Health Education Research, Vol. 18, No. 4, 477-487,
August 2003
© 2003 Oxford University Press
Repeated Pap smear screening among Mexican-American women
Center for Health Promotion and Prevention Research, University of Texas–Houston School of Public Health, Houston, TX 77030, 1 Latino Research and Policy Center, University of Colorado at Denver, Denver, CO 80204, and 2 Disease Prevention and Control Research Center, Baylor College of Medicine, Houston, TX 77030, USA
*To whom correspondence should be addressed E-mail: maru{at}sph.uth.tmc.edu
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Abstract |
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The factors that influence repeated cervical cancer screening among Latina women are not well understood. Studies of compliance in this population over-emphasize initial or recent screening and under-emphasize how this practice is repeated over time. The purpose of this study was to identify the demographic and psychosocial factors associated with repeated Pap smear screening among low-income Mexican-American women living in two urban communities in Texas. A total of 1804 Mexican-American women were interviewed as part of a community survey. Multiple regression results indicate that demographic characteristics such as age, marital status, level of acculturation and health insurance were associated with the total number of Pap smears reported for the 5 years prior to the interview. Pap smear beliefs were the strongest predictor of repeated screening, while global beliefs about cancer did not significantly explain the results. Health promotion interventions should take into consideration the cultural and psychosocial needs of Mexican-American women, placing emphasis on their specific screening-related beliefs, if they are to succeed in promoting repeated compliance with Pap smear screening guidelines.
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Introduction |
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Protection against cervical cancer may involve repeated screening over a lifetime. Current guidelines indicate that all sexually active women and/or those who have reached 18 years of age should undergo an annual Pap smear test. After a woman has three or more consecutive, negative examinations, the Pap test may be performed less frequently at the discretion of her physician (Committee on Gynecologic Practice, 1995
; American Cancer Society, 2001). A woman may decide to screen less frequently based on her physician’s recommendation, but if no physician counter-indicates this practice and there are no compliance barriers, she is likely to continue to screen regularly. This observation is based on the fact that more than 50% of US women report getting a Pap smear every year (Colditz et al., 1997; American Cancer Society, 2001). It has been argued that getting Pap smears too frequently could lead to false positive results and may increase expense without any real health benefit (Colditz et al., 1997). While these population-level criticisms may be true, Latinas tend to have lower rates of repeated compliance compared to other US women (American Cancer Society, 2001). The factors that determine repeated cervical cancer screening among Latinas are not well understood. Studies of compliance in this population have over-emphasized initial screening and have under-emphasized the factors responsible for maintaining this practice over time. This report is based on Programa A Su Salud, a cancer prevention study conducted in Texas, and its purpose is to identify the demographic and psychosocial factors associated with repeated Pap smear screening among low-income Mexican-American women living in urban communities.
Screening among Mexican-American women
Despite the more frequent occurrence of cervical cancer in Latinas (American Cancer Society, 1999), various studies have determined that they are less likely than non-Latina white women to participate in preventive cancer screening (Harlan et al., 1991; Suarez et al., 1991; Rolnick et al., 1996). Nearly 19% of Latinas over 18 years of age report not having had a Pap smear in the last 3 years (American Cancer Society, 2001).
Previous research among Mexican-American and other Latina women has identified barriers associated with current cancer screening practices (Nápoles-Springer et al., 1996; Peregallo et al., 1997). Latinas who are single, older, less educated, have limited income and no health insurance are less likely to participate in routine Pap smear screening (Harlan et al., 1991; Norman et al., 1991; Nápoles-Springer et al., 1996). While these results are not unique to Latinas, when added to culturally specific health beliefs and barriers, they provide an additional burden to their seeking health care. Some studies suggest that acculturation factors, such as language spoken (Harlan et al., 1993; Wilcox and Mosher, 1993) and cultural beliefs (Perez-Stable et al., 1992; Chavez et al., 1997), are associated with Latinas’ failure to seek preventive health care. However, we do not know if these demographic and psychosocial factors also play a role in repeated Pap smear screening.
The role of beliefs
According to the Theory of Reasoned Action, beliefs about a behavior and the relevance that important others give to such behavior influence intentions to act (Ajzen and Fishbein, 1980). Beliefs may also directly influence behavior, bypassing the role of intentions (Sheeran et al., 2001). Beliefs about Pap smears appear to be related to actual participation in cancer screening. Compared to women who do not get the exam, women who get Pap smears are more likely to believe that benefits outweigh barriers to the exam (Burak and Meyer, 1997); they also have more Pap smear-related positive attitudes and social norms (Barling and Moore, 1996). Beliefs about health locus of control (Bundek et al., 1993) and fatalismo (i.e. the belief that fate controls everything) also influence Latinas’ cervical cancer screening (Chavez et al., 1997). Thus, specific screening beliefs influence screening behavior among all women, while more global (but culturally relevant) beliefs also influence Latinas screening practices. The extent to which both global and specific beliefs influence repeated Pap smear screening among Latinas needs further exploration, since their relative influence is not well understood and past research has provided equivocal results (Chavez et al., 1997; Ramirez et al., 2000).
Measurement issues
Admittedly, research on compliance with Pap smear screening has generally disregarded repeated screening. Research with Latinas has also focused on the determinants of initial or recent compliance (Perez-Stable et al., 1994; Morgan et al., 1995; Harmon et al., 1996), although there have been some notable exceptions (Peragallo et al., 1997). Perhaps the neglect of repeated screening is due to the fact that guidelines emphasize at least one Pap smear every 3 years and compliance requires the completion of only one Pap smear over this time period. However, assessment of repeated Pap smear screening requires the report of multiple instances of screening over several years and may be subject to a recall bias, with women tending to over-report number of Pap smears (Bowman et al., 1997). Reporting also becomes problematic when screening behavior is established through surveys based on self-reports, a method known to provide unreliable results (Bowman et al., 1997).
Another important reason for the lack of emphasis on repeated screening may be the implicit assumption that current screening is representative of past screening and that the determinants of compliance remain constant over time. Most theories of behavior change emphasize the initial adoption of protective behavior and tend to be less explicit about repeated behavioral compliance (Ajzen and Fishbein, 1980; Rosenstock, 1990). The work conducted by Proshaska and Di Clemente (Proshaska and Di Clemente, 1992) is an exception to this disproportionate focus on initial or short-term change. Thus, although the study of repeated Pap smear screening faces problems of recall and assessment mode, it is necessary in order to establish the factors that maintain cancer screening compliance over time.
The purpose of this study was to identify the psychosocial and demographic factors associated with repeated Pap smear screening in the 5 years prior to the interview among Mexican-American women living in two urban communities in Texas. We chose to measure repeated screening using a 5-year time frame because it is long enough to allow the measurement of several instances of screening behavior, but short enough to minimize biases in recall. Consistent with previous research assessing the health behavior of Mexican-American women and other Latinas, we hypothesized that demographic and psychosocial characteristics would influence repeated Pap smears screening, acting as barriers or facilitators of screening behavior. In addition, we hypothesized that global cancer beliefs and specific Pap smear screening beliefs would influence screening behavior.
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Method |
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Data were collected as part of the baseline survey for Programa A Su Salud: Mexican-American Participation in Cancer Prevention, a community intervention study funded by the National Cancer Institute to increase compliance with breast and cervical cancer screening. Data collected from October 1991 to May 1992 provided information on 1804 Mexican-American women and constitute the basis for this report.
Participants
A sample of the population of predominantly Mexican-American residential areas in Houston and San Antonio, Texas was surveyed. At the time this research study was initiated, 44 721 persons lived in San Antonio’s six selected census tracts situated on the city’s West Side; 53% of these residents were females. The median age was 25.6, the median household income was $8061 and 86% of the residents spoke Spanish. In Houston, 41 562 persons lived in the seven selected census tracts. Forty-eight percent of the residents were female, the median age was 24.2 years, the median household income was $12 134 and 80% of the residents spoke Spanish. The study sample was stratified by place of interview and age of respondent, in order to measure breast and cervical cancer screening according to age-appropriate guidelines. In each site, the sample consisted of Mexican-American women; 450 were aged 18–39 and 450 were 40 or older.
Sample selection
Eligible survey participants were selected using a multi-stage random sampling procedure. First, residential areas comprised of adjacent census tracks were selected and matched according to the proportion of residents who reported Latino ethnicity in the 1980 census. Second, within each selected census track, a computer program randomly selected residential blocks using census records. Third, addresses of properties that appeared to be residential (including home and cottage industries) were entered into a computer database. Fourth, a computer program systematically selected every third residence, identifying those households eligible for enumeration. Fifth, personal enumeration interviews were conducted to determine (1) if the residence was inhabited, (2) whether the occupants were of Mexican-American origin, and (3) gender and age of the residents. After the enumeration was completed, only one Mexican-American woman 18 years or older per household was selected to participate in the baseline interview. If more than one woman in a household was eligible, an algorithm was used to select the person whose birthday fell nearest the date of the interview.
Instrument
A survey questionnaire was designed to collect information about cancer screening and other health practices of Mexican-American women. The questionnaire was administered as a personal interview conducted either in English or Spanish at the residence of the respondent. Items included in the Women’s Health Survey were pooled from existing questionnaires, including the Behavioral Risk Factors Surveillance System survey questionnaire (Centers for Disease Control and Prevention, 1991) and other surveys administered to Latinos. In addition, items included in the baseline questionnaire had been tested previously in El Paso and San Antonio as part of a cancer prevention study conducted with a similar population (Ramirez and McAlister, 1988). The bilingual research team translated items not already written in Spanish. The questionnaire consisted of 12 sections exploring the following topics: perceived health, reproductive health, cervical and breast cancer screening, access to health care, demographic characteristics, acculturation, cancer awareness, tobacco and alcohol use, media exposure, social support, and perceived stress. Half of the sample in each site (n = 450) also completed a nutrition survey in addition to the 12 sections. The questionnaire consisted mostly of multiple-choice items, in which participants were given the option to use response cards to cue the possible response options.
Interviewer selection and training
Between 10 and 20 bilingual/bicultural female interviewers from each of the two selected study sites were recruited through newspaper ads or by word of mouth. Interviewers attended a 3-day training workshop, after which they went into the field. Alternatively, women hired during the study to replace those who could not continue were trained by observing a more experienced interviewer and by attending a 1-day workshop. Regardless of the training format, workshops included role playing, developing skills for contacting respondents, specifics of the interview protocol and response-coding practice.
Each interview lasted between 40 and 90 min, depending on whether the nutrition survey was also included. Before the interview was begun, a consent form emphasizing confidentiality, voluntary participation and the project’s significance was read by the interviewer and signed by the respondent. Each participant received $10 by mail for completing the interview. These procedures received approval from the Committee for the Protection of Human Subjects at the University of Texas–Houston Health Science Center prior to their implementation.
Measures
Demographic variables used in data analysis were coded as is indicated in Table I. It must be noted that although age, education and acculturation are presented as categorical variables in Table I, they were entered as continuous variables in the multiple regression equation. Separate scales were constructed to measure psychosocial influences on Pap smear screening including acculturation level and Pap smear beliefs. The measure of repeated Pap smear screening is also described in this section.
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Acculturation
Acculturation was administered according to procedures indicated for the Acculturation Rating Scale for Mexican-Americans (ARSMA) validated by Cuéllar et al. (Cuéllar et al., 1980
). However, we selected language as our measure of acculturation, because prior research indicates that language use accounts for the greatest proportion of variance in acculturation scales and has been used in this manner in previous studies (Olmedo and Padilla, 1978; Cuéllar et al., 1980; Marin et al., 1987). The acculturation scale was created by averaging three types of reported language use: spoken language, preferred language and language of thinking. Respondents were asked to rate the three questions about language use on a five-point Likert scale response format: 1 = ‘English only’, 2 = ‘English mostly’, 3 = ‘Both Spanish and English’, 4 = ‘Spanish mostly’ and 5 = ‘Spanish only’. Responses were scored so that higher scores represented greater acculturation level. The test of internal validity of this scale indicates that it had a high level of internal consistency (Cronbach’s standard 
= 0.94). Acculturation was also coded as a categorical variable to conduct the cross-tabulations presented in Table II. The averaged score was categorized as ‘low’ (1–2.49), ‘moderate’ (2.50–3.49) or ‘high’ (3.50–5) by using cut-points proposed by members of the NCI Initiative on Cancer Prevention in the Hispanic Community (Kaplan et al., 1996).
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Pap smear and cancer beliefs
Twelve items measuring commonly held beliefs about Pap smear compliance are presented in Table II and were coded as ‘true’ or ‘false’ depending on the respondent’s ability to correctly identify accurate or inaccurate beliefs about Pap smears. An index of beliefs was also calculated by summing the score on the 12 items. A higher score on the scale indicated correct identification of accurate beliefs on a greater proportion of items. This scale was found to have an acceptable level of internal consistency (Cronbach’s standard
= 0.80). We also attempted to create a scale measuring global beliefs about cancer, but the internal consistency of the scale was too low (Cronbach’s standard = 0.16). Instead, we used the following questionnaire items as separate variables in the regression equation: ‘If I had cancer, I would want to know’, ‘Cancer treatment is worse than the disease’ and ‘Just about anything causes cancer’. Responses were coded as 1 = ‘disagree’, 2 = ‘don’t know’ and 3 = ‘agree’.
Pap smear screening
The section probing questions about Pap smear screening was prefaced by a narrative describing the difference between a vaginal smear and a Pap smear. Specifically, differences in procedures and exam results were highlighted before asking the Pap smear screening questions. Repeated Pap smear screening was measured with the question: ‘How many Pap smears have you had in the last 5 years?’. The answer was coded as a numerical variable and was used as the main outcome in the multiple regression analysis. Respondents who had never heard or never had a Pap smear were coded as ‘0’.
Data analysis
Data collected as part of the community survey were entered and analyzed using the SPSS statistical software package. A team of four data entry clerks edited, coded and entered all community survey data. Double entry was used to maintain maximum accuracy of entry per record.
A multiple regression analysis was conducted to assess the simultaneous influence of demographic (age, income, education, marital status and health insurance) and psychosocial (acculturation, Pap smear and global beliefs) variables on the total number of Pap smears reported by Mexican-American women in the 5 years prior to the interview. Variables selected for inclusion in the regression equation were identified in the literature review as being related to Pap smear screening and were coded as indicated in Methods. Given our interest in exploring the importance of beliefs among Mexican-American women, we also cross-tabulated each specific cancer and Pap smear belief by age and acculturation level, in order to identify significant group differences. All associations were tested with the 
2 statistic.
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Results |
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The following section describes the demographic characteristics of 1804 women who participated in the community survey. Since we were interested in identifying the determinants of repeated Pap smear screening only among women getting regular gynecological care, we eliminated from subsequent data analysis all cases of women who reported getting Pap smears due to prior health problems (n = 270). Preliminary analyses indicate that differences in demographic characteristics between women receiving regular Pap smears and those of the total sample were not statistically significant.
Demographic characteristics
A total of 1804 women completed the community survey and the target sample size (n = 900) was closely approximated in each study site (Table I). Age group distribution also approximated the desired stratification level. The age of respondents ranged from 18 to 91 years and the average age for the sample was 45 years. Additional demographic information presented in Table I indicates that the majority of respondents were married and reported a low family income, with most reporting an annual income of under $10 000. Although the median level of education was Grade 8, the majority reported less than 6 years of schooling. Half of the respondents indicated that they had some form of health insurance, but only 20.7% reported having a place to go for regular gynecological care. When asked who provided their gynecologic care, most respondents (67.2%) indicated that they received care from their regular physician, while some (12.1%) reported not receiving any regular gynecologic care at all. Compliance with Pap smear guidelines was calculated as completing two or more Pap smears in the 5 years prior to the interview. Forty-three percent of the sample was not compliant with Pap smear screening guidelines.
Acculturation level was based on reported language use. Over half of the respondents were classified as having a low level of acculturation (54.4%), or as communicating mostly or exclusively in Spanish. In contrast, 18.4% were classified as highly acculturated, or as speaking only English. Consistent with their language preference, half of the respondents (52.2%) reported being born in Mexico.
Beliefs about cancer and Pap smears
As indicated in Table II, the most common Pap smear beliefs included ‘Doctor should tell me if I need a Pap smear’ (52.5%) and ‘Pap smears are expensive’ (52.0 %). The 2 results indicate that there were significant differences in Pap smear beliefs by age and acculturation level. There were significant statistical differences in all Pap smear beliefs by age group, except for variables measuring Pap smears as painful, not needed after menopause or after hysterectomy. In all instances, women over 40 were more likely to endorse inaccurate beliefs. When results were cross-tabulated by acculturation level, the pattern that emerged was similar. Women classified as having a low acculturation level were more likely to endorse the same inaccurate beliefs about Pap smears that were identified as more prevalent when results were cross-tabulated by age group. The scores on the Pap smear beliefs scale ranged from 0 to 11 points; the mean score was 7.07 and the standard deviation was 2.56. Scores on the Pap smear beliefs scale indicate that study participants endorsed beliefs consistent with current Pap smear guidelines, although they also had some misconceptions, as previously described.
Global beliefs about cancer were cross-tabulated by age group and acculturation level. The most commonly endorsed cancer belief was ‘If I had cancer, I would want to know’. The strongest statistical differences in global cancer beliefs were found when results were cross-tabulated by age group. In every instance, women over 40 years of age were more likely to believe that cancer treatment is worse than the disease, that anything causes cancer and they were less likely to want to know if they had cancer. The only difference detected when results were cross-tabulated by acculturation level was in the belief that anything causes cancer. Low acculturated women were more likely to endorse this belief (Table II).
Factors that influence repeated Pap smear screening
A multiple regression analysis was conducted to assess the simultaneous influence of demographic and psychosocial variables on the total number of Pap smears reported for the 5 years prior to the interview. A total of 1534 cases of women seeking regular gynecological care were included in this analysis. The average number of reported Pap smears for the previous 5 years was 2.56 with a standard deviation of 2.31. The variables significantly associated with repeated Pap smear screening were: Pap smear beliefs, age of respondent, marital status, acculturation and health insurance (Table III). Global cancer beliefs, annual family income and years of education were not significantly associated with repeated screening. These results indicate that women who have more accurate beliefs about Pap smears, those under 40 years of age, married, more acculturated and who have health insurance are likely to report completing more Pap smears in the 5 years prior to the interview. Variables in the regression equation accounted for 20% of the total variance (R2 = 0.20, F = 37.81, P < 0.000) in repeated Pap smear screening.
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Discussion |
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Consistent with previous research, our results indicate that demographic and psychosocial characteristics are associated with repeated Pap smear screening among low-income Mexican-American women. Pap smear beliefs accounted for more variance in repeated screening, compared to other variables entered in the regression equation, while none of the global beliefs about cancer were statistically significant. While specific beliefs seem more salient for behavior repeated over time, global beliefs seem to have a weaker influence. As women screen more frequently, their beliefs may begin to reflect cancer prevention information provided to them by health care personnel during these visits and, in turn, beliefs may influence women’s continued participation in regular screening.
Age, marital status and acculturation also emerged as significant factors associated with repeated Pap smear screening. More acculturated women reported more Pap smears, perhaps because their ability to communicate in English enables them to become full participants of the US culture and gain greater access to the American medical system. This process of cultural integration is more likely to affect younger, married women who may seek active participation in the medical system, due to family planning and childbearing needs. Older women screen less frequently because they face greater barriers to screening and also because physicians’ recommendations for older women are less insistent on frequent screening. Income and education were not significantly associated with repeated Pap smear screening, perhaps because there was not enough variability in this sample. However, access to health insurance had a significant influence. In a population in which the education of the majority is below high school level and the average family income falls below the federal poverty level, access to health insurance seems to be critical to consistent, continuous Pap smear screening.
In sum, this study indicates that the factors associated with repeated Pap smear screening are similar to those identified in initial or recent screening. Demographic and psychosocial characteristics such as age, acculturation and marital status continue to play a role as barriers or facilitators of screening behavior over time. Given the limited interpretability of results by income and education, we cannot exclude them as potential influences on repeated screening. The most significant finding of this study is the strong association between specific Pap smear beliefs and repeated screening. Participation of Mexican-American women in regular cancer screening seems to be more influenced by specific beliefs than has been previously reported.
Limitations
This study is based on self-reported Pap smears during personal interviews. As a result, it suffers from the limitations of all studies that are based on self-reports and rely on information recalled from memory. Namely, women in this study may have over-reported the total number of Pap smears that they completed in the 5 years prior to the interview (Bowman et al., 1997). While we do not believe over-reporting may have varied by any of the key demographic characteristics of this sample, we believe that it may have occurred due to social desirability effects (Marin and Marin, 1991).
This study attempted to identify factors associated with Pap smear screening reported for the 5-year period prior to the interview. This time frame is useful for understanding factors associated with the behavior of women who screen yearly, or nearly every year, but the results may not be applicable for women who screen at 3-year intervals and still meet cancer screening guidelines. Long-term, prospective studies with multiple measurement waves and with independent validation measures are needed to understand repeated screening longitudinally, but few studies of this type have been implemented.
Perhaps the strongest limitation of this study is the age of the data. Ten years have passed since these data were collected and other projects have attempted to increase participation of Mexican-American women in cancer screening (Ramirez et al., 2000). The Centers for Disease Control have also launched the National Breast and Cervical Cancer Early Detection Program, which may have increased participation of Latinas in cancer screening, although they still lag behind other ethnic groups (Bernard et al., 2001). Consistent with current theories of behavior change, we believe that the psychosocial factors identified in this study continue to have relevance for understanding the screening behavior of Mexican-American women and for the understanding of repeated screening, a topic that has remained under-studied.
Implications of the study
Community interventions must give priority to older, Spanish-speaking, Mexican-American women without health insurance and target them with information about who needs to be screened and what is involved in the Pap smear examination. Media campaigns should emphasize specific beliefs about Pap smears, such as the fact that Pap smears are not painful and that some health clinics provide them at a relatively inexpensive price. Information should also be provided about the necessity of regular Pap smear screening and that a doctor’s recommendation is not a prerequisite for the examination. Above all, future community interventions should emphasize the need for repeated compliance with cancer screening guidelines over a woman’s lifetime.
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Acknowledgements |
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We would like to thank Andrew Springer, Arlene Correa and Alan Wells for their contribution to this paper. This study was based on a 5-year community intervention grant (5-U01-CA-52939) awarded by the National Cancer Institute to A. L. McA. and A. G. R.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
|---|
Ajzen, I. and Fishbein, M. (1980) Understanding Attitudes and Predicting Social Behavior. Prentice-Hall, Englewood Cliffs, NJ.
American Cancer Society (1999) Cancer Fact and Figures. ACS, Atlanta, GA.
American Cancer Society (2001) Cancer Fact and Figures. ACS, Atlanta, GA.
Barling, N.R. and More, S.M. (1996) Prediction of cervical cancer screening using the Theory of Reasoned Action. Psychological Reports, 79, 77–78.[ISI][Medline]
Bernard, V.B., Lee, N.C., Piper, M. and Richardson, L. (2001) Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection Program, 1991–1998 (United States). Cancer Causes and Control, 12, 61–68.[CrossRef][ISI][Medline]
Bowman, J.A., Sanson-Fisher, R. and Redman, S. (1997) The accuracy of self-reported Pap smear utilization. Social Science and Medicine, 44, 969–976.
Bundek, N.I., Marks, G. and Richardson, J.L. (1993) Role of health locus of control beliefs in cancer screening of elderly Hispanic women. Health Psychology, 12, 193–199.[CrossRef][ISI][Medline]
Burak, L.J. and Meyer, M. (1997) Using the health belief model to examine and predict college women’s cervical cancer screening beliefs and behavior. Health Care for Women International, 18, 251–262.[Medline]
Centers for Disease Control and Prevention (1991) Behavioral Risk Factor Surveillance System Survey Questionnaire. Department of Health and Human Services, Atlanta, GA.
Chavez, L.R., Hubbell, F.A., Mishra, S.I. and Burciaga Valdez, R. (1997) The influence of fatalism on self-reported use of Papanicolaou smears. American Journal of Preventive Medicine, 13, 418–424.[ISI][Medline]
Colditz, G.A., Hoaglin, D.C. and Berkey, C.S. (1997) Cancer incidence and mortality: the priority of screening frequency and population coverage. The Milbank Quarterly, 75, 147–173.[CrossRef][ISI][Medline]
Committee on Gynecologic Practice (1995) Recommendations on frequency of Pap test screening. Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. International Journal of Gynecology and Obstetrics, 49, 210–211.
Cuéllar, I., Harris, L.C. and Hasso, R. (1980) An acculturation scale for Mexican American normal and clinical populations. Hispanic Journal of Behavioral Sciences, 2, 199–217.
Harlan, L.C., Bernstein, A.B. and Kessler, L.G. (1991) Cervical cancer screening: who is screened and why? American Journal of Public Health, 81, 885–891.
Harmon, M.P., Castro, F.G. and Coe, K. (1996) Acculturation and cervical cancer: knowledge, beliefs and behaviors of Hispanic women. Women and Health, 24, 37–57.[CrossRef][ISI][Medline]
Kaplan, R.M., Navarro, A.M., Castro, F.G., Elder, J.P., Mishra, S.I., Hubbel, A., Chvrala, C., Flores, E., Ramirez, A.G., Fernández Esquer, M.E. and Ruiz, E. (1996) Increased use of mammography among Hispanic women: results from the NCI cooperative group on cancer prevention in Hispanic communities. American Journal of Preventive Medicine, 12, 467–471.[ISI][Medline]
Marin, G. and Marin, B.V. (1991) Research with Hispanic Populations. Applied Social Research Methods Series 23. Sage, Newbury Park, CA.
Marin, G. Sabogal, F., Marin, B.V., Otero-Sabogal, R. and Perez-Stable, E.J. (1987) Development of a short acculturation scale for Hispanics. Hispanic Journal of Behavioral Sciences, 9, 183–205.[Abstract]
Morgan, C. Park, E. and Cortes, D. (1995) Beliefs, knowledge and behavior about cancer among urban Hispanic women. Journal of the National Cancer Institute Monographs, 18, 57–63.[Medline]
Norman, S.A., Talbott, E.O., Kuller, L.H., Krampe, B.R. and Stolley, P.D. (1991) Demographic, psychosocial, and medical correlates of Pap testing: a literature review. American Journal of Preventive Medicine, 7, 219–226.[ISI][Medline]
Nápoles-Springer, A., Perez-Stable, E.J. and Washington, E. (1996) Risk factors for invasive cervical cancer in Latino women. Journal of Medical Systems, 20, 277–293.[CrossRef][Medline]
Olmedo, E. and Padilla, A.M. (1978) Empirical and construct validation of a measure of acculturation for Mexican Americans. Journal of Social Psychology, 105, 179–187.[ISI]
Peragallo, N.P., Alba, M.L. and Tow, B. (1997) Cervical cancer screening among Latino women in Chicago. Public Health Nursing, 14, 251–255.[ISI][Medline]
Perez-Stable, E.J., Sabogal, F., Otero-Sabogal, R., Hiatt, R.A. and McPhee, S.J. (1992) Misconceptions about cancer among Latinos and Anglos. Journal of the American Medical Association, 268, 9219–3223.
Perez-Stable, E.J., Otero-Sabogal, R., Sabogal, F., McPhee, S.J. and Hiatt, R.A. (1994) Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan. Archives of Internal Medicine, 154, 1073–1081.[Abstract]
Ramirez, A.G., Suarez, L., Lauffman L., Barroso, C. and Chalela, P. (2000) Hispanic women’s breast and cervical cancer knowledge, attitudes and screening behaviors. American Journal of Health Promotion, 14, 292–300.[ISI][Medline]
Ramirez, A.G. and McAlister, A.L. (1988) Mass media campaign—A Su Salud. Preventive Medicine, 17, 608–621.[CrossRef][ISI][Medline]
Rolnick, S., La Ferla, J.J., Wehrle, D., Trygstad, E. and Okagaki, T. (1996) Pap smear screening in a health maintenance organization: 1986–1990. Preventive Medicine 25, 156–161.[CrossRef][ISI][Medline]
Rosenstock, I.M. (1990) The Health Belief Model: explaining health behavior through expectancies. In Glanz, K. Lewis, F.M. and Rimer, B.K. (eds), Health Behavior and Health Education. Theory, Research and Practice. Jossey-Bass, San Francisco, CA, pp. 39–62.
Sheeran, P., Cooner, M. and Norman, P. (2001) Can the Theory of Planned Behavior explain patterns of health behavior change? Health Psychology, 20, 12–19.[CrossRef][ISI][Medline]
Suarez, L., Martin, J. and Weiss, N. (1991) Data-based interventions for cancer control in Texas. Journal of Texas Medicine, 87, 70–77.
Wilcox, L.S. and Mosher, W.D. (1993) Factors associated with obtaining health screening among women of reproductive age. Public Health Reports, 108, 76–85.[ISI]
Received on December 11, 2001; accepted on June 27, 2002
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