1 3 3
Cad . Saúd e Púb lic a, Rio de Jane iro , 14(Sup. 3):133-147, 1998 A RTIGO A RT I C L E
M ammography and Pap t est screening
among low-income fore i g n - b o rn Hispanic
women in the USA
Mamo g rafia e te ste Papanic o lau e m mulhe re s
latinas d e b aixa re nd a no s Estad o s Unid o s
1 Un i versity of Texa s – H ou st on H ealt h Scien ce Ce n t e r, S ch oo l of Pu b l i c H e a l t h , Cen t er for H e a l t h Prom o t io n Re s e a rch a n d D e ve l o p m e n t . 1 200 H erm a n Pre s s l e r, Ro om W - 9 3 8 , H o u s t o n , Tex a s 7 7 0 3 0 - 9 9 6 0 ,U S A . 2 De p a rt m en t of Gy n e c o l o g i c On c o l o gy Un i v ersit y of Tex a s M .D . An d e r s o n Ca n cer Ce n t e r, 1 5 1 5 Holcom b e Bl vd . , Box 67, Ho u s t o n , Tex a s ,7 7 0 3 0 ,U S A . 3 Ma c ro In tern at ion al In c . 117 85 Belt sv il le D ri ve Ca l ve rt o n , M a ry l a n d 2 0 7 0 5 - 3 1 1 9 ,U S A .
M ari a E. Fern an d ez 1 Gu i llerm o To rt o l e ro - Lu n a 2 Ro b e rt S. Gold 3
Abstract Litt le is k n ow n ab ou t t h e f actors in flu en cin g screen i n g a m on g low - in co m e Hi s p a n i c w om en p a rt i c u l a rly a m on g recen t im m igra n t s . A sam p le o f 148 low - i n c o m e , l ow - l i t e ra t e , f o r-eign -born Hisp an ic w om en residin g in th e Wash in gto n DC m etropo litan area pa rticip ated in th e s t u d y. Th e m ean a ge of th e sam p le w as 46.2 (SD = 11.5), 84% re p o rted a n n u al h o u seh o ld in co m es ≤ $ 1 5 , 0 0 0 . All w om en w ere Spa n ish sp ea k ers a n d h a d low accu ltu ration leve l s . N in ety six perc e n t h ad re p o rted h a v in g a Pap sm ear, bu t 24% w ere n ot in com plian ce w ith reco m m en d ed scre e n i n g ( Pap test w ith in t h e last 3 yea rs). Am on g w om en 40 an d o lder, 62% h a d re c e i ved a m am m o gra m , bu t o n l y 33% w ere co m p li a n t w it h a ge a p p rop ri a t e recom m en d ed m a m m ogra p h y scre e n i n g g u i d e l i n e s . Wo m en in th is stu d y h a d m o re m iscon cep tion s ab ou t can cer th a n Hisp an ics in oth er s t u d i e s . Mu l t i varia te logistic m od els for correlates of Pap t est an d m am m o grap h y screen in g be-h av ior in dicate tbe-h at factors su cbe-h as fear of tbe-h e screen in g test , e m b a r ra s s m e n t , an d lack of k n ow ledge in flu en ced screen in g beh a v ior. In con clu sion , w om en i n th is stu d y h ad low er rates of m a m m o g ra p h y screen in g th an n on Hispan ic w om en an d low er rates of com p lian ce w ith re c o m m e n d -ed M a m m o g rap h y an d Pap t est screen in g gu idelin es.
Key words Breast Ne o p l a s m s ; M a m m o g ra p h y ; Ce rv ix N e o p l a s m s ; Hispan ic Am e r i c a n s
Resumo Este estu d o d et erm i n ou o s f a tores q u e in f lu en ciam a co n d u t a d e m u lh eres latin as d e b aix a ren d a n o s EUA , em face d o m on itoram en to p ela m am o grafia (M M ) e por m eio d o test e de Pap an icolau ( T P ) , em u m a am ostra d e 148 m u lh eres la tin as, resid en tes n a regiã o m et ro p o l i t a n a de Wash in gton DC. A idad e m édia n a am ostra foi d e 46,2 an o s (desv io p ad rão 11,5), e 84% re l a t a-v am ren d a fam iliar an u al m en or qu e qu in ze m il d ólare s . Tod as as m u lh eres falaa-v am esp an h ol e a p re s e n t a vam n íveis red u z id os d e acu ltu ra ç ã o ; 96% destas in form av am ter realiz ad o TP, m as 24% n ão re l a t a va m ad esã o às n o rm as re com en d ad a s d e ra s t re a m e n t o. En t re aq u ela s com q u a re n t a a n os ou m ais, 62% h av iam realiz ad o M M , m as som en te 33% d e acord o com as n o rm as d e ro t i n a . A freqü ên cia d e con ceitos equ iv ocad os sobre o cân cer n este gru po de m u lh eres foi m aio r qu e a ob-s e rv ad a p ara m u lh ereob-s lat in aob-s em ou troob-s eob-stu doob-s. Modeloob-s logíob-sticoob-s m u lti v aria d oob-s p a ra va r i á-v eis correlacion ad as à con du ta n o ra s t rea m en to p elo TP e M M in d icam qu e fatores com o o m edo d o t este, v ergon h a e d escon h eci m en to tive ra m in flu ên cia. Con clu iu -se q u e a s m u lh eres n esse es-tu do a pre s e n t a ram m en or freqü ên cia d e ra s t ream en to p or M M qu e m u lh eres n ão latin as, além d e a p re s e n t a rem ta m bém n íveis m ais red u z id os de a desão às n orm a s d e ra s t ream en to por TP e M M .
FERNANDEZ, M. E.; TO RTO LERO -LUNA, G . & G O LD, R. S. 1 3 4
Cad. Saúde Púb lica, Rio de Jane iro , 14(Sup . 3):133-147, 1998
The Hisp a n ic p o p u la t ion is t h e fa st e st grow i n g e t h n ic m in o rit y gr o u p in t h e U n it e d St a t e s c o m p r isin g 11.5 % o f t h e p o p u lat io n (U.S. Bu -re a u o f t h e Ce n s u s, 1997). Th e Ce n s u s Bu -re a u e s t im a t e s t h a t b y t h e ye a r 2050 H isp an ics will acco u n t fo r m o re th a n 25% o f t h e U.S. p op u la -t ion . Of -t h e 28 m illion p e rso n s of Hisp an ic o r i-gin in t h e Un ited Sta te s in 1996, m o re th an o n e t h i rd w e re fo re ign b o rn . Am o n g H is p a n ics 25 ye ar s an d o ld e r, t h ere we re m o re fore i g n - b o rn p eo p le t h an U.S.-b orn , 7.9 an d 6.7 m illion p ers o n ers , re ers p e c t i ve l y. Ove r 1.5 m illio n fo re i g n b o r n Hisp an ics we re from Ce n t ra l Am er ica , in -c lu d in g ove r 650,000 fro m El Sa l va d o r a lo n e (U .S. Bu re a u o f t h e Ce n s u s, 1997). Sin ce fo r-e i g n - b o r n H isp a n ics d iffr-e r fr o m n a t ivr-e - b o rn Hisp a n ics in a n u m b e r o f wa ys, it is im p o rt a n t t o e xa m in e t h e fa c t o rs t h a t in flu e n c e p ro t e c-t i ve h e a lc-t h b e h a vio r a m o n g c-t h is sp e c ia l a n d l a rge grou p o f Hispa n ics in t h e U.S. Th e cu rre n t s t u d y e xa m in e d c o rre la t e s o f m a m m o gra p h y a n d Pa p t e st sc re e n in g b e h a vio r a m o n g for -e i g n - b o r n H isp a n ic wo m -en .
Alth o u gh Hisp a n ic wo m e n h ave a lowe r o ve ra ll in c id e n c e o f b re a st ca n ce r t h a n n o n -Hisp a n ic wh ite wo m en , t h ey a re a t grea t e r r i s k fo r p re se n t in g with lar ger t u m ors with re g i o n -a l o r d ist -a n t m e t -a s t -a se s (D-a ly e t -a l., 1985; R i c h a rd son e t a l., 1987). Ad d i t i o n a l l y, t h e in ci-d e nce o f b reast can cer a m on g Hisp an ic w o m e n is in cre as in g a t a ra t e t h re e t im e s grea t e r t h a n t h a t o f An glo -wo m e n (Sa i n t - Ge r m ain & Lo n g-m a n , 1993). Ce r vic a l c an ce r is t h e t h ird g-m o s t c om m o n ca n ce r a m o n g Hisp a n ic wo m e n , wh ile it ra n ks sixt h fo r n o n -H isp a n ic w h it e w om en (Hia tt & Pasick, 1995). Am o n g Hi s p a n i c wom en , b ot h in cid e n ce a n d th e m orta lit y ra t e s f rom cervica l ca n ce r a re twice a s h igh a s t h o se o f n o n -Hisp a n ic w o m e n (Mille r e t a l., 1996; An d e rs o n & Ma y, 1995; Te xa s Ca n c e r Co u n c i l , 1 9 9 4 ) .
Deb ate con tin u es a b ou t a pp ro p ria te scre e n -in g -in tervals, th e efficacy of screen -in g for certa-in a ge gro u p s, a n d co st effe ct iven e ss o f scre e n i n g . Still, th ere is wid e sp read agreem en t tha t scre e nin g fo r b re ast a n d c er vica l ca n ce rs wh e n co m -b in e d with ap p ro p ria t e fo llow - u p , will re su lt in re d u ct io n s in m or t a lit y fro m t h e se ca n ce rs ( Sh a p i ro e t a l., 1988; H u r le y & Ka l d o r, 1992; Ta b a r et a l. 1992) .
Alt h o u gh s cre e n in g ra t e s fo r b re a s t a n d c e r vic al ca n c e r a re in c re a sin g, u n d e r u t i l i z a -t ion is s-t ill a m a jor con cern in -t h e Un i-ted S-t a -t e s ( He rn a n d ez , 1992; Fu lt o n , 1992). Ma m m o g ra -p h y scre e n in g c a n re d u ce b re a st ca n c e r m o t ality b y a p p roxim a t e ly o n e t h ird t h rou gh e a r-ly d e t e ct io n a n d p ro m p t t re a t m e n t . Howe ve r, b a r r ie rs s t ill e xist t h a t d isco u ra ge o r p ro h i b i t
wom e n , p a rt icu larly m in o rity wo m e n , fro m b e -in g scre en e d (Rim e r e t a l., 1991). Bo th th e 1992 Na t ion al He alth In t e rvie w Su r ve y an d th e 1995 Mam m ograp h y Attitu d es an d Usage Stu d y sh ow th at th e p ro p o r tion o f wom e n fo llowin g gu id e -lin e s fo r scree n in g wa s lower am o n g old e r, low i n c o m e, low ed u cat e d , a n d u n in su re d wo m e n (An d e rson & Ma y, 1995; Ma rt in e t a l., 1996).
H isp an ic w om e n are le ss like ly t o p ra c t i c e ca n c e r sc re e n in g b e h a vio rs in clu d in g m a m -m o g ra p h y, clin ical b rea st e xa -m , b re ast se lf-e x-a m x-a n d Px-a p sm ex-a r t h x-a n n o n -Hisp x-a n ic wo m e n ( Fu lto n , 1992; Ch a vez e t al., 1986; Ha rla n e t al., 1991; Ra m i re z e t a l., 1987; Ve r n o n e t al., 1992; Bre en & Ke s s l e r, 1994). Fu rt h e rm o re , u n d o cu -m e n t ed Hisp an ic wo-m en are le ss likely t o h ave h a d Pa p t e s t s o r p ra ct ice BSE t h a n t h e ir le ga l c o u n t e r p a r t s (Ch a ve z e t a l., 1986). Da t a fro m t h e 1987 Na t io n a l He a lt h In t e r vie w Su r ve y s h owe d t h a t m o re Hisp an ic w om e n (19.7 p e r -ce n t ) h a d n e ve r h e a rd o f a Pa p sm e a r t h a n e i-t h e r Bla c k wo m e n (5.1 p e rce n i-t ) or W h i i-t e wom en (2.6 p ercen t) (Ha rla n et al., 1991). Sp a n -i s h -sp e a k-in g wo m e n w e re le ss l-ike ly to h a ve h e a rd o f Pa p sm e a rs a n d to h a ve b e en in co m -p lia n ce wit h s c re en in g reco m m en d at ion s th a n En g l i s h -s p e a kin g w o m e n . Wh e n co m p a r i n g Hispa n ic wom en’s co m p lia n ce rat es by co u n tr y o f o rigin , “Ot h e r Hi s p a n i c s” h a d s ign ifica n t ly l owe r ra te s t h a n Cu b a n , Me xica n , an d Pu e rt o Rica n wo m en . Th is is im p o rt an t b e cau se “Ot h -e r H i s p a n i c s” id -e n t ifi-e d wo m -e n fro m C-e n t ra l an d Sou th Am e rica. Ma n y re s e a rch e rs h a ve ex-am in e d t h e re a so n s wh y so m e gro u p s o f wom e n are ch ro n ica lly u n d e rscre e n e d . (Za p k a e t al., 1996; O’Ma lle y e t a l., 1997; Fre e m an & Wa s f i e, 1989). Ava ilab ilit y o f se r vice s a n d fi-n a fi-n c ifi-n g o f t h e s cre e fi-n ifi-n g s e r vice s a re ofi-n ly t h e m o st ob v i o u s. Wo m e n’s kn ow le d ge a b o u t ca n -ce r an d ca n -ce r s cr e e n in g, h e r b e lie fs a b o u t ca n ce r risk, fe a rs a b o u t s cr e e n in g, fa t a lism , e m b a r ra ssm en t an d co n cern a b o u t p ain or d is-c o m f o rt is-ca n a lso h ave a n im p a is-ct o n sis-cre e n i n g b e h a vio rs (Rim e r e t a l., 1989; Pe a rlm a n e t a l., 1996; Rim e r e t a l., 1996; Fra zie r e t a l., 1996; He d e g a a rd e t a l., 1996; Ha rlan e t a l., 1991; Ca l l e e t a l., 1993; To rt o l e ro Lu n a e t al., 1995; Pe re z -Sta b le et a l., 1992; Mo rgan & Le vin , 1995). Ma n y wo m en w h o a re m o t iva te d t o o b t a in scre e n i n g a re d e t e rre d b y e n viro n m e n t a l fa ct o rs s u ch a s lack of t ra n s p o rta tio n , lack of re c o m m e n d a t i o n f rom a h e a lt h ca re p r ov i d e r, la ck o f h e alt h in s u ra n c e, cost , la n gu a ge b arri e r s, a n d la ck of so -cia l t ie s (O ’Ma lle y e t a l., 1997; Taylo r e t a l., 1995; Fox & St e in , 1991).
Cad . Saúde Púb lic a, Rio de Jane iro , 14(Sup. 3):133-147, 1998 t o p a rt icip a t e in a h e a lt h e d u c at io n in t e rve n
-tio n stu d y. Th e in ter ven t ion assessed th e e ffec-t i ven ess o f a m u lffec-tim e d ia in ffec-t erven ffec-tion o n b re a s ffec-t a n d cer vical ca n ce r scre en in g kn ow l e d g e, a tt i-t u d e s, a n d b e h a vio ra l in i-te n i-t . Th e resu li-t s o f i-t h e i n t e r ve n t io n s t u d y a re p r e se n t e d e ls e wh e re ( Fe rn a n d ez, 1995). Th e an alyses fo r t h e cu rre n t p ap er we re co n d u ct ed on d a ta ga th ere d d u r i n g a b a se lin e in t er vie w a m on g p a r t i c i p a n t s.
M e t h o d s
St udy sample
Th e sam p lin g fram e for t h e stu d y in clu d ed Hi s-p a n ic wo m e n livin g in o r a ro u n d Wa s h i n g t o n DC. In d ivid u a ls o f H is p a n ic o rigin o r d e s ce n t we re t h o se w h o cla s sify t h e m s e lve s in o n e o r m o re o f t h e sp e cific Hisp a n ic o rigin cate gori e s su c h a s Pu e rt o Rica n , Me xic an , Ce n t ral o r So u t h Am e ric a n , o r Cu b a n , a s we ll a s t h o s e wh o in d ica t e d t h a t t h e y a re o f o t h e r Sp a n i s h / Hisp a n ic o rigin (U.S. Bu re a u o f t h e Ce n s u s, 1997). Pa rticip an ts we re re c ru ited through p ost-e d a n d vost-e rb a l a n n o u n cost-e m ost-e n t s. Fl yost-e rs wost-e rost-e p o st e d in a n d aro u n d clin ic s an d n e igh b o ri n g a re a s. Clin ic st aff a lso verb ally re c ru ite d p art i c-i p a n t s. An n o u n c e m e n t s we re a ls o m a d e c-in Ad u lt En glish as a Secon d Lan gu age (ESL) c l a s s-e s a t t h s-e Sp a n ish Ed u c a tio n a n d Ds-e vs-e l o p m s-e n t Ce n t e r (SED Ce n t e r ). A c o n ve n ie n c e s am p le wa s d ra w n fro m t h o s e wo m e n w h o e xp re s s e d i n t e re st in p a rt ic ip a t in g a n d wh o fit t h e e ligi-b ilit y cr i t e r ia . In o rd e r t o ligi-b e e ligiligi-b le fo r t h e s t u d y, t h e p ar t ic ip a n t h a d t o b e a H i s p a n i c wo m an , age 30 or old er, with n o h isto ry of ca n -c e r. Wom e n wh o exp re ssed a n in t erest an d m e t th e e ligib ility cri t e ria we re a ske d t o p a rt i c i p a t e in a n in t e r v i e w. On e h u n d re d a n d fo rt y e igh t wo m e n p a rt icip a t ed in th e in t erv i e w.
Data collection
Six b ilin gu a l Hisp a n ic in t e r v i e we rs (o f Me x ican , Ce n t ra l or Sou th Am er ica n o rigin ) we re re -c ru it e d a n d t ra in e d . Th e in t e r v i e we rs b e -ca m e fa m ilia r with t h e o b je ct ive s of t he stu d y, t h e re s e a rch p roto co l, an d th e d a ta co llect io n in stru -m e n t s. Resp o n ses we re re c o rd ed on p re - c o d e d i n t e r vie w fo rm s. A d a t a co llec tio n co o rd i n a t o r wa s p resen t a t e ach sit e to en su re t h a t t he d ata c o lle c t o rs we re fo llow in g t h e d at a c o lle c t io n p ro t o co l, t o a ssist in fo rm c o m p le tio n , a n d t o re vie w a ll d a t a fo rm s fo r co m p le t e n e s s. T h e Dat a co lle ct ion p erio d la ste d for 15 d a ys ove r a p e rio d o f t hre e a n d a h a lf we e k s.
MAMM O G RAPHY AND PAP TEST IN HISPANIC W O M EN IN USA 1 3 5
Dependant variables
Fo u r d ich ot o m o u s d e p e n d e n t va r ia b le s w e re u se d in t h e in ve s t iga tio n , t wo va ria b le s d e -s c r ib in g m a m m ogr a p h y- -s c re e n in g -st a t u -s an d t wo d e s cr ib in g Pa p t e st s cre e n in g st a t u s. Be -h a v i o ra l in t en t t o ob ta in a m am m o gram a n d / o r Pa p test w it h in th e followin g th re e m o n t h s was a sse ssed a m on g wo m e n wh o we re n o n -a d h e r-e n t t o scrr-e r-en in g gu id r-e lin r-e s.
M ammography status variables
Two d ic h o t o m o u s d e p e n d e n t va ria b le s w e re u sed to ch a ra c t e ri ze p rio r b reast can cer s c re e n -in g b e h a vio r. Th e firs t wa s wh e t h e r o r n ot a wo m a n h a d e ve r re c e i ved a m a m m o gram . T h e seco n d was a m easu re m e n t of co m plian ce w it h A m e r ica n Ca n ce r So cie t y (ACS) b re as t ca n ce r s c ree n in g gu id e lin es. A wom an was con sid ere d t o b e in c o m p lia n c e if sh e wa s age 40-49 ye a r s a n d h a d h a d a m a m m o gr a m w it h in t h e p a s t t wo ye a rs p rio r t o t h e st u d y, o r if s h e wa s 50 ye a rs a n d o ld e r a n d h a d h a d a m a m m o gr a m wit h in t h e ye a r p rio r t o th e st u d y. An a lyse s o f s c re e n in g b e h a vio rs fo r b re ast ca n c er we re re -s t ricte d to wo m en 40 yea r-s an d old e r.
Pap test status variables
An alo go u s t o t h e m a m m o gr ap h y s cre e n i n g va ri a b l e s , t w o d ic h o t o m o u s d e p e n d e n t va r i-a b le s we re i-a lso u se d t o ch i-ar i-a c t e ri ze p rio r ce r-vic a l ca n ce r sc re e n in g b e h a vio r. Th e fir st wa s wh e t h e r or n o t a wo m a n h ad e ve r re c e i ve d a Pa p t e st . Th e se co n d w a s a m e a s u re m e n t o f c o m p lia n ce wit h scre e n in g gu id e lin e s fo r ce r-vica l ca n ce r. Wom e n re p o r t in g h a vin g h a d a Pa p sm e a r wit h in t h e p a st th re e ye a rs p rio r t o t h e stu d y we re con sid ered t o b e in co m p lia n ce wit h gu id e lin es.
Behavioral intent
FERNANDEZ, M. E.; TO RTO LERO -LUNA, G . & G O LD, R. S. 1 3 6
Cad. Saúde Púb lica, Rio d e Jane iro , 14(Sup. 3):133-147, 1998
gu id e lin e s a cc o rd in g t o t h e ir re p o r t e d p r i o r s c re e n in g b e h avio r.
C o v a r i a t e s
a) De m o g ra p h ics ch a ra c t e r ist ics an d a ccu lt u r-a tion : p r-art icip r-a n t s r-age, le ve l of e d u cr-a tio n , m r- ar-it a l st a t u s, e m p lo ym e n t s t a t u s, e t h n ic o ri g i n , p lace o f b irt h , a n d le n gth of tim e in th e Un i t e d St at e s we re o b t ain ed .
Ac c u l t u ra t ion is d e fin e d a s t h e p r o ce ss o f ch a n ge o ccu rrin g as a resu lt o f con ta ct b etwe e n c u l t u ra l grou p s (Ke e f e, 1980). To assess t he leve l o f a ccu lt u ra t io n , a sh or t 5 ite m Like rt scale d e-velop ed an d valid at ed b y Ma rin et a l. (1987) w a s u se d . Ma r in a n d c o lle a gu e s s t a t e t h a t t h e five ite m s co u ld re p re se n t a va lid an d re liab le sh o rt a c c u l t u ra t io n s ca le (Ma r in e t a l., 1987). T h e s e it e m s in clu d e lan gu a ge o f p re f e re n ce t o sp ea k a t h o m e , wit h fri e n d s , re a d / sp e a k, la n gu age u sed a s a ch ild , a n d lan gua ge yo u t h in k in .
b ) Kn owle d ge : Se ve ra l q u e s t io n s c on ce r n -in g b asic b rea st a n d cervica l can ce r kn ow l e d g e w e re a ske d . Kn o wle d ge o f scre e n in g m e t h o d s wa s a sse sse d b y askin g wo m e n t o n a m e m e th -o d s -of b re ast ca n cer scree n in g (“ways th ere a re t o ch eck fo r b rea st ca n ce r”). Po ssib le re s p o n s-e s ws-e rs-e “m a m m o g ra m / m a m m o g ra p h y, clin ical b re a st e xa m in at io n , a n d b re a s t se lf-e xa m in a-t i o n”. Th e kn owled ge score wa s d e a-te rm in e d ac-c o rd in g t o t h e n u m b e r o f m e t h o d s a w o m a n co u ld m e n t io n . Th e ra n ge o f re s p o n se s wa s f ro m ze ro t o th re e . Kn owle d ge o f ce rvica l can -c e r s -cre e n in g (Pa p t e st ) wa s a ls o a sse s se d b y askin g wom en if t h e re wa s an y way t o ch eck for c e rvica l ca n ce r, a n d if so, wh at we re t h e y. Ce r-t a in re s p o n s e s su ch a s “la p ru e b a d e l c a n c e r” (t est fo r can ce r) a n d “c i t o l o g í a” (cit o lo gy) we re a lso a cce p tab le re s p o n s e s.
Kn owled ge of sign s an d sym p tom s for b reast ca n c e r wa s a lso a sse sse d . Th e list o f s ign s an d sym p tom s in clu d ed p resen ce of lu m p s, ch an ges in t h e skin o r su rfa ce o f b rea st , ch a n ge s o r d iff e re n ce s in b re a st size, an d p re se n ce o iff se cre -t i o n s, b lo od , in fla m m a-t ion , a nd p a in . Th e q u e s-t io n wa s o p e n -e n d e d a s kin g w om e n s-t o liss-t a ll t h e sign s a n d sym p t o m s of b re a st c a n ce r t h a t t h e y kn e w. Pa rt icip a n ts w e re a lso a ske d a b o u t sp e cific r e co m m e n d a t io n s re g a rd in g t h e fre -q u e n c y w it h w h ich a wo m a n t h e ir age sh o u ld h a ve a m am m o gra m , clin ical b re a st e xa m in a-t io n (CBE), Pa p a-t e sa-t , a n d p ra c a-tice b re a sa-t se lf-e xa m in a t ion (BSE). Wo m lf-e n wlf-e rlf-e a s klf-e d “ h ow o ft en sh ou ld a h ea lth y wo m a n yo ur a ge h a ve a m a m m o g r a m ?” Sim ila r q u e st io n s we re a ske d a b ou t a Pap sm e ar, CBE, a n d b rea st self-exam ?” K n ow le d ge a b o u t b re a st an d ce r vica l c an -cer scree n in g m e th od s, im p o rt an ce o f e arly d
e-te ct ion , an d risk fact o rs fo r b re ast a n d ce r v i c a l ca n cer em p loyin g a “t ru e / f a l s e / d o n’t kn ow” re -sp on se for m a t we re also u sed . Knowled ge q u e s-tion s we re a d ap t ed fro m t h o se u se d in a n in te r-vie w q u e s t io n n a ire a b o u t ca n c e r sc re e n i n g ( Sa i n t - Ge rm a in & Lo n gm a n , 1993).
c) At tit u d es ab ou t ca n cer: It e m s m ea su ri n g at t it u d e s a b o u t ca n c e r we re a d a p t e d fr o m t h o se d e ve lo p e d b y Pe re z - St a b le e t al. (1992). Th e it e m s in t h is sca le we re a ls o d e e m e d re l e -va n t fo r fo re i g n - b o r n H isp a n ic wo m e n in t h e Wa s h in gt o n DC a re a b as e d o n fin d in gs fro m fo cu s grou p s a n d in d ep th in terviews co n d u ct -e d d u r in g t h -e p la n n in g o f t h is s t u d y. Th -e at t i-t u d e s r e fle ci-t e d b y i-t h e ii-t e m s a ls o e m e rge d in t h e se fo cu s gro u p s a n d in - d e p th in t e rv i e w s ( He rn a n d ez, 1992).
d ) Pre d is p o sin g fa c t o rs a n d b a rr ie rs: Pre -d is p o sin g fa c t o rs a re c h a r a c t e r ist ic s o f a p e r-so n or p op u la tio n t h a t m otivate b e h avio r p ri o r t o t h e o cc u rre n ce o f t h e b e h a vio r (Gre e n & K re u t e r, 1991). Th ese in clud e fear of d e te ctio n , e m b a r ra ssm e n t , fe a r o f sp e cific p r o c e d u re s, an d th e he alt h b elief m od el va riab les in clud in g p e rc e i ve d s u s ce p t ib ilit y, p e rc e i ve d b e n e fit s, a n d p e rc e i ve d b a rri e r s. A n u m b er o f qu est ion s we re u sed t o m ea su re t h ese h e alth b e lief m od -e l va ri a b l -e s. Tw o q u -e s t ion s t h a t a d d e ss p -e r-c e i ve d su sr-cep tib ility, we re a d ap t ed from a sr-cale d e ve lo p ed b y Re yn o ld s (1987) a n d we re m o d i-fie d slight ly t o m e a su re p erc e i ve d su sce p tib ili-ty t o ce r vical can cer as well a s t o b re a st ca n ce r ( Re y n o l d s, 1987). Two ot h e r it e m s a ske d ab ou t b en e fits an d b arrie rs to m a m m ogra p hy scre e n -in g. Th e -in st ru m e n t a ls o -in c lu d e d q u e s t io n s th a t a ske d p articip an t s a b o u t th eir le ve l o f fe a r a n d e m b a rr a ss m e n t o f e a ch o f t h e scre e n i n g p ro c e d u res (Pap te st , m am m ogra p h y, CBE, an d BSE). Re sp o n se o p t ion s ra n ged fro m 1 t o 10. A su b s e t o f t h e se it e m s w a s u s e d t o c a lcu la t e a Ma m m o g ra p h y Ba r r ie rs sc a le t h a t in clu d e d ite m s con ce rn in g t h o se fact o rs fo u n d t o in flu -e n c -e m a m m o gra p h y u t iliza t io n (Fo x & St -e i n , 1991). Re lia b ilit y a n a lysis re ve a le d a cce p t a b le i n t e rn a l con sist e n cy relia b ility (.61).
M AMMO G RAPHY AND PAP TEST IN HISPANIC WO MEN IN USA 1 3 7
C ad. Saúde Púb lic a, Rio de Jane iro , 14(Sup . 3):133-147, 1998 op e n - e n d e d . Th e p a r t ic ip a n t was a ske d t o
id e n t ify re a so n s wh y s h e h ad n o t h a d a Pa p t e st, m a m m o gra m , CBE, o r p ra ct ic e d BSE. Th e se b ar rie r q u e st io n s we re a d a p t e d fro m an i n t e rvie w qu e st ion n a ire a b o u t ca n ce r s cre e n in g d evelo p ed fo r u se with lowin com e Hi s p a n -ic wo m e n (Sa i n t - Ge rm a in & Lo n gm a n , 1993).
d ) Self e ffica cy: Is d e fin ed a s “th e con v iction th at on e ca n su ccessfu lly ex ecu te t h e beh av ior re q u i red t o p rod u ce th e ou t co m es”( Ba n d u ra , 1977:79). In th e cu rren t stu d y, self-efficacy re f e r s sp e cific a lly t o se lf-p e rc e p t io n s o f c a p a c it y t o p e rf o r m BSE, t o com m u n ic at e e ffect ive ly wit h t h e p h ysicia n (o r h e a lth ca re p rovid e r ), a n d t o fin d wa ys t o o b t ain a cce ss to h e a lth care (Go n -z a l e-z & Go n -z a l e -z, 1990). Se lf-effica cy wa s m e a-s u red b y 11 ite m a-s t h at e licit a-se lf-p e rce p t ion a-s of cap acit y t o p erf o r m an d te ach BSE, to co m m u -n ica t e e ffect ive ly with t h e p h ysicia -n (o r h e a lth c a re p rovid er), an d to fin d wa ys t o get a cce ss to h e a lt h care. Th e s elf-e ffica cy sc ale u se d in t h e c u r re n t stu d y is m ad e u p o f clo sed -e n d e d , Lik-e rt - t yp Lik-e qu Lik-e s t ion s d Lik-e vLik-e lo p Lik-e d b y Go n z a l Lik-e z & Go n z a l ez (1990). Th e Se lf Effica cy Scale wa s in -t e r n a lly c o n s is-t e n -t wi-t h a Cro n b a c h Alp h a o f .79. Su b sca le s also sh owe d go od in t e rn a l co n -s i -s t e n c y: t h e BSE, ove rco m in g b a r ri e r -s, a n d co m m u n ica t io n s su b sc a le s h a d Cro n b a ch Al-p h as of .68, .58, a n d .78 re s Al-p e c t i ve l y.
Th e sca les for accu ltu rat ion , att itu d es a b o u t c a n c e r, a n d s e lf-e ffica cy u s e d in t h e p re s e n t stu d y h a d b ee n p re viou sly t ran slat ed an d u se d in Sp an ish a s we ll as in En glish. Th e rem a i n i n g i n s t ru m e n ts we re p ro fe ssio n ally t ra n sla te d an d b a c k - t ra n s la t e d a cco rd in g t o t e ch n iq u e s re c-om m e n d e d b y Br islin , Lo n n e r a n d T h o rn d i k e ( Br islin e t a l., 1973; Ch a p m a n & Ca rt e r, 1979).
St atistical analysis
De s c ri p t i ve sta tistics we re com p u t ed for all d e -p e n d e n t va r ia b le s (-p r io r sc re e n in g b e h a vio r an d in t e n t io n t o ob t a in a m a m m o gra m ) a n d c ova ria te s (d e m o gra p h i c s, a ccu lt u ra t io n le ve l , b a r ri e r s, kn ow l e d g e, a t t it u d e s , p re d i s p o s i n g f a c t o r s, a n d s e lfe ffic ac y). Bi va r ia t e re l a t i o n -sh ip s b e twe en d ep en d e n t va riab les a n d cova ri-a t e s we re te st e d fo r in d e p e n d e n ce u sin g Pe ri-a r-s o n’r-s c h i- r-sq u a r e d t e r-st o r Fi r-s h e r’r-s e xa ct t e r-s t . Fu rt h e rm o re, t h e re la t io n s h ip s b e t we e n o u t -com es an d cova riat es we re an a lyzed b y t wo a ge s t ra t a (30-49 ye a rs a n d 50 ye a rs a n d o ld e r). First , u n iva ria t e lo gist ic re g re ss io n m o d e ls w e re u se d t o a s se s s t h e a ss o cia t ion b e t we e n c ova ria t e s o n sc re e n in g p ra c t i c e s. O n ly va ri-a b le s wit h ri-a p vri-a lu e o f ≤ 0.25 ( Wa ld χ2) in t h e
u n i va riat e a n a lysis w e re c o n sid e re d fo r in clu
-sio n in t h e m u lt iva ria t e a n a lysis. Th e n , m u lt i-va riat e lo gis t ic m o d e ls we re p e rf o r m e d t o a s-se s s t h e in d e p e n d e n t e ffe ct o f t h e s e le ct e d va ria b le s o n scre e n in g b e h a vio rs. An a lyse s o f s c re e n in g b e h a vio rs fo r b re a st ca n c er we re re -s t r ict e d to w o m e n 40 ye a r-s a n d o ld e r, wh ile a n a lyse s fo r s cre e n in g b e h a vio r s fo r ce r v i c a l ca n ce r in clud ed all wom e n .
R e s u l t s
Study population
A s a m p le o f 148 Hisp a n ic w o m e n livin g in o r a r o u n d Wa sh in gt o n D C we re in c lu d e d in t h e a n a l y s i s. All w e re fo re i g n - b o r n H i s p a n i c s. T h e m a j o r it y o f t h e s u b je ct s we re Ce n t ra l Am e r i-c a n (61%) w it h t h e se i-con d la rge st grou p b ein g So u t h Am e r ica n (27%). O n ly 7% a n d 5% of t h e su b je cts we re Me xica n an d Ca rib b e a n , re s p e c-t i ve ly ( Ta b le 1). Pa rc-t i c i p a n c-t s’ a ge ra n ge d fro m 30 t o 77 ye a r s (m e a n a ge 46 ye a r s, SD = 11.5).
Tab le 1
De mo g rap hic c harate ristic s o f stud y po p ulatio n.
Va r i a b l e n p e rc e n t
Age (years)
3 0 - 3 9 5 6 3 8 4 0 - 4 9 4 2 2 9
50 + 4 9 3 3
Education (years)
< 6 4 0 2 8
6-11 5 3 3 7
1 2 + 5 2 3 6
Place of origin
Ce ntral Ame rica 8 8 6 0 So uth Ame ric a 4 1 2 8 M e x i c o 1 0 7 C a r i b b e a n 8 5
M arital stat us
S i n g l e 3 5 2 4 M a rr i e d 6 7 4 7 S e p a r a t e d / d i v o rc e d 1 9 1 3 Wi d o w e d 1 5 1 0 O t h e r 1 1 7
I n c o m e
< $15 ,000 1 2 1 8 4 $ 1 5 , 0 0 0 + 2 3 1 6
E m p l o y m e n t
FERNANDEZ, M. E.; TO RTO LERO - LUNA, G . & GO LD , R. S. 1 3 8
Cad . Saúd e Púb lic a, Rio de Jane iro , 14(Sup. 3):133-147, 1998
Th e m ajorit y o f wo m e n h a d low e d u ca tio n lev-e ls wit h a m lev-e a n of 8 ylev-e a rs (SD = 4.5) o f sch o o l co m p le t e d . Fo rty seve n p e rce n t h a d six o r le ss ye ar s of sc h oo lin g a n d 15% o f th e s a m p le h ad le ss th an th re e yea rs o f form al e d u ca tion . So m e o f th e su b je ct s ad m itt ed to n o t kn owin g h ow t o re a d , o th e r s re q u e st e d t h a t t h e d at a co lle c t o r sign t h e ir n am e fo r t h e m o n t h e co n sen t fo rm . Fifty th ree p ercen t of th e wom en were em p loyed at th e tim e o f th e stu d y (24% fu ll-t im e an d 29% p a r t -t im e e m p loym e n t ) a n d o n e t h ird o f t h e wo m e n (37%) in d ica t e d t h a t t h e y we re u n e m -p l oye d . Ye a rly h o u se h old in co m e s o f le ss t h an $15,000 we re re p o rt e d b y 84% of t h e wo m e n . Fifty t h re e p e rce n t o f wo m e n we re m a rr ie d o r livin g in m ar rie d like sit u a t io n , 24% we re sin -g l e, a n d 10% we re wid owe d .
Th e le n gt h of t im e livin g in t h e Un i t e d St a t e s va rie d co n sid e ra b ly a n d r an ge d fro m le ss t h a n o n e ye a r t o 33 ye a rs (m e a n 9, SD = 6.9). On e t h ird o f th e sam p le (34%) h a d lived in t h e Un ite d St a te s fo r 5 ye ar s o r le ss in d ic at in g t h e re l a t i ve ly h igh p ro p o r t io n o f re ce n t im m i-g ra n t s. Alt h o u i-gh a p p r o xim a t e ly 40% o f t h e sa m p le h a d live d in t h e Un it e d St a t e s fo r 10 ye a rs o r m o re, t h e se wo m e n still h a d re l a t i ve l y l ow a ccu lt u ra t ion le vels a s in d ica t ed b y t h e a c-cu ltu ration scale. Fifty n in e p ercen t h ad th e low-e st p o ssib llow-e a cc u lt u ra t io n sc orlow-e o f fivlow-e p o in t s (o u t o f 25 p o in t s). Sixt y se ve n p e rc e n t o f t h e s a m p le re p o rt e d s p e a kin g o n ly Sp a n ish , 95% sp oke o n ly Sp a n ish at h o m e, 90% said t h e y o n -ly t h ou gh t in Sp an ish , an d 83% com m u n ica t ed wit h frie n d s on ly in Sp a n i s h .
• S c reening behavior and intent
Nin e t y t h re e p e rc e n t o f wo m e n (n = 138) re -p o rt e d h a vin g e ve r h a d a Pa -p sm e a r. Howe ve r, o n ly 42% o f wo m e n h a d h a d o n e in t h e ye a r p rio r t o t h e st u d y an d 71% h a d h a d o n e wit h in t h e p re viou s t h re e ye a r s. T h e re f o re, 24% o f t h e sa m p le we re n o t in co m p lian ce wit h scre e n i n g re co m m e n d a t io n gu id e lin e s fo r ce r vica l ca n -c e r. Se ve n t y e igh t p e r-ce n t of w om e n re p o rt e d h avin g h ad a clin ica l b reast e xa m an d 79% h ad p ra cticed b re ast -se lf e xam in a tio n a t lea st o n ce in th eir life. Am on g wo m e n over 40,62% re p o rt-e d h a vin g h ad a m a m m o gra m , b u t o n ly 33% we re in com p lia n ce with scre en in g re c o m m e n -d a t io n s a t t h e t im e o f st u -d y fo r a wo m a n o f t h e ir a ge (m am m o gra m e ve ry on e t o t wo ye a r s fo r w o m e n 40-49 ye a rs o ld a n d a n n u a lly fo r wo m e n 50 ye a rs a n d ove r ). No d iffe re n ce s in s c re e n in g b e h a vio rs w e re o b se rve d b e t we e n you n ge r (le s s t h a n 50 ye a rs o ld ) a n d o ld e r wo m e n (Fried m an et a l., 1995). Eigh t y four p ercen t of wom en in n on co m p lian ce with scre e n
-in g m am m o gra p h y re co m m e n d a t io n s (n = 56) sa id th at th e y we re p la n n in g t o ob tain a s c re e n -in g m a m m ogra p h y wit h -in t h e n e xt 3 m o n t h s. Am o n g t h e 35 wo m e n n o t in c o m p lia n ce wit h Pap t e s t s cre e n in g gu id e lin e s, 79% s a id t h a t t h e y in t e n d e d t o re c e i ve a Pa p w it h in t h e n e xt t h ree m o n t h s.
Att it udes and beliefs
Nin e t e e n p e rc e n t o f p a rt ic ip a n t s sa id t h e y wo u ld fe e l u n co m for t ab le t o u ch in g o r kissin g so m e o n e w it h c an ce r, 20% b e lie ve d t h a t ca n -ce r wa s a con t agio u s d ise a se , 63% we re a fra i d of th e word can ce r, a n d 77% b e lieve d th at can -ce r is like ge t t in g a d e a t h s e n t e n c e . Ho we ve r, o n ly 7% t h o u gh t t h e re is lit t le o n e c a n d o t o p re ven t get tin g can cer an d 13% p e rcen t d id n ot b e l i e ve th a t ce rvica l can cer cou ld b e cau sed b y a sexu a lly tra n sm itt e d d isea se.
• K n o w l e d g e
K n ow le d ge a b o u t m e t h o d s for e a rly d e t e ct io n of b re a st a n d ce r vic a l c an ce r a n d s ign s an d sym p t o m s o f ca n c e r w a s lo w. Sixt e e n p e rc e n t of wo m e n we re n o t a b le t o m e n t io n a n y m e t h od of e ar ly d e te ct ion o f b re ast can ce r a n d 49% m e n t io n e d o n ly o n e m e t h o d . Fift y n in e p e rce n t m e n t io n e d m a m m o gra p h y, 33% clin i-ca l b re a st e xa m , a n d 51% a b re a s t se lf-e xa m . Si m i l a r l y, on ly 66% we re ab le t o m e n t io n t h e Pa p s m e a r a s a m e t h o d fo r e a r ly d e t e c t io n o f c e rvical ca n ce r.
Alt h o u gh 65% a n d 55% o f wo m e n re p o rt e d th at “lu m ps in th e bre a s t”an d “p a i n”we re sign s a n d sym p t o m s o f b re a st ca n c e r, o n ly a sm a ll p ro p o rtion o f wom en we re a b le to m en tion an y o t h e rs sign s an d s ym p to m s. Ve r y fe w w om e n sa id th a t ch a n ges in b re ast size (2%), sca ly skin (4%), swo llen b re asts (8%), a n d se cretio n (12%) we re sign s a n d sym p to m s o f b rea st ca n ce r.
K n o wle d ge a b o u t scre e n in g re c o m m e n d a -t ion gu id e lin e s wa s low. Se ve n -t y n in e p e rc e n -t kn e w t h at a w om a n sh o u ld h ave a Pa p sm e a r e ve r y o n e t o t h re e ye a r s. Sixt y se ve n p e rc e n t sa id th a t a wo m an sh ou ld ha ve a clin ica l b re a s t e xa m a n n u a lly. Bu t on ly 52% o f w o m e n kn e w t h e re com m e n d a tio n fo r sc re en in g m a m m og-ra p h y for a wo m a n he r a ge an d o n ly 42% kn ew t h at b re a s t se lf e xa m in a t io n sh o u ld b e p ra c -ticed m o n t h ly.
M AMM O G RAPHY AND PAP TEST IN HISPANIC WO M EN IN USA 1 3 9
Cad . Saúde Púb lic a, Rio de Jane iro , 14(Sup. 3):133-147, 1998 t h a t “m a m m o g rap h y can d et ect lu m p s,”9 7 %
a g re ed th a t “e a rly detection of b reast can cer in -c reases th e li k elih ood of -cu rin g breast -can -cer,”
98% a gre ed t h a t “a m am m ogra ph y w as im po r-tan t for ea rly d et ect io n o f b reast can cer,”9 5 % a g re ed t h a t th e “recom m en d atio n for w om en 50 years an d over is an n u al m am m ogra p h y,”6 9 % agreed th ere were“altern ative treatm en t m e t h o d for b reast can cer oth er t h a n m astectom y,”a n d 85% o f w o m e n a gre e d t h a t t h e “risk o f bre a s t can cer is h igh er am on g w om en w ith fam ily his-t o ry.”In a d d it io n , 96% sa id it wa s t ru e t h a t t h e
“ Pap test w a s a test t o d etect cerv ical ca n cer,”
an d 74% an d 72% agreed th at “som e can cers are cau sed by sexu ally tran sm itted d iseases,”a n d “a h igh fat i n tak e in creases th e risk of so m e typ es of can cer.”L owe r levels of kn owle d ge we re e vi-d en t in oth er areas. For exam p le, 60% of w o m e n i n c o r re ct ly a gre e d t h a t t h e “risk of breast can -cer d ecreases w ith age,”79% t h o u gh t t h a t “ i n -ju ries in crease th e risk of can cer,”a n d 32% in d i-c a t e d t h a t it w as t r u e t h a t “a w o m an d oes n o t n eed a m am m ograp h y u n less t h ere is a lu m p.”
Ad d it io n ally 34% in co rre ctly agre ed t h at “t h e re is n o n e ed o f brea st selfex am in a tio n if m am -m o g rap h y is n egative”a n d on ly 45% o f wo m e n a g re e d t h a t “b rea st self ex am in a tion sh ou ld b e p e rform ed m on th ly.”
P redisposing factors and barr i e r s
Ap p r o xim a t e ly 22% o f wo m e n s a id t h a t t h e y d id n o t fe e l su sce p t ib le t o b re a st o r ce r v i c a l c a n c e r. Se ve ral b arriers to scre en in g we re id e n -tified in th is p op u lat io n . Em b a r rassm e n t a b o u t t h e Pa p s m e a r t e st wa s e xp re sse d b y 53% o f wo m e n , wh e re a s, o n e -t hird o f t h e wom e n said th ey wou ld b e em b a rra ssed a b o ut m a m m o gra -p h y (36%) an d clin ical b re a st exa m (34%). On l y 13% o f w o m e n , h o we ve r, s a id t h e y wo u ld b e e m b a r rasse d a b o u t p ract icin g a b re a st se lf-e x-a m . A lx-arge p ro p o rtion of wom en re p o rt ed fex-a r o f d et e ctin g ca n ce r (90%). W h e re a s, a b o u t h alf o f t h e wo m e n re p o r t e d fe a r a b o u t t h e Pa p sm e a r t e st (56%), m a m m ogra p h y p ro c e d u r e (46%), a n d clin ical b re a st e xa m (44%). In a d d it io n , 55% sa id it h e y w e re a fra id o f m am m o gra -p h y b e in g -p a in fu l a n d 48% e x-p re s se d t h at t h e c o st o f m a m m o gra p h y wo u ld b e a b a r rie r t o ob ta in on e.
Th e m o s t co m m o n re a s o n s e xp re s se d b y w om e n age d 40 ye a rs a n d ove r fo r n e ve r h a v-in g h ad a m a m m o gra m (n = 34) o r a c lv-in ica l b re a s t e xa m (n = 35) we re la c k of sign s a n d sym p t o m s (10 a n d 11 w o m e n , re s p e c t i ve l y ) an d la ck o f a d o ct o r’s re co m m e n d a t io n (6 a n d 4 wo m en , re s p e c t i vely). On ly two wom en m e n tio n e d e m b ar ra s sm e n t or co st o f m a m m o gra
-p h y, a n d t w o wo m e n s aid e m b a r ra ss m e n t fo r a c lin ic a l b re a s t e xa m a s a re a s o n fo r n e ve r h a vin g ob t a in e d t h e t e st s. W h e re a s, h alf o f t h e wo m e n wh o re p o rt ed n e ve r h avin g p e rf o rm e d a b re a st s e lf-e xa m (n = 27) e xp re ss e d t h at t h e m a in re aso n w as n o t kn owin g h ow t o p e r f o rm it (n = 13). Am on g th e sm all n u m b e r of wom en w ho re p o rt ed n eve r h avin g h ad a Pa p sm ea r, (n = 10) t h re e e xp re sse d t h a t t h e y “n e ver th ou gh t abou t it/forgot”an d two e xp re sse d “c o s t”a s t h e rea son for n o t h a vin g h a d t h e te st .
• S e l f - e ff i c a c y
Se lf-e ffica cy t o c o m m u n ic at e e ffe c t ive ly wit h h e a lt h ca re p rovid e rs a n d t o ove rc o m e e n vi-ro n m e n ta l b arriers wa s h igh . Howe ver self-e ffi-cacy to p e rf o rm an d t ea ch b reast self-exam in a-t io n was lowe r. Over 80% p e rcen a-t o f wom en re-s p o n d e d t h a t t h e y we re ce r t a in o r re-so m e wh a t c e r t ain t h a t t h e y co u ld “a sk q u est io n s to a p rov i d e r”(89%), “u n derstan d a health prov i d e r ’s ex p l a n a t i o n”(85%), “u n d ersta n d t h e ex a m ”
(86%), a n d “ex p lain resu lts to oth ers”( 8 6 % ) . Sim ilarly, large p rop ortion s of wom en were con-fid e n t o r so m e wh at co n con-fid e n t t h a t t h e y c o u ld
“k eep do cto rs’ a p p o i n t m e n t s”(88%), “ f o l l ow d o c t o r s’ re c o m m e n d a t i o n s”(95%), a n d “h a ve som ebod y t o tak e th em to th eir a pp oin tm en ts”
(78%). Fe we r wo m e n , h ow e ve r, sa id t h e y we re c on fid e n t o r so m e wh at co n fid e n t t h e y co u ld : p e rf o rm a b rea st self-exa m in atio n (57%), d etect a lu m p (53%), o r t ea ch so m e on e else th e b re a s t self-exa m (58%).
• Univariate analysis
FERNANDEZ, M. E.; TO RTO LERO - LUNA, G . & G O LD , R. S. 1 4 0
Cad. Saúd e Púb lica, Rio d e Jane iro , 14(Sup. 3):133-147, 1998
we re le s s like ly t o h a ve e ve r h ad a Pa p s m e ar t ha n wo m en with h igh er sco re s (83% vs. 95%, p = 0.06). No sign ific an t d iffe re n c e s in t h e p ro -p o r t ion o f wo m e n in co m -p lia n ce with ce rv i c a l c a n ce r s cre e n in g re c o m m e n d a t io n we r e d e -t ec-t e d b e -twee n wo m en wi-t h low a n d h igh selfe ffica cy scorselfe. Si m i l a r l y, n o sign ifica n t a ssocia t io n s we re o b se r ve d b e t we e n c e rvic a l s cre e n -in g b e h a vio r s an d fe a r o f d e t e c t -in g ca n ce r o r fe ar o f t h e wo rd ca n cer.
On ly “fea r of m a m m ogra p h y”wa s s t at is t i-c a lly s ign ifii-ca n t ly a s so i-c ia t e d w it h b o t h h a v-in g e ve r h a d a m a m m o gra m an d wit h com p li-a n c e wit h b re li-ast cli-a n ce r scre e n in g gu id e lin e s. Wo m e n re p o rt in g “fear o f th e m am m ogra p h y”
w e re le ss like ly t o h a ve e ve r h a d a m am m o -g ra m t h a n wo m e n wh o s aid t h e y we re “n o t a f raid of the test”(46% vs. 75%, p = .02) an d we re le ss like ly t o b e in com p lia n ce wit h scre e n i n g recom m e n d a t io n s (16% vs. 47%, p = 0.009). Al-t hou gh n oAl-t sAl-taAl-t isAl-t ically significa n Al-t, wom en wh o sa id th ey we re “ve ry fearfu l of d etectin g can cer”
we re le ss like ly t o h a ve e ve r h a d a m a m m o -g ra m (58% vs. 70%). Old e r wo m e n (a -ge d 50 ye a rs a n d over) we re m ore like ly to re p o rt e ve r h a vin g h a d a m am m ograp h y th an wom en aged 40-49 ye a rs o ld (69% vs. 52%, p = 0.10). T h e p ro p o rt io n of w o m e n re p o r t in g h a vin g e ve r h a d a m a m m o gra m in cre a se d wit h in c re a s i n g n u m b e r o f years sh e re sid e d in th e U.S. Am o n g w o m e n wit h five o f le s s ye a rs o f re sid e n c y in th e U .S., 48% re p o r t e d h a vin g h a d a m a m m o -g ram co m p a re d t o 62% o f t h o se wit h 6-9 ye a r s a n d 69% o f t h ose wit h 10 o r m o re yea rs of re s i-d e n cy (p = 0.24). Wom e n re p o r t in g t h a t t h e y we re “e m b a r rassed by th e test”we re le s s like ly t o h ave e ve r h ad a m a m m o gra m t h a n wo m e n re p o r t in g n o t b e in g e m b a rra s se d b y t h e t e st (46% vs. 70%, p = 0.13) Th ey we re a lso le ss likely t o b e in c o m p lia n ce wit h s cre e n in g gu id e -lin es (21% vs. 44%, p = 0.07).
• M ultivariate analysis
Aft e r c o n sid e rin g a ll t h e ot h e r va ria b le s in t h e m o d e l o n ly se lf-e ffic ac y t o ove rco m e b a rr i e r s rem ain ed a sta t ist ica lly sign ifican t p re d ictor o f Pa p sm e ar scre e n in g ( Ta b le 2). Wo m e n wit h a l ow se lf- e ffic a cy s co re we re 90% le s s like ly t o h a ve e ve r h a d a Pa p sm e ar (OR = 0.09; 95% CI 0.01-0.63). Alt h ou gh n o t s t a t ist ic ally s ign ific a n t , w om e n wit h le s s t h a n 6 ye a r s o f e d u ific a -t io n a n d wo m e n wh o s a id -t h e y we re afra id o f t h e t e st we re 77% a n d 68% le ss like ly t o h a ve e ve r h a d a Pa p s m ea r re s p e c t i ve l y. Em b a r ra s s-m en t a b ou t th e Pa p ss-m ea r was a n in d ep en d e n t fa ct o r a ss o cia t e d wit h a lowe r like lih o o d o f h avin g h ad a Pap sm e ar wit h in t h e t h re e ye a r s
p rio r t o t h e st u d y a ft e r c o n sid e ra t io n fo r a ge, ed u ca t ion , ye a rs livin g in th e U.S., an d se le f-ficacy co m m u n ica t ion sco re (Tab le 3). Wo m e n re p o rt in g t h a t t h e y we re ve r y e m b ar ra sse d b y t h e Pa p t e st we re 68% le ss like ly t o h a ve h a d a te st wit h in t h e la st t h re e ye a rs (OR = 0.32; 95% CI 0.13-0.80). Un like t h e asso cia t io n o b se rve d b e t we e n Pa p t e st sc re e n in g an d se lf-e ffica c y fo r ove rco m in g b a rr i e r s, wo m e n wit h lowe r s c o re s o n t h e su b -scale asse ssin g se lf-e ffica cy fo r co m m u n ic at in g w it h p rovid e rs we re , su r-p ri s i n g l y, 6 t im e s m o re like ly t o re r-p o r t e ve r h a vin g h a d a Pa p sm e a r (OR = 6.25; 95% CI 1 . 1 8 - 3 2 . 9 7 ) .
Am o n g wo m en a ge d 40 ye ars an d old e r th e on ly fa ctor in d ep e n d e n tly asso cia te d with eve r h a vin g h a d a m am m o gra m w a s kn ow l e d g e s c o re (Tab le 4). Wo m e n with in t e rm ed ia t e a n d l ow kn o wle d ge sco re s we re 86% (O R = 0.14; 95% CI 0.03- 0.75) an d 88% (OR = 0.12; 95% CI 0.020.76) le ss like ly t o h a ve e ve r h a d a m am -m o g ra p h y t h a n wo -m e n w it h h igh kn ow l e d g e s c o re s. Th e resu lts a lso su ggest th a t “fe ar o f t he t e s t” m ay b e a ssociate d with a lower likelih ood o f h a vin g e ve r h a d a m a m m ogra p h y. Wo m e n re p o rt in g t o b e so m e wh a t fe a rfu l o f t h e t e st we re 83% le s s like ly t o h a ve e ve r h a d a m a m -m o g ra p h y (OR = 0.17; 95% CI 0.03-0.91) a n d t h o s e re p o r t in g t o b e ve r y fe ar fu l o f t h e t e st w e re 61% le s s like ly t o h ave e ve r h a d t h e t e st (OR = 0.39; 95% CI 0.12- 1.29). No o th e r fa ct o rs we re sign ifican tly asso cia ted wit h t h is b eh a vio r a lth o u gh, wo m en w h o sa id th e y we re ve ry e m
-Tab le 2
Multivariate lo g istic re g re ssio n fo r e ve r having had a p ap sme ar amo ng wo me n 30 ye ars and o ld e r.
Va r i a b l e O R 95 % CI
Age (years)
< 50 1.0
5 0 + 0 . 5 8 0 . 1 1 - 3 . 1 8
Educat ion (years)
12+ 1 . 0
6 - 1 1 4. 10 0 . 3 5 - 4 8 . 3 9 < 6 0. 23 0 . 0 4 - 1 . 4 6
Fear of pap smear
N o fe ar 1 . 0
So me fe ar 0 . 9 6 0 . 0 7 - 1 2 . 3 8 F e a r 0 . 3 2 0 . 0 6 - 1 . 7 9
S e l f - e ff icacy to o v e rcome b arr i e r s
H i g h 1 . 0
MAMMO G RAPHY AND PAP TEST IN HISPANIC WO MEN IN USA 1 4 1
Cad. Saúde Púb lic a, Rio d e Jane iro , 14(Sup . 3):133-147, 1998 b a r ra ss e d a b o u t m a m m o gra p h y, wh o re p o rt
-e d ly f-e a rfu l o f t h -e p ro c -e d u r-e , a n d wh o t h o s -e c o n s i d e re d c o st a b a r rie r fo r o b t a in in g a t e st , we re le s s like ly t o re p o r t e ve r h a vin g h a d a m a m m o g ra m .
Fe a r o f t h e t e st wa s fo u n d t o b e as so cia t e d wit h co m p lia n c e wit h re c o m m e n d e d m am -m o g r a p h y gu id e lin e s in a si-m ila r w a y a s t h e a ss oc ia t io n o b se r ve d fo r h a vin g e ve r h a d a m a m m o g ra m (Tab le 5). Wo m en re p o rt in g t o b e som ewh a t fearful o f t h e t est we re 91% less like -ly t o b e in co m p lia n ce wit h re c o m m e n d e d gu id e lin e s (OR = 0.09; 95% CI 0.01-0.92) a n d th ose wh o said t h e y we re ve ry fearful o f th e t est we re 61% le ss likely t o h a ve e ve r th e t est (OR = 0.29; 95% CI 0.29-1.19). Alt h o u gh n o t st a t ist i-ca lly s ign ific a n t , o ld e r wo m e n , wo m e n wit h l ower le ve ls o f e d u cat io n an d kn owled ge score, a n d w om e n wh o e xp re sse d e m b a rra ssm e n t o r fe ar o f m a m m o gr ap h y we re le ss like ly t o h a ve b e en in com p lia n ce with scre en in g re c o m m e n -d a t i o n s.
D i s c u s s i o n
Th e re s u lt s of t h is s t u d y in d ic at e t h a t t h e fa c-t o rs in flu e n c in g b re a s c-t a n d ce rvica l c a n ce r s c re en in g a m on g low in co m e fore i g n - b o rn Hi s-p a n ic wo m e n a re sim ila r t o t h os e a s so cia te d with scree n in g b eh avio r a m o n g oth e r grou ps o f H isp a n ic wo m e n . Howe ve r, so m e d iffe re n c e s we re id e n t ifie d wh en fin d in gs we re c o m p a re d wit h p revio u s stu d ie s a m on g va rio u s gro u p s o f Hisp a n ic wo m e n . Sixt y t wo p e rce n t o f wo m e n h a d h a d a le a st o n e m a m m o gra m in t h eir life -t im e a n d o n ly 33% we re in c om p lia n ce wi-t h s c ree n in g re c o m m e n d a t i o n s. Th e se re su lt s are sim ila r t o th o se ob se rve d b y To rt o l e ro - Lu n a e t a l. (1995) in Cor p u s Ch rist i, Te xa s a n d b y Ka-p la n e t a l. (1996) in Ar i zo n a , Sa n Di e g o , Co l-o rad l-o an d Ca l i f l-o rn ia , b u t h igh er t h a n th l-o se re-p o r t e d b y t h e NCI Ca n c e r Scre e n in g Co n s o r-t ium (1995) a n d Ka p la n er-t al. (1996) in Te x a s.
A large p ercen t a ge o f wo m e n re p o rt ed h a v-in g h a d a Pa p t e st a t le as t o n c e v-in t h e ir live s (93%), h a vin g h a d o n e wit h in t h e la s t t h r e e
Tab le 4
Multivariate lo g istic re g re ssio n fo r e ve r having had a mammo g rap hy amo ng wo me n 40 ye ars and o ld e r.
Va r i a b l e O R 9 5% CI
Age (years)
4 0 - 4 9 1 . 0
5 0 + 2 . 0 4 0 . 7 2 - 5 . 7 9
Knowledge score
H i g h 1 . 0
I n t e rm e d i a t e 0 . 1 4 0 . 0 3 - 0 . 7 5 Lo w 0 . 1 2 0 . 0 2 - 0 . 7 6
E m b a rrassed by m a m m o g r a p h y
No t e mb arr a s s e d 1 . 0
So m e what e mb arr a s s e d 1 . 0 3 0 . 2 4 - 4 . 3 6 Ve ry e mb arr a s s e d 0 . 4 5 0 . 1 4 - 1 . 5 1
Fear of mammography
No fe ar 1 . 0
So me fe ar 0 . 1 7 0 . 0 3 - 0 . 9 1 F e a r 0 . 3 9 0 . 1 2 - 1 . 2 9
Cost is barrier f or m a m m o g r a p h y
U n l i k e l y 1 . 0
So me what unlike ly 1 . 0 3 0 . 2 4 - 4 . 3 6 Ve ry like ly 0 . 4 5 0 . 1 4 - 1 . 5 1
Fear of w ord cancer
N o 1 . 0
Ye s 2 . 8 1 0 . 9 4 - 8 . 4 1 Tab le 3
Multivariate lo g istic re g re ssio n fo r c o mp lianc e with p ap sme ar g uide line s (3 ye ars) amo ng wo me n 30 ye ars and o ld e r.
Va r i a b l e O R 95% CI
Age (years)
< 50 1.0
5 0 + 0 . 9 6 0.38-2.39
Education (years)
12+ 1 . 0
6 - 1 1 1.39 0 .49-4.00 < 6 0 . 7 7 0 . 2 8 - 2 . 1 4
Years leaving in t he U.S.
1 0 + 1 . 0
5 - 9 2 . 0 8 0 . 7 1 - 6 . 0 7 < 5 1 . 1 6 0 . 3 8 - 7 . 2 8
E m b a rrassed by p ap smear
No t e mb arr a s s e d 1 . 0
So m e what e mb arr a s s e d 1 . 6 6 0 .3 8-7.28 Ve ry e mb arr a s s e d 0 . 3 2 0 . 1 3 - 0 . 8 0
S e l f - e fficacy communicat ion score
H i g h 1 . 0
L o w 6 . 2 5 1 . 1 8 - 3 2 . 9 7
If diag nosed wit h cancer would like t o know
Ye s 1 . 0
FERNANDEZ, M. E.; TO RTO LERO - LUNA, G . & GO LD , R. S. 1 4 2
Cad . Saúd e Púb lic a, Rio de Jane iro , 14(Sup. 3):133-147, 1998
ye a rs (71%), a n d h a vin g h a d o n e wit h in t h e year p rio r t o st u d y (42%). Th e h igh p ro p o rt i o n o f w om e n re p o rt in g h a vin g e ve r h a d a Pa p s m e ar is s im ila r t o t h a t re p o r t e d a m o n g Hi s-p a n ic wo m e n in Te x a s. Nin e t y five s-p e rc e n t o f wo m e n 35 ye a r s a n d o ld e r in Co rp u s Ch ri s t i , Te xa s re p o r t e d h a vin g e ve r h ad a Pa p s m e ar ( To rt o l e ro - Lu n a e t al., 1995). Si m i l a r l y, 82% o f u r b an Hisp a n ic wo m e n 40 ye ar s an d o ld e r re -sid in g in Texa s re p o rted h a vin g h ad a t le ast on e Pap sm e a r in t h eir life t im e ( Th e Na t ion al Ca n -ce r In s t i t u t e / Can -cer Scre en in g Co n s o rt ium for U n d e r s e r ve d Wo m e n , 1995). Th e p e rce n t o f wom en re p o rtin g ha vin g h ad a Pa p sm ear w i t h -in th e la st t h re e ye a rs (71%) wa s sligh t ly lowe r t h a n th a t re p o rte d b y Pe rez - Sta b le e t a l. (1994) in Ca l i f o r n ia (88%) b u t h igh e r t h a n in Te x a s H is p an ics (57%) ( Th e Na t io n a l Ca n c e r In s t
i-t u i-t e / Ca n ce r Scre e n in g Co n s o ri-tiu m fo r Un d e r-s e rved Wo m en , 1995).
In t e r p re t a t io n a n d c o m p a r is o n o f sc re e n -in g r a t e s b e t we e n s t u d ie s n e e d s t o t a ke -in t o c o n s i d e ra tio n rece n t u p w a rd tren d s in cerv i c a l an d b re a st ca n cer scree n in g (Ac k e rm an n et a l., 1992). T h re e re c e n t st u d ie s s u p p o r t t h is in -c re as in g t re n d , p a r t i-cu la rly a m on g Hi s p a n i -c wo m e n (Bre e n & Ke s s l e r, 1994) (Ka p la n e t a l., 1996) (An d e rs o n & Ma y, 1995). D at a fro m t h e 1987 a n d 1990 Na t io n al He a lt h In t e rvie w su r -ve ys in d ica t e t h a t t h e p r o p o rt io n o f Hi s p a n i c wo m e n re p o r t in g s cre e n in g m a m m o gra m s wit h in t h e la st ye ar in cre ased from 13% in 1987 to 31% in 1990 (Breen & Ke s s l e r, 1994). Si m i l a r-l y, Ka p r-lan et a r-l. (1996) su gge st ed an in cre a s i n g t re n d in m am m o gra ph y scre en in g a m o n g Hi s-p an ic wom e n from a s-p s-p roxim a t ely 20% in 1987 t o a p p ro xim a te ly 60% in 1993 (Ka p la n e t a l., 1996). An d erson & Ma y (1995) a lso o b se rve d an i n c re a sin g t re n d in c e r vic a l c a n ce r scre e n i n g ra t es am on g Hisp a n ic w om e n . Th e se d at a su g-ge st s t h a t t h e in cre a se in scre e n in g ra t e s ove r t im e m a y b e p ar t ia lly a t t rib u t a b le t o p u b lic h e a lt h e d u c at io n a n d o t h e r h e alt h p ro m o t i o n e f f o r t s t o in cre a se sc re e n in g a wa re n e s s a n d u t i l i z a t i o n .
Misco n cep t ion s a b o u t ca n ce r an d fa t alistic att it u d e s tow a rd d ia gn o sis a n d t rea t m e n t h ave b e e n re p o r t e d m o re fre q u e n t ly a m o n g Hi s -p a n ic wo m e n t h a n in n o n - His-p an ics wo m e n ( Pe re z - St a b le e t a l., 1995; Na p o l e s - Sp rin ge r e t al., 1996; To rt o l e ro - Lu n a e t a l., 1995; Mo rga n & Le vin , 1995). Si m i l a r l y, kn ow le d ge a b o u t ca n -c e r, sign s an d sym p to m s of -ca n -ce r, ea rly d et e-c- ec-t io n m e ec-t h o d s, a n d fre q u e n c y o f sc re e n in g is l ower am on g Hisp an ic wo m e n (Pe rez - St a b le et a l., 1995; Na p o l e s Sp rin ge r e t a l., 1996; To r -t o l e ro - Lu n a e-t a l., 1995; Mo rga n & Le vin , 1995). Co m p a re d wit h p re vio u s st u d ies, a la rge r p r op o rt io n of wom en in ou r stu d y h ad m isco n ceop -t io n s a b o u -t ca n ce r. Fo r e xa m p le, 79% in o u r st u d y a gre e d t h a t “i n ju ri es cou ld in crease th e risk of can cer”c o m p a red with 58% in th e stu d y b y Mo rgan & Le vin (1995). Se ve n t y se ve n p e r -ce n t o f o u r sa m p le a gre e d t h a t c a n c e r w a s a d e at h se n t e n c e co m p a re d wit h 46% b y Pe r e z -St a b le (1992), 54% b y To rt o l e ro - Lu n a e t a l. (1995), a n d 56% by Mo rga n & Levin (1995).
We fo u n d t h a t 20 % o f w o m e n b e lie ve d t h a t ca n c e r is c on t agio u s, w h e re a s o n ly 9% of wo m en in t h e stu d y b y Mo r gan & Le vin (1995) d id . In ad d it io n , fe a r o f t h e wo rd “c a n c e r” w as re p o r t e d b y 63% o f o u r sa m p le a n d 71% in t h e st u d y b y To rt o l e ro - Lu n a et a l. (1995). Si m i l a r l y, k n owle d ge ab ou t ca n ce r, sign s an d sym p to m s o f ca n c e r, e a rly d e t e c t io n m e t h od s, a n d fre -qu e n cy of scre en in g wa s low in o u r st u d y as in
Tab le 5
Multivariate lo g istic re g re ssio n fo r c o mp liance with mammo g rap hy g uide line s amo ng wo m e n 40 ye ars and o ld e r.
Va r i a b l e O R 95% CI
Age (years)
4 0 - 4 9 1 . 0
5 0 + 0 . 7 0 . 2 2 - 2 . 0 4
Educat ion (years)
12 + 1 . 0
6 - 1 1 1 . 1 4 0 . 2 9 - 4 . 5 1 < 6 0 . 5 3 0 . 1 3 - 2 . 2 5
Knowledge score
H i g h 1 . 0
I n t e rm e d i a t e 0 . 8 2 0 . 2 0 - 3 . 2 8 Lo w 0 . 5 3 0 . 1 3 - 2 . 2 5
E m b a rrassed by m a m m o g r a p h y
N o t e mb arr a s s e d 1 . 0
So me what e mb arr a s s e d 0 . 5 7 0 . 1 1 - 3 . 0 2 Ve ry e mb arr a s s e d 0 . 7 2 0 . 1 8 - 2 . 9 3
Fear of mammog raphy
No fe ar 1 . 0
So me fe ar 0 . 0 9 0 . 0 1 - 0 . 9 2 F e a r 0 . 2 9 0 . 0 7 - 1 . 1 9
S e l f - e fficacy communicat ion score
H i g h 1 . 0
L o w 0 . 4 7 0 . 0 7 - 3 . 3 7
S e l f - e ff icacy t o o v e rcome barr i e r s
H i g h 1 . 0
MAMMO G RAPHY AND PAP TEST IN HISPANIC WO MEN IN USA 1 4 3
Cad. Saúde Púb lic a, Rio d e Jane iro , 14(Sup . 3):133-147, 1998 o t h e r st u d ie s a m o n g H isp a n ic wo m e n (Pe re z
-Stab le et a l., 1995; Na p o l e s - Sp rin ge r et a l., 1 9 9 6 ; To rt o l e ro - Lu n a e t a l., 1995; Mo rga n & Le vin , 1 9 9 5 ) .
It is im p o rt a n t t o n o t e t h a t w o m e n p e r -f o rm e d m u ch b e tt e r in th e “t ru e / -f a l s e” kn ow l-e d gl-e it l-e m s t h a n o n t h l-e o p l-e n - l-en d l-e d it l-em s t h at a s ke d t h e m t o re ca ll in fo r m a t io n (e .g. ab o u t s c re e n in g o r sign s a n d s ym p t o m s o f ca n ce r). H e n c e t h e d iffe re n ce in p e rce n t co rre c t b e -t we e n -t h e 96% of wom e n wh o a gre ed wi-t h -t h e t ru e / false stat em en t th a t a Pa p te st is to te st fo r c e rvica l ca n ce r ve rsu s t h e 66% o f wo m e n wh o we re a b le t o m e n t io n t h e Pa p t e st wh e n a ske d a b o u t “wa ys t o d e t e c t ce r vica l ca n ce r.” T h e t ru e / fa lse it e m s m e a su r e t h e lowe st le ve l o f k n ow l e d g e, (i.e. re c o gn it io n ) wh ile t h e o p e n e n d e d ite m s m o re a ccu r a t e ly a ss e s s u n d e r -s t a n d i n g .
In p re vio u s st u d ie s, fe a r o f fin d in g ca n c e r a n d fea r o f t h e scre e n in g p ro c e d u re h ave b ot h e m e rge d as b a rrie rs t o b rea st a n d cervica l ca n -cer scree n in g (Ba st a n i e t al., 1994; Mu n n , 1993; Ro e t z h e im e t a l., 1993). In t h e cu rr e n t st u d y, fe a r o f d e t e c t io n wa s also a sso c ia te d wit h s c re e n in g b e h a vio r alth o u gh t h e fin d in gs we re n ot statistically sign ifican t. For exam p le, w o m e n re p o rt in g high e r le vels of fea r of d et ectin g can cer we re le ss likely t o h ave eve r h ad a m a m m o -g ra m . By con tra st , wom en who re p o rt ed h i-gh er l e vels o f fea r a b o u t th e word ca n cer we re m o re likely to h ave h ad a m a m m ogram (OR = 2.81, CI 0.948.41) a n d t o b e c om p lia n t wit h re c o m -m e n d ed b reast ca n ce r scree nin g gu id elin e s (OR = 5.83, CI 1.52-22.36). Wh y wo u ld fe a r o f t h e w o rd ca n c e r b e p o sit ive ly a sso cia t e d wit h m a m m o g ra p h y screen in g, b u t fe ar of d e te ct in g c a n c e r b e n e ga t ive ly a s so c ia t e d w it h m am -m o g ra p h y? Pe rh ap s t h e se see-m in gly con t ra d i c-t o r y fin d in gs in d ic a c-t e c-t h a c-t ic-t e m s in q u iri n g ab o u t fe a r o f t h e wo rd “c a n c e r” a n d fea r o f d e -te ct in g ca n cer m ea su re t wo d istin ct con stru c t s. Fe ar o f th e word ca n cer d e n ot es a gen e ra l wo r-ry o r a n xiet y a b o u t t h e d isea se wh e rea s fe a r o f d e tectin g ca n cer m a y assess a ve ry sp ecific fear m o re clo se ly re la t e d t o t h e a ct o f s c re e n i n g . W h e re a s fe a r o f t h e w ord ca n ce r m a y a ct a s a m o t i vat in g fa c tor cu e in g wo m en t o act t o p ro -t e c-t -t h e ir h e a l-t h , fe a r o f d e -t e c-t in g ca n ce r m a y re p re se n t a n e gat ive b e lie f c lo se ly re la t e d t o t h e cu lt u ra l t h e m e o f fa t alism o (Ch a ve z e t a l., 1997). Fat ilis m o m a y b e a b a rrie r in t h e se n s e th at it m a y le ad so m e Hisp a n ics to a ssu m e th at t h e re is lit tle th a t t h e y can d o to p re ve n t can cer ( Pe re z St a b le e t al., 1992). Fu rt h e rm o re, th e b e -lie f t h a t c a n ce r is a d e a t h se n t e n ce a m o n g a l a rge p ro p o rt ion o f wo m en in o u r st u d y (77%), m a y a c t as a sign ific a n t d et e r re n t t o scre e n i n g
p ra c t i c e s. Wo m e n m ay b e lie ve t h at if ca n cer a lw ays m e a n s d e a t h t h e re is n o p o in t t o scre e n -in g, an d t h e y m a y p re fe r n o t to kn ow th ey h a ve c a n c e r. Th e p r o p o r t io n o f wo m e n re p o rt i n g t h a t t h e y t h o u gh t ca n ce r wa s like a d e a t h se n -t en ce in -th is s-t u d y was h igh er -th an am on g Ca l-i f o r n l-ia H l-i sp a n l-ics l-in a p re vl-iou s st u d y (77% vs. 46%) (Pe rez -St ab le et a l., 1992).
Fe ar o f t h e scre e n in g t e st wa s a sign ifican t b a r rie r t o b re a st an d cervic al can ce r scre e n i n g a m o n g w o m e n in t h e s a m p le . Wo m e n re p o rt -in g at le ast so m e fear of th e p ro c e d u re we re b e-t wee n 60% an d 80% less likely e-t o h ave e ver h a d a m a m m o gr a m a n d 70% t o 90% le s s like ly t o b e in com p lia n ce wit h m a m m ograp h y scre e n -in g gu id e l-in e s. Fo r Pa p t e st , wo m e n re p o rt i n g fe a r o f th e e xa m we re alm o st 70% less likely t o e ve r h a ve re c e i ve d it . Th e s e fin d in gs s u gge s t t h a t alt h o u gh fe a r o f ca n ce r m a y n o t d e t e r a wo m an fro m s cre e n in g, fe a r o f t h e s cr e e n i n g p ro c e d u re it se lf is a b a r r ie r t h a t sh o u ld b e a d d r e sse d a m o n g low in co m e fo re ign b o r n Hi sp a n ic wo m e n . It is u n cle a r wh e t h e r o r n o t t h is fe ar is b as e d o n a fe a r o f t h e u n kn o wn , a w o m a n’s o wn p rio r e xp e r i e n c e , o r wh a t o t h e r wom e n h a ve t o ld th e m a b o u t t he p ro c e d u re.
Em b a r rassm e n t was an im p o rta n t fa cto r in -flu e n cin g Pa p t es t u t iliza t io n am o n g t h e s t u d y p o p u la t io n . Wom e n wh o sa id t h e y w o u ld b e e m b a r ra sse d a b o u t h a vin g a Pa p t e st we re sig-n ific a sig-n t ly le s s like ly t o b e isig-n co m p lia sig-n ce wit h Pa p t est scree n in g gu id e lin e s (OR = .32, CI .13-.80). Si m i l a r l y, wo m e n wh o sa id th e y w ou ld b e “ve r y e m b ar ra s s e d ” ab o u t h a vin g a m am m o -g ram we re ab ou t h a lf a s like ly t o h ave eve r h ad o n e or to b e in co m p lian ce with re c o m m e n d e d m a m m o g ra p h y s cr e e n in g gu id e lin e s. Se ve ra l st u d ies co n c u r w it h t h is fin d in g a n d n o te t h a t wo m e n wh o in d ica t e e m b a r ra ssm e n t a re le s s like ly t o h a ve h a d a m a m m ogram o r a Pap t e st in th e p ast year (Ste in e t a l., 1992; Harla n et a l . , 1991; Rich ard son et a l., 1992).
FERNANDEZ, M. E.; TO RTO LERO -LUNA, G . & G O LD, R. S. 1 4 4
Cad. Saúde Púb lica, Rio de Jane iro , 14(Sup . 3):133-147, 1998
s c r e e n in g s e r v i c e s. T h e re a re m a n y p ro g ra m s t h a t p ro vid e lo w a n d n o co s t sc re e n in g t o wo m en in n eed . Hea lth fairs offerin g free m a m -m o g ra p h y a n d Pa p te st scre en in g a re co n d u ct-e d ct-evct-e ry yct-e ar in t h ct-e co m m u n it y from w hich th ct-e sa m p le wa s se lect e d . It is likely th a t co st w as a p e rc e i ved b a rr ie r a m on g wo m en wh o h ad n ev-e r h a d a m a m m o gr am b u t a m o n g t h o sev-e wh o h a d , (a n d we re s im p ly n o n - co m p lian t wit h s c re e n in g re c o m m e n d a t io n s ) co s t wa s n o t a s i m p o rt an t issu e b eca u se th e y kn ew h ow t o o b -t a in low co s-t m am m o gra m s.
Beca u se t h ere was litt le va riab ilit y in a ccu l-t u ral-tio n le ve ls a m on g wom e n in l-th e sa m p le, il-t d id n ot p r ovid e m u ch in fo rm a t ion a s a n e x-p l a n a t o r y va ria b le in t h e m u lt iva riat e m o d e ls. Th e n u m b er of yea rs in t h e Un ite d St at es was a va riab le con sid ered in th e m u ltiva ria te m o d els, b u t d id n o t e m e rge a s a fa c t o r in flu e n cin g m a m m o g r a p h y or Pa p t e st sc re e n in g. Re s u l t s in d ica t e d , h o we ve r, t h a t w om e n livin g in t h e U S fo r 5-9 ye a rs we re t wice a s likely t o b e in com p lian ce with recom m en d ed Pap test screen-in g gu id e lscreen-in e s a s re ce n t im m igra n t s (le ss t h a n 5 ye a rs) an d wo m e n wh o h ad live d in t h e U S fo r t e n o r m o re ye a r s. Re ce n t im m igran t s m a y h a ve lowe r scree n in g ra t e s t h a n o t h ers fo r se v-e ral rv-e a s o n s. Pro b lv-e m s wit h a n “u n d o c u m v-e n t-e d ” sta tu s m akt-e it d ifficu lt t o ob ta in h t-e alth ca rt-e b eca u se t h ey m a y b e in e ligib le fo r fed e ral p ro -g ra m s. Re ce n t im m i-gr a n t s h a ve m an y o t h e r b a r r iers in clu d in g, la n gu age, com p e tin g p ri o r i-t i e s, a n d la ck o f kn ow le d ge a b o u i-t s cre e n i n g t h a t m a y p re ve n t t h e m fro m ob t a in in g n ee d e d s c re e n i n g s. It is less clear wh y wom e n wh o h a d l i ve d in t h e U S fo r t e n ye ar s or m o re we re le s s like ly t o b e in co m p lian ce wit h re c o m m e n d e d gu id e lin e s t h a n wo m e n w h o h a d live d in t h e U S for 5-9 ye a r s.
K n owle d ge a b o u t b re a s t an d ce r vica l c a n -ce r a n d ca n -cer scre e n in g sign ifica n tly p re d i c t-e d m a m m o gra p h y scrt-et-e n in g a m o n g wom t-e n in t h e st u d y. Wo m en with low leve ls o f kn ow l e d g e we re sign ifica n t ly less like ly (OR = .12, CI 0.02-0.76) t o h a ve eve r h a d a m am m o gra m . Kn ow l-e d gl-e h owl-e vl-e r w as n ot im p o rt a n t in p rl-e d i c t i n g Pa p t est screen in g in th is p op u la t ion . Alth ou gh m a n y st u d ie s h a ve d e m o n st r at e d t h a t kn ow l-e d gl-e alon l-e is n o t p rl-e d i c t i vl-e of h l-e a lth b l-e h avior, c e rta in t yp es o f kn owle d ge a re ofte n p re re q u i-site s fo r b e ha vio r ad o p t ion o r ch a n ge t o o ccu r. Fo r e xa m p le, fo r a wo m a n t o p r ac t ice b re a s t ca n ce r scre e n in g a cco rd in g to t h e a p p ro p ri a t e a ge - sp e c ific r e c o m m e n d a t i o n s, sh e n e e d s t o k n ow wh a t t yp e o f t e s t s h e n e e d s a n d wh a t t h ose re co m m e n d a tio n s are. Ot h e r, m o re ge n -e ra l t yp -e s o f kn o wl-e d g-e su ch a s in fo rm a t i o n a b o u t th e an at om y o f th e b reast o r t h e b io logy
o f c a n ce r w o u ld m o st like ly b e u n re la t e d t o m a m m o g r a p h y sc r e e n in g. Th e s p e cific t yp e o f kn o w le d ge a ss e s s e d in t h e c u rre n t s t u d y d e a lt wit h t yp e s o f b re a s t an d c e rvic a l c an ce r s c re e n in g a n d sc re e n in g re c o m m e n d a t i o n s, a n d a wa re n ess th a t b rea st a n d cervica l ca n ce r, if d e te cte d early ca n b e cu red . Th e m isco n ce p t io n s ab o u t c an ce r m e n t io n e d a b ove d e m o n -s t ra te th e la ck of b a -sic kn owle d ge a b o ut ca n ce r an d early d e te ction a m on g m an y wo m en in t he s a m p l e. Beca u se t h e se m isco n ce p tio n s lea d t o ot h er b a rr iers su ch a s fe ar, b elie f th at ca n ce r is i n c u ra b l e, a n d m isco n c e p t io n s a b o u t t re a t -m en t , la ck o f kn owle d ge -m a y b e an e ve n -m ore i m p o rta n t fa ct or in flu en cin g scree n in g a m on g ve r y lo w lit e ra t e wo m e n a n d t h o s e wit h low ed u ca t ion le ve l s.
Wo m e n wh o h a d lo w se lf-e ffic ac y in o ve r-co m in g b arriers we re sign ifica n tly less like ly to h a ve e ve r h ad a Pap te st . By con t ra st, a b elief in h e r a b ilit y t o ove rco m e b a rr ie r s wa s n o t a sig-n ifica sig-n t p re d icto r o f m am m o gra p h y scre e sig-n i sig-n g . An u n exp ecte d fin d in g occu rre d fo r se lfeffica -cy for com m u n ica tion with p rov i d e r s. Alt h o u g h n o t s t a t ist ica lly s ign ific a n t , wo m e n wh o h ad l ow se lf e ffica cy fo r c om m u n ic a t in g wit h p rovid e rs w e re h a lf as like ly t o b e in co m p lia n ce w it h m lia m m o grlia p h y s cr e e n in g gu id e -lin e s t h a n wom e n wh o re p o rte d a h igh le vel o f con fid e n ce in h er a b ility t o com m u n icat e w it h p rov i d e r s. By co n t r a st , w o m e n w h o h a d low se lf-efficacy for co m m u n ica t in g wit h p rov i d e r s we re m o re like ly t o b e in co m p lia n ce wit h Pa p t e s t s cre e n in g gu id e lin e s. Sin c e t h e d a t a is c ro ss se c t io n a l in n a t u re, o n e p o ss ib le e xp la -n a t io -n o f t h is fi-n d i-n g is t h at t h e d ir e ct io -n of ca u sa t io n is o p p o sit e of wh at wou ld b e e xp ect -e d . Fo r -e xam p l-e, wo m -e n wh o h a v-e h a d Pa p tests an d wh o h ave b ee n e xp osed to co m p licat-e d licat-e xp la n a t ion s o f rlicat-e s u lt s or n licat-e ga t ivlicat-e licat-e xp licat-e r i-en ces co m m un ica t in g wit h p rovid er s m a y su ffe r a d e cre as e d le ve l o f s e lfe ffic ac y fo r co m -m u n icat io n . Th ose wo -m en wh o h a d n e ve r h a d a Pap t e st o r w h o h a d n o t h a d o n e in se ve ra l ye a rs (n o n co m p lia n t ) m a y b e m o re op t im ist ic ab ou t t h eir a b ilit y t o co m m u n ica t e effect ive l y wit h p rov i d e r s. Fu rt h e r exp lo rat io n o f th is va ri-a b le is wri-a rrri-a n t e d .
L i m i t a t i o n s
