Women’s understanding of the term ‘Pap smear’: A comparison

of Spanish speaking versus English speaking women.

David L Howard, Beth Soulli, Nicole Johnson, Saladin CooperUniversity of Missouri Kansas City

Cervical Cancer Rates in U.S. All Women

The American Cancer Society's estimates for cervical cancer in the United States for 2015: About 12,900 new cases of invasive cervical cancer will be

diagnosed. About 4,100 women will die from cervical cancer.

Cervical Cancer #14 cause of cancer deaths in women in U.S.

American Cancer Society. Cancer Facts & Figures 2015. Atlanta: American Cancer Society; 2015.

Why are we talking about cervical cancer screening?RESULTS FROM A NATIONAL SURVEY IN 2012 [2012 Behavioral Risk

Factor Surveillance System survey—133,851 women.]

Benard VB, Thomas CC, King J, Massetti GM, Doria-Rose VP, Saraiya M; Centers for Disease Control and Prevention (CDC). Vital signs: cervical cancer incidence, mortality, and screening - United States, 2007-2012. MMWR Morb Mortal Wkly Rep.2014 Nov 7;63(44):1004-9.

Race/ethnicity Percent NOT screened in the past 5 years

Overall Those with NO Insurance

White 10.8 28.8

Hispanic 11.7 16.7

Why are we talking about cervical cancer screening?

Benard VB, Thomas CC, King J, Massetti GM, Doria-Rose VP, Saraiya M; Centers for Disease Control and Prevention (CDC). Vital signs: cervical cancer incidence, mortality, and screening - United States, 2007-2012. MMWR Morb Mortal Wkly Rep.2014 Nov 7;63(44):1004-9.

REGION Cervical cancer Incidence rate2007-2011(age adjusted)

Cervical cancer Death rate2007-2011(age adjusted)

Percent of women 21-65 not screened in past 5 year2012

Northeast 7.5 2.1 10.9South 8.5 2.7 12.3Midwest 7.4 2.2 10.6West 7.3 2.1 11.5

Hispanic women in the US and cervical cancer

Between 2000 and 2010 the Hispanic population in the US grew by 43%, four times the growth of the total population (1)

In the U.S Hispanic women have the highest incidence of cervical cancer (2) 11.1 per 100,000 [2005-2009] vs. 7.2 per 100,000 for non Hispanic white women Incidence ratio of 1.6 [statistically significant]

Hispanic non-adherence to follow up after abnormal cytology results have also been reported to range between 20 and 90% [3]

(1) Ennis SR, Rios-Vargas M, Albert NG. The Hispanic Population: 2010. U.S. Census Bureau;2011 (2) American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012. (3) Engelstad LP, Stewart SL, Nguyen BH, et al. Abnormal Pap smear follow-up in a high-risk population. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2001;10(10):1015-1020.

Hispanic women in the US and cervical cancer

Given the Lower uptake of cervical cancer screeningPoorer adherence to follow up after abnormal cytologyHigher incidence of cervical cancer

We thought it was important to re-assess understanding of the purpose of a Pap smear among this group, especially after the most recent and dramatic changes to cervical cancer screening guidelines.

Pilot studyAn initial pilot study was conducted among 174 women (164 English

speaking; 10 Spanish speaking)

We developed and administered two versions of our survey73 women completed Version A94 women completed Version B

Survey directly adapted from survey used in two prior studies: Head SK, Crosby RA, Moore GR. Pap smear knowledge among young women following

the introduction of the HPV vaccine. Journal of pediatric and adolescent gynecology. 2009;22(4):251-256.

Blake DR, Weber BM, Fletcher KE. Adolescent and young adult women's misunderstanding of the term Pap smear. Arch Pediatr Adolesc Med. 2004;158(10):966-970.

Pilot studyWe then analyzed the internal consistency of responses to the

primary research questions within each survey.

One version (version A) was superior to the other in terms of internal consistency of responses.

This version was then exclusively administered to participants in the second phase of the study(exclusively Spanish speaking)

Pilot studyIn our pilot study we found that

74% of women completing version A could identify at least one correct descriptor for the term Pap smear

Women who could identify at least one correct descriptor for the term 'Pap smear' were on average older than those who could not (mean = 36.9 vs. 28.7 years; p = 0.012).

67% of women completing version B of the survey could not distinguish between a pelvic exam and a pap smear.

Study Objectives To assess and quantify Spanish-speaking women’s ability to identify

correct descriptors for the term “Pap smear”

To directly compare the ability of Spanish speaking women to that of English speaking women to identify correct descriptors for the term “Pap Smear”

To determine whether age is associated with Spanish-speaking women’s understanding (as was found in our pilot study among primarily English speaking

women)

Hypotheses (developed based on our pilot study among English Speaking women) 1. A majority of Spanish speaking women would be able to

identify at least one correct synonym for the term 'Pap smear'

2. Similar to English speaking women, Spanish speaking women able to identify at least one correct descriptor for the term 'Pap smear' would be significantly older than those unable to do so

3. Similar to English speaking women, a majority of Spanish speaking women would not be able to distinguish between a pelvic exam and a Pap smear

Research Design/SubjectsSingle institution study—urban teaching hospital in Kansas City MissouriAnonymous, voluntary, cross-sectional survey Survey was translated into Spanish by certified medical translator and

was designed, per IRB requirements, to read at an 8th grade level. Predominantly low-income women on either Medicaid or uninsuredPregnant patients includedExcluded: cannot speak or read Spanish, have legal guardians, <18 y.o

Survey (as approved by IRB) ENGLISH SPANISH

Survey, cont.

Survey, cont.

Statistical Analysis We compared characteristics between Spanish-speaking women

who could versus those who could not identify at least one correct descriptor for the term ‘Pap Smear.’

We compared the proportion of Spanish speaking women choosing each possible descriptor for the term Pap smear to the proportion of English speaking women choosing that same response.

Continuous variables compared using the Student’s T test and categorical variables compared using the chi square test

All analyses done using STATA version 8 (College St. TX)

Results123 Spanish speaking women

116 answered all questions

Compared to English speaking participants, Spanish speaking participants were:older age at sexual debut significantly less likely to report ever being tested for an STI, Significantly less likely to report having one or more sexual

partners in the past year Significantly less likely to report ever having an abnormal pap

smear. Significantly MORE likely to be pregnant at the time of the

survey.

Detailed breakdown of participants’ responses to the survey question asking them to identify synonyms/descriptors for the term Pap smear.Correct synonym or descriptors for term Pap Smear

Spanish Speaking womenN=116

English speaking womenN=66

p-value

Test for HPV 29(25) 30(45.5) 0.005Test for cervical cancer 

64(55.2) 43(65.2) 0.19Test for early changes in the cervix that might lead to cervical cancer 

55(47.4) 41(62.1) 0.06

Test for pre-cancer cells in the cervix 

55(47.4) 37(56.1) 0.26       Total identifying at least one correct descriptor 86(74.1) 51(77.3) 0.63       Incorrect synonym or descriptors for term Pap Smear

     Pelvic exam 

53(45.7) 52(78.8) 0.001 Test for STD 29(25) 40(60.6) 0.001

Checkup 

25(21.6) 37(56.1) 0.001Test for pregnancy 

21(18.1) 24(36.4) 0.006None of the above 

2(1.7) 0(0) 0.28I really have no idea. 

15(12.9) 8(12.1) 0.88

Characteristics of participants who identified at least one correct synonym or descriptor for the term Pap smear, stratified by primary language (Spanish versus English).  English Speaking women Spanish speaking women

  Identified at least one correct synonym or

descriptor N=54

Did not identify at least one correct synonym or

descriptor N=19

p-value1 Identified at least one correct synonym or descriptor

 N=86

Did not identify at least one correct synonym or

descriptor,

N=30

p-value1

Age (mean, 95% CI)

37.6 (34.1-41.2) 27.1(23.1-31.1) 0.004 35.7(33.1,38.2) 29.5(26.1,32.9) 0.011

Age at first sexual encounter (mean, 95% CI)

15.8(15.2,16.3) 16.5(14.1,18.9)0.33

17.9(17.3,18.4) 17.5 (17.1,17.9) 0.55

Ever had abnormal Pap

Yes 27(52.9) 5(33.3) 0.18 18(21%) 6(20%) 0.93

No 24(47.1) 10(66.7)   66(77%) 23(77%)  

Ever had HPV vaccine

Yes 8 (15.6) 1 (6.7) 0.35 16(19%) 2 (7%) 0.17

No 41(80.4) 14(93.3)   67(78%) 24 (80%)  

Ever had STI

Yes 26(51) 8(53.3) 0.87 16 (19%) 6(20%) 0.78

No 25(49) 7(46.7)   68 (79%) 22(73%)  

Ever been tested for STI

Yes 47(92.2) 12(80.0) 0.10 13(15%) 2 (7%) 0.25

No 3(5.9) 3(20.0)   72(84%) 27 (90%)  

Summary of Results For both English speaking and Spanish speaking women a majority (77% and

74% respectively) were able to identify at least one correct descriptor for the term 'Pap smear'.

For both English speaking and Spanish speaking women, those who could identify at least one correct descriptor for the term Pap smear were significantly older than those who could not.

Combining the pilot study with the current study 170 out of 283 women (60%) could not differentiate a Pap smear from a pelvic exam

Unexpectedly, Spanish speaking women were significantly less likely to choose incorrect descriptors.

ConclusionsMajority of US women still conflate a Pap smear with a pelvic examAge and primary language(English vs. Spanish) appear to be associated

with understanding of the term ‘Pap smear’

There is a clear need for more research into the factors behind this association and how we can improve understanding (of the purpose of Pap smears) specifically among younger women.

END TALK

Why are we talking about cervical cancer screening?

Nearly all cases of cervical cancer could be prevented with regular screening.

½ of cervical cancers diagnosed in the US are in women never screened.

An additional 10% of cancers occur among women not screened within the past 5 yrs.

Rates are much higher in low-resource, medically underserved populations vs the general US population.

Why are we talking about cervical cancer screening?

5 year relative Survival rates by stage at diagnosis(2004-2010): All stages-68% [10 year=64%] Locally invasive—91% [uterine 95%, ovarian 92%]

47% of cervical cancers diagnosed at this stage Regional mets—57% [ovarian=72%, uterine=68%] Distant mets—16% [ovarian=27%] Reference: American Cancer Society. Cancer Facts &

Figures 2015. Atlanta: American Cancer Society; 2015.

EXTRA SLIDES

Further discussion Understanding women’s misperceptions of what a pap smear entails can help shape

educational programs that focus on increasing awareness of cervical cancer and the need for screening.

For instance, women seen in the ED for pelvic complaint may undergo pelvic exam and STI screening, but think they had pap smear. This belief may prevent them from scheduling a well woman exam if they think they have undergone their necessary cervical cancer screening.

It is important to educate women on what tests are being performed at time of pelvic exam.

Also, important to educate on current cervical cancer recommendations and when next pap smear is due.

Barriers to Screening It is important to identify other barriers that prevent women,

especially Hispanic women, from obtaining cervical cancer screening Common barriers include:

knowledge of cervical cancer screening and etiology, acculturation, lack of access, and cultural beliefs

Lower acculturated Hispanic women, often characterized by limited education, low literacy levels, and the use of Spanish language, are less likely to utilize cervical cancer screening services than highly acculturated or bicultural women.

Punishment, or castigo, from a higher being is more prevalent in Hispanic women. Widely held belief that God can punish people by giving them cancer.

Belief health care only needed in the presence of symptoms. Belief screening only necessary if at risk or cancer runs in the family

Misperceptions about development of cervical cancer: poor hygiene, abortion, fate, vaginal trauma, antibiotics and having intercourse during menses

Embarrassment as a Screening Barrier gender differences between women and their

providers exposure of private body parts discussions about sexual activity (especially to

someone other than their partners) view cervical cancer may imply immoral behavior

Shelton et. al. Cervical Cancer Screening Among Immigrant Hispanics: An Analysis of Country by Origin, J Immig Minor Health, 2012;14:715-720

Non-adherence to pap screening is associated with:

For women born in Mexico, married/partnered women were more likely to be adherent, while increasing age (41+) was associated with decreased adherence.

Older age Alcohol use

Unmarried Language barriers

Lower education Less acculturation

Low income Male physician

No children Embarrassment

Last Dr visit >1 yr Low knowledge

No insurance Poor communication with clinic staff

No other cancer screens

Behavioral Theories 1. Health belief model: preventive health behavior depends on the desire to

avoid illness and the belief that a specific health action will prevent illness. Dimensions: perceived susceptibility to illness, perceived severity of an illness or of leaving it untreated, perceived benefits of recommended actions to prevent or treat a disease, and perceived barriers to following recommendations

2. Social cognitive theory: based on assumption that an individual’s behavior is determined by the interaction between behavior, personal factors, and environmental influences. Constructs include: individual’s capacities to learn by observing others, to have confidence in performing a behavior (self-efficacy), to anticipate the outcomes of a behavior, and to self-regulate behavior.

3. Theory of planned behavior: assumes that behavioral beliefs, normative beliefs (perceptions of whether important individuals approve or disapprove of performing the behavior), and perceived control over behaviors predict behavioral intentions, which in turn predict behaviors.

4. Transtheoretical model: behavioral change is a process involving progress through 5 stages: precontemplation, contemplation, preparation, action and maintenance. Processes of change are activities that people use to progress through the stages, and include consciousness raising and helping relationships.

Principles for Culturally Proficient Health Services for Hispanic/Latino Families and Communities

Involve family members. Show respect – Always be respectful, and explain without being condescending. Get personal – Hispanics typically prefer being closer to each other in space than non-

Hispanic whites do. Ask about their life (family, friends, and work), and share life stories and pictures. Encourage them to ask questions. Take seriously the responsibility and respect conferred on the provider. Reach out to the community – Community-based organizations within Hispanics

neighborhoods, barrios, colonias, and other ethnic enclaves provide a significant point of entry and opportunity to expand on any outreach effort in which you may be involved.

Respect traditional healing approaches – Hispanic patients may combine respect for the benefits of mainstream medicine, tradition, and traditional healing with a strong religious component.

American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012.

Thank you!David Howard MD, PhDSaladin Cooper, MDGerard Malnar, MD, MBANicole Johnson, MD***All clinic nurses and staff for helping with distribution and

collection of surveys***

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Comparison Among Race/Ethnicity

American Cancer Society. Cancer Facts & Figures for Hispancis/Latinos 2012-2014. Atlanta: American Cancer Society, 2012.

Hispanic Implications There has been a 43% increase in the Hispanic population in the

U.S. in the past decade Estimated that by 2050, 30% of the U.S. Population will be

Hispanic Cancer is the leading cause of death among Hispanics (Heart

disease #1 for Whites, Blacks) Cervical cancer incidence rates among Hispanic women are

about 60% higher than those among non-Hispanic whites. The highest incidence of cervical cancer among Hispanic women

is in the Midwest, likely due to large numbers of new immigrants in this region.

Does the General Public Understand What a Pap Smear Is? Many women cannot differentiate a pap smear from a Pelvic

exam. In the English version of study, 74% of women thought pap

smear and pelvic exam were synonymous. Because women are no longer undergoing annual pap

smears, the ability to differentiate between a pap smear and a pelvic exam are now important.

Think pap smear occurred during ED visit May not schedule well woman exam if think obtained all

necessary screening