

.....................................................................................................................................................................................................................................

Practicing Protestant

.....................................................................................................................................................................................................................................
c

Other

..............................................................................................................................................................................................................................................

Marital status

..............................................................................................................................................................................................................................................

Married

150

49

Unmarried, live with partner

50

17

Divorced/separated/widowed

65

21

Never married/never lived with partner

39

13

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

Language preference

.....................................................................................................................................................................................................................................

Primary spoken, Spanish

271

87

Primary written, Spanish

253

81

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
d

Education

.....................................................................................................................................................................................................................................

Some high school, eighth grade

86

28

High school diploma/GED/vocational or

trade school graduate

82

27

..............................................................................................................................................................................................................................................

.....................................................................................................................................................................................................................................

Associates degree

61

20

Bachelors degree

39

13

Advanced degree

38

12

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Current employment status

.....................................................................................................................................................................................................................................
e

Employed

181

60

Not employed

119

40

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Annual household income, $

.....................................................................................................................................................................................................................................

24,999

123

43

25,000-49,999

92

32

50,000

69

24

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Years living in United States

.....................................................................................................................................................................................................................................

1-5

40

13

260

87

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
a

Total number of survey respondents equaled 318. Nonresponses are not included in the data; b Percentages express the
fraction of total number of respondents answering the specific question; c Other included more than 1 religion (n 7) or
no religion (n 7); d Educational attainment question asked the highest grade of school completed or highest degree
received; e Of this number, 25% have more than 2 jobs, 55% work 26-40 h/wk, and 25.5% work over 40 h/wk.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

R ESULTS
Respondent characteristics
A total of 318 Hispanic women either entirely or partially completed the survey
and provided data available for analysis.
The mean response rate for each question on the survey was 87%. The respondents were aged 19-78 years, with a mean
age of 42 years. The majority of respon-

dents were originally from the Dominican Republic (28%), Puerto Rico
(22%), Central America (19%), and
the United States (13%, born in the
United States). Eighty-seven percent of
respondents reported living in the
United States for longer than 5 years,
with 77% having lived in Boston longer
than 5 years.

Research

The majority of respondents were bilingual. However, 88% indicated Spanish as their primary spoken language and
87% indicated Spanish as their primary
written language. Fifty-six percent of respondents had a high school level education or less; 69% specified that more than
half of their education had been obtained
outside the United States and in Spanish.
Most of the women reported being married, Catholic, and employed and declared an annual income of less than US
$25,000. The demographic characteristics of survey respondents are listed in
Table 1.

Language preferences and length

of time in the United States
and use of screening
Responses were categorized for analysis
based on age and length of time residing
in the United States. The data reflected
that Hispanics aged 30 years or older and
living in the United States less than 5
years maintain Spanish as the preferred
language at home and for communication of health care information. Analysis
of the data based on length of time residing in the United States showed that although 80% of total respondents prefer
speaking Spanish, only 65% of Hispanics
living in the United States less than 5
years are bilingual compared with 85%
of Hispanics residing in the United States
for 5 years or longer (P .0026). Also,
93% of Hispanics living in the United
States less than 5 years prefer speaking
Spanish at home compared with 78% of
those Hispanics living in the United
States 5 years or longer (P .0420).
Further analysis of the data based on
length of time living in the United States,
indicated that Hispanics living in the
United States less than 5 years were 2.950
times more likely to speak only Spanish
(P .0026) and 3.304 times more likely
to prefer speaking Spanish (P .0420).
Hispanics living in the United States for
5 years or longer were also more likely to
visit a health care provider for scheduled
visits (P .0201), to have 4 or more routine health care visits in the preceding 5
years (P .0417), and to have had routine screening mammograms and Papanicolaou smears (P .0016 and P
.0053, respectively). Table 2 shows lan-

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TABLE 2

Characteristics of Latina respondents according to US residency duration

Characteristic

%a

> 5 y (%)b

< 5 y (%)b

P value

Language preference

................................................................................................................................................................................................................................................................................................................................................................................

Speak Spanish and a second language fluently

306

82

85

65

.0026

Prefer speaking Spanish

303

80

78

93

.0420

Prefer Spanish for health care information

304

63

59

88

.0005

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Health care services utilization practices

................................................................................................................................................................................................................................................................................................................................................................................

Visited health care providers office for scheduled appointment in the past year

297

96

97

90

.0201

296

73

75

59

.0417

.......................................................................................................................................................................................................................................................................................................................................................................

Had 4 routine health care visits in the last 5 y

.......................................................................................................................................................................................................................................................................................................................................................................

Had 4 mammograms in the last 5 y

271

33

36

11

.0016

Had 5 Pap smears in the last 5 y

296

98

90

58

.0053

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Fatalistic attitudes towards cancer

.......................................................................................................................................................................................................................................................................................................................................................................

Would not want to be informed of cancer diagnosis

295

.2996

.......................................................................................................................................................................................................................................................................................................................................................................

Would want provider to inform family of cancer diagnosis

297

50

49

55

.5112

Believe cancer is deadly

296

74

76

67

.2401

.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
a

The percentages of overall respondents answering affirmatively to the question. The parenthetical n next to each case demonstrates total number of respondents for each question; b This is
the percentage of women within the age group that answered affirmatively to the question.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

guage and health care utilization practices among respondents based on length
of time living in the United States.

Age
Hispanics aged 30 years or older similar
to those living in the United States 5
years or less prefer speaking Spanish at
home (P .0053) and receiving health
care information in Spanish (P .0001).
Hispanics 30 years old or older were
0.495 less able to independently fill out
the health encounter form in English (P
.0410). When assessed between age
groups and time in the United States,
women 30 years old or older were more
likely to be among those who did not
want to know of cancer diagnosis and
did consider cancer to be incurable;
however, this was not statistically significant. Table 3 lists language preference,
health care services utilization practices,
and attitudes toward cancer for respondents based on age.
Socioeconomic status and social
networking and screening practices
The relationship between socioeconomic status (SES) and social networking on Papanicolaou smear practices was
also investigated. Women with 5 or more
lifetime Papanicolaou smears were 1.610
199.e4

times more likely to have lived in the

United States 5 years or longer, 1.706
times more likely to speak a second language, and 1.712 times less likely to need
a translator during their health care encounter. They were also 1.363 times
more likely to be employed and 1.544
times more likely to feel comfortable
asking for time off from work to see a
health care provider.
Analysis of health utilization behavior
among Hispanics stratified according to
number of lifetime Papanicolaou smears
demonstrated that Hispanics with 5 or
more Papanicolaou smears were 1.712
times more likely to have had 4 or more
mammograms in the previous 5 years (P
.0424). These women were also more
likely to have had a history of an abnormal Papanicolaou smear, history of cervical dysplasia, and an abnormal colposcopy. These trends were not statistically
significant. Table 4 shows the influence
of SES and social networking on Papanicolaou smear screening practices, as reported by these women.

Knowledge and attitudes about

dysplasia and cancer
Forty-nine percent of respondents (n
124) correctly identified the Papanico-

American Journal of Obstetrics & Gynecology AUGUST 2009

laou smear as a test performed on the

cervix and screening for cancer. Although the majority of respondents (n
221; 74%) believed cancer is deadly, they
also indicated wanting to be informed of
a cancer diagnosis (n 290; 97%; Table
3). However, only 152 women (51%)
reported wanting their health care provider to inform a family member of the
cancer diagnosis. When asked if they
considered a cancer diagnosis to be
fatal, 221 women (74%) answered
affirmatively.
When these responses were analyzed
based on age stratification, respondents
reported wanting to know about a cancer
diagnosis, primary fear of a cancer diagnosis, and a belief that cancer is incurable
in similar proportions, irrespective of
age. Analysis of responses measuring the
venues through which women learn
health care information demonstrated
that 88% of the women (n 262), irrespective of age or time living in the
United States, cited radio or television
over written material as their preferred
media for learning new information.
Among all respondents, 77% (n 220)
stated that they listened to the radio,
preferably in Spanish, at least 1 hour per
week, whereas 72% (n 191) reported

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Research

TABLE 3

Characteristics of Latina respondents according to age

Characteristic

%a

> 30 y (%)b

< 30 y (%)b

P value

Language preference

.......................................................................................................................................................................................................................................................................................................................................................................

Live in the United States 5 y

300

87

89

80

.0640

Prefer to speak Spanish at home

304

80

84

68

.0053

Fluency in Spanish and a second language

284

89

88

91

.6197

Prefer having health care information in Spanish

304

63

69

39

.0001

Independently fill out health providers health history and information form in
English

304

71

69

82

.0410

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................

................................................................................................................................................................................................................................................................................................................................................................................

Health care services utilization practices

.......................................................................................................................................................................................................................................................................................................................................................................

Visited health care providers office for scheduled appointment in the past year

294

96

98

91

.7797

Express discomfort with pelvic exam

289

84

85

81

.4424

Health care provider shares cultural background

292

19

21

13

.2279

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
c

Attitudes toward cancer

.......................................................................................................................................................................................................................................................................................................................................................................

Would want health care provider to inform them of cancer diagnosis

293

97

97

98

.5167

Chose death as primary fear associated with cancer diagnosis

308

44

44

44

.8106

Believe cancer is incurable

308

23

24

18

.3202

.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
a

The percentages of overall respondents answering affirmatively to the question. The parenthetical n next to each case demonstrates total number of respondents for each question; b This is
the percentage of women within the age group that answered affirmatively to the question; c Other fears associated with cancer were unknown treatment and belief that cancer was incurable.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

watching at least 1 hour of television per

week, also preferably in Spanish. Eightyfour percent (n 254) of the women
stated that they read health care information in posters or pamphlets at the health

care providers office. However, 74% of

them (n 223), irrespective of age or
length of time living in the United States,
declared that most of the information was
difficult to comprehend.

Comment
The current investigation evaluated barriers present earlier in the cervical cancer
screening continuum via assessment of
self-conceived obstacles to obtaining Pa-

TABLE 4

Influence of socioeconomic status and social networking on Papanicolau

smear screening practices among respondentsa
Characteristic

< 5 lifetime
Papanicolaou smears

> 5 lifetime
Papanicolaou smearsb
88 (53%)

OR

P value

1.172

.5008

Have an education at or below high school

diploma, GED, vocational, trade school

75 (57%)

Are employed or have been employed within

the past 12 mo

73 (56%)

Comfortable asking employer for time off to

visit health care provider

29 (23%)

Participate in weekly church-sponsored,

nonreligious activity

22 (20%)

Need a translator during health care encounter

33 (26%)

28 (17%)

1.712

.0617

Obtained 4 or more mammograms in 5 y

32 (26%)

56 (38%)

1.712

.0424

................................................................................................................................................................................................................................................................................................................................................................................

103 (64%)

1.363

.1974

................................................................................................................................................................................................................................................................................................................................................................................

52 (31%)

1.544

.0797

................................................................................................................................................................................................................................................................................................................................................................................

29 (22%)

1.069

.8326

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Have a history of abnormal Papanicolau smear

18 (24%)

45 (38%)

1.867

.0570

Have had a colposcopy

27 (39%)

54 (48%)

1.424

.2542

Have a history of low-high grade dysplasia

11 (14%)

29 (24%)

1.920

.0900

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

GED, general educational development; OR, odds ratio.

a

Data are expressed as number (percentages). Nonrespondents are not included in data; b The 2 test was used to compare categorical variables.

Watts. Understanding barriers to cervical cancer screening among Hispanic women. Am J Obstet Gynecol 2009.

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panicolaou smears. To our knowledge,

this study is the first to examine these
barriers among a large sample of exclusively Hispanic women living in the
Northeast and directly surveyed, with a
121 question instrument. The study is
unique in having directly surveyed the
women with a detailed questionnaire instrument, as well as in asking specific
questions measuring basic knowledge
and the use of screening services, acculturation, and health utilization practices
among a large group of Hispanics in the
United States. Our study also evaluated
the role of age and length of time living in
the United States as potential variables
affecting acculturation and screening
knowledge and practices.
Our study is limited in that the group
of women surveyed reside in a metropolitan city in the Northeast and excluded
Portuguese Hispanic women. However,
the distribution across racial categories
was similar to the results of the 2000 US
Census, suggesting a similar racial distribution in the general Hispanic population and among our respondents. In addition, the study has a selection bias for
women who have the literacy to read
pamphlets and the newspaper. Nonetheless, in spite of the potential bias for more
educated and acculturated women, we
still saw differences in health care utilization practices.
Of concern, we found that the population of women at the highest risk for cervical dysplasia and cancer (those 30
years old and living in the United States
5 years) were those who reported decreased screening practices compared
with women younger than 30 years and
living in the Unites States for 5 years or
longer.
In addition, we found the preference
for Spanish to be more marked among
Hispanic women aged 30 years or older
and living in the United States less than 5
years. Although bilingual, these women
preferred speaking Spanish and as such
favored having health care information
communicated in Spanish. These women
were less capable of independently filling
out health forms. Our study would suggest
that older age ( 30 years) and length of
time living in the United States ( 5 years)
are associated with lower levels of accultur199.e6

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ation and this may be related to the lower
percentages of patients screened in this
population.
These results are consistent with previous studies of health care utilization by
more diverse populations. Previous
studies have investigated barriers to
screening, suggesting that the major ones
are personal or cultural, socioeconomic,
and institutional.8-10 Cultural and personal barriers include origin of birth,
language proficiency, level of acculturation, and patient-health provider relationship.8-10 The demographic results in
this study reflect some of these personal
and cultural barriers. Our results support previous findings that Hispanics
prefer Spanish as their written and spoken language, even if they report being
bilingual. Lack of English proficiency
has been reported in other studies as a
factor contributing to nonadherence
to screening.11-14
Cultural assimilation may be a special
challenge for Hispanics born outside the
United States. In our study, 85% of respondents cited a Latin American country as their birth place, with only 13%
claiming the United States as their country of birth. Among our study population, 76% (n 226) reported living in
the United States for longer than 8 years.
Strategies to improve screening rates
among Hispanics in the United States
may need to address factors that pertain
to an older segment of the population
with less acculturation, despite length of
time residing in the United States.
Our results challenge previous results
indicating that a major personal barrier
in cervical cancer screening is the womans lack of knowledge about the role of
Papanicolaou smear in cervical cancer
prevention.12,15,16 In our study, 41% of
respondents (n 124) correctly identified the Papanicolaou smear as a test performed on the cervix and screening for
cancer. Although this response is higher
than previously reported, increasing
knowledge about the rationale behind
Papanicolaou smear should still be the
target of future education strategies and
intervention among underserved minority women who may be at a higher
risk of developing cervical cancer.

American Journal of Obstetrics & Gynecology AUGUST 2009

Our study supports previous investigations reporting that Hispanic women

have a fatalistic attitude toward the discovery of a cancer following a screening
test.3,16 The majority of women in our
survey considered a cancer diagnosis to
be deadly. However, the majority of
these women reported wanted to be informed of their cancer diagnosis. In this
respect, our results contradict previous
investigations showing that Hispanics
prefer not knowing a cancer diagnosis
and that this attitude in turn may influence their nonadherence to screening
programs.3,16
Our respondents did report a desire to
keep their families uninformed of a cancer diagnosis. This attitude may manifest
a special personal barrier among these
women for providers caring for them in
their ability to partner with family members as part of the support and resource
network for these patients. It may represent a special opportunity for the design
of strategies aimed at improving a culturally appropriate exchange of pertinent medical information among Hispanic patients and their families.
The patient-provider relationship
may also play a critical role in adherence
to health care guidelines and participation in screening programs. In our study,
a statistically significant proportion of
women 30 years of age or older as well as
those living in the United States for less
than 5 years stated a preference for having their health care information communicated in Spanish as well as having
their provider be of the same cultural
background. However, only 19% of respondents (n 56) reported having
a health care provider of Hispanic
background.
The preference among our respondents for Spanish-speaking providers
underscores the fact that sociocultural
differences between patients and health
care providers affect communication
and clinical decision-making processes.17 Language may be only 1 of the
many factors that, at least from the patient perspective, dictates a culturally
competent encounter. If these sociocultural differences are not identified, understood, communicated, and addressed in
the clinical encounter, they may result in

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lack of patient satisfaction, inadequate participation, and worse health outcomes.18
As Hispanics become a growing population in the United States, it is imperative to continue investigating the sociocultural differences that obstruct care
and to create programs with the intent of
alleviating these barriers. In the case of
cervical cancer, the impact of these cultural differences needs to be better understood in the context of cervical cancer
screening and diagnosis. A better understanding of these differences will result in
the design of cross-cultural medical education. These culturally competent
frameworks will ultimately facilitate the
exploration and negotiation of critical
health care issues and decisions and result in better health outcomes, especially
among the older and more recent immigrant population.
Socioeconomic factors (such as education and income level, medical insurance, and medical cost of care) have been
described as forces contributing to disparities in health care. Studies have
shown that medically uninsured women
are less likely to participate in screening
programs.19 Data from 2000 generated
by the Behavioral Risk Factor Surveillance Survey linked to state data on the
National Breast and Cervical Cancer
Early Detection Program showed that
low income and lack of medical insurance were major barriers to Papanicolaou screening among Hispanic and African American women. The majority of
these women reported medical costs as a
barrier.20
Similar barriers were reported for all
racial/ethnic groups in data obtained
from the 2000 National Health Interview
Survey and confirmed in other studies.13,16,21,22 In our study, 99% of women
(n 277) reported having some form of
health insurance, suggesting that lack of
health insurance is not the only factor
affecting a womans ability to participate
with screening programs and corroborating other investigations noting that
despite the presence of adequate health
insurance, underserved minorities are
still at risk of disparities in accessing the
health care system.16
In 2007, the Commonwealth of Massachusetts passed a constitutional amend-

ment to assure universal health coverage

for all state residents, which may in part
explain the high insurance rate seen in our
study. It is important to underscore that
our study did not collect detailed information on insurance coverage. The level of
coverage among respondents was not assessed, and indeed some women may have
had to pay more than others to cover the
cost of their health care. The lack of association between health care insurance and
screening practices may be an important
consideration to contemplate in the design
of strategies aiming at improving screening
rates among Hispanics in the United
States. These programs must address some
of these other barriers, beyond health insurance, and not assume that adequate
cost of care coverage will result in higher
compliance rates with screening.
Fifty-six percent of respondents reported an education level of high school
or less. Several other investigations have
shown that low levels of education are
reliable indicators for screening nonadherence.14,16 Forty-three percent of respondents reported an annual income of
less than US $25,000. Metaanalyses of
studies identifying barriers to screening
have shown that, irrespective of other
variables, poverty is a strong predictor of
screening, diagnosis, treatment, and survival odds.10
Structural barriers have also been
shown to affect participation in the
health care system. Subset analysis of the
women living in the United States for 5
years or longer showed that they were
also more likely to visit their health care
providers office for regularly scheduled
appointments (as opposed to emergency
room services) and to have routine
screening tests. This may reflect a previously described association between
physician recommendation and participation in appropriate screening regimens.11,15,21,22 Bazargan et al19 reported
that women who stated that their health
care provider had never told them to
have a Papanicolaou smear were half as
likely to undergo screening when compared with the women whose provider
recommended the test.20
Sixty percent of our respondents reported working at least 1 job. Special
consideration needs to be given to work-

Research

ing Hispanic women in the design of

screening programs. Institutional barriers to screening, as stated by many of our
respondents, include long wait time at
health centers, transportation difficulties, family support, and difficulty with
child care. Programs targeted to improve
on these disparities must also take into
consideration strategies to address and
overcome these institutional barriers.
An important discovery of the current
study is the identification of radio and
television as potential venues to disseminate information among Hispanics. Information campaigns should consider
these media venues because they may
help increase knowledge and awareness
of cervical cancer and its prevention
among Hispanic women in the United
States. Our study provides important information as to the time of day these
messages may be more effectively
disseminated.
Lastly, our respondents declared reading written information (pamphlets and
posters) displayed at their health centers.
Importantly, few of them reported understanding the information. Education
campaigns should be designed to respect
the cultural and education background
of the population they are targeting. For
Hispanics in the United States, these
messages may be more effective if written in Spanish and if they address some
of the barriers described earlier, which
may be unique to this vulnerable segment of the US population.
The existence of disparities in health
care for cervical cancer screening and
treatment is well recognized. Recent research has focused on identifying and alleviating the barriers that contribute to
these disparities. Minority populations
in the United States are younger and increasing in proportion at faster rates
than the Caucasian population and represent an especially vulnerable segment
of the population.
The persistence of these disparities
and the continued population growth
may equate to an increasing burden on
our health care system. This may also result in a social and economic impact
affecting underserved communities
shouldering increased morbidity and
mortality from screening and treatment

AUGUST 2009 American Journal of Obstetrics & Gynecology

199.e7

Research

Oncology

of cervical cancer. Culturally appropriate education regarding cervical cancer,

the importance of cervical screening, and
the role of prophylactic vaccination can
significantly reduce incidence and mortality rates for all populations. Such education should target not only members
of high-risk populations but also the
physicians who treat them. Developing
culturally competent physicians will
make a significant impact in overcoming
barriers and reducing health disparities.
To our knowledge, our study represents the largest group of directly surveyed Hispanic women in the United
States on questions regarding cervical
cancer screening. Our results indicate
that age and length of time living in the
United States may be independent risk
factors for barriers contributing to disparities in cervical cancer screening and
potential treatment, consistent with previous studies. The social difficulties inherent to acculturation inform health
behavior and translate to health disparity
in this population.
The findings suggest that cultural differences between patients and providers
create a discomfort among these patients, which is not easily bridged. In fact,
television and radio may be an effective
way to reach this population. In addition, materials in Spanish that are readily
available in health care centers do make a
difference for patients. Our results may
help in the design of continued federally
funded and community-level programs
or in the training of patient navigators by
identifying barriers that may be especially relevant to older and more recent
Hispanic immigrants in the United
States. Future studies validating our re-

199.e8

www.AJOG.org
sults among Hispanics in other regions
of the United States would be helpful. f
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